Optimal management of Graves orbitopathy: a multidisciplinary approach

Graves' thyroid disease is a relatively common disorder in endocrinology and general internal medicine practice. Graves' hyperthyroidism is mediated by circulating stimulating autoantibodies. Up to 60% of patients with Graves' hyperthyroidism develop some form of Graves' orbitopathy. Immune reactivity to the thyroid-stimulating hormone receptor is also thought to play a role in the immunopathogenesis of Graves' orbitopathy. Graves' orbitopathy is characterised by a wide open eye appearance, caused by upper eyelid retraction and soft-tissue swelling that causes exophthalmus. Symptoms include photophobia, sandy feeling in the eye, painful eye movements and diplopia. Visual acuity may be reduced. In some cases emergency treatment is necessary to prevent irreversible vision loss. Smoking should be stopped. Mild to moderate Graves' orbitopathy may be an indication for corticosteroid treatment or radiotherapy. Once inflammatory signs and symptoms have waned, surgery can be performed to correct residual diplopia, exophthalmus or lid retraction. The presence of Graves' orbitopathy has consequences for the management of Graves' hyperthyroidism. Adequately controlled Graves' thyroid dysfunction is likely to improve Graves' orbitopathy, while radioactive iodine treatment can worsen the condition. Due to the wide variety in clinical presentation and the possible interference between treatment of thyroid disease and eye disease, the management of more complicated patients with Graves' orbitopathy can best be performed in combined thyroid-eye clinics, in which the patient is seen simultaneously by the ophthalmologist and the endocrinologist.

Activity of irofulven (IROF) combined with capecitabine (CAPE) in patients (pts) with advanced thyroid carcinoma: Phase II international multicenter study (preliminary results)

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Background: IROF, the first compound of the acylfulvene class to enter clinical trials, has demonstrated antitumor activity in a variety of chemoresistant tumors. Currently available chemotherapy offers limited benefit to pts with advanced thyroid cancer. A phase I trial of an IROF/CAPE combination showed confirmed partial responses in 2/4 pts (Alexandre, ASCO 2003). An international multicenter 2-stage, phase II trial was initiated to evaluate the objective response rate (RECIST) in pts with advanced thyroid cancer. Methods: Eligibility criteria included advanced Differentiated, Medullary or Anaplastic (D/M/A) thyroid cancer, ECOG PS 0–2, no benefit from prior I131 and ≤1 prior chemotherapy regimen. Pts received IROF 0.4 mg/kg (30 min IV infusion), days 1 and 15 and CAPE orally 2000 mg/m2 day 1 to 15 every 28 days. Results: As of Dec-05, 23 pts (D/M/A: 14/5/4) have been treated. Pt characteristics are (D/M/A); median age: 60/55/61 years (range 34–74), median PS: 1/1/1; prior chemotherapy in 4/1/2 pts; all had metastatic disease predominantly lung, bone and lymph nodes, with a median of 2/1/3 sites of metastasis. Median number of cycles given was 5/4/1. Efficacy: All pts are evaluable. No objective responses observed to date, SD was observed in 11 (79%)/ 3 (60%)/0 pts with median duration 4.8/5.2/0 months; 2/11 (D) pts with SD had 14% and 19% decreases in tumor size. Safety: Main adverse events were thrombocytopenia (grade [G] 1–2: 24% pts), neutropenia (G1–2: 17%; G3: 4%), nausea (G1–2: 41%), asthenia (G1–2: 41%); 1 pt had G3 asthenia. No pts discontinued due to toxicity. Conclusions: No objective responses were observed in pts with differentiated thyroid cancer treated with IROF/CAPE every 2 weeks, with 79% SD. Tolerance was acceptable and accrual is ongoing in the anaplastic cohort.

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Significant clinical and biologic activity of RAF/VEGF-R kinase inhibitor BAY 43–9006 in patients with metastatic papillary thyroid carcinoma (PTC): Updated results of a phase II study

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Purpose: Oncogenic defects in the genes involving RAS-RAF-MAPK signaling pathway (RAS, BRAF, or RET/PTC) occur in ∼60% of PTC. VEGF also plays a critical role in thyroid cancer progression. Due to lack of effective treatment, systemic therapy for iodine-refractory PTC is desperately needed. Methods: The primary endpoint of this phase II trial was to assess the objective response rates of BAY 43–9006 in pts with metastatic PTC. Secondary endpoints included clinical response correlation with 1) serum thyroglobulin (Tg) levels; 2) functional imaging including FDG-PET, and DCE-MRI; and 3) tumor genotype and degree of signaling inhibition in tumor biopsies. Using a minimax 2-stage design, 16 or 25 chemo-naïve pts with iodine-refractory PTC were to be enrolled in Arm A (accessible tumor for biopsy). An exploratory Arm B was designed with a plan to halt accrual as soon as Arm A was fully accrued. Eligible pts for Arm B had other subtypes of thyroid cancer or prior chemo, and did not require tumor biopsies. Pts received BAY 43–9006 at the dose of 400 mg PO BID. Response was assessed every 8 wks using RECIST. Results: A total of 58 pts (Arm A = 20, Arm B = 38) were enrolled from October 2004 to August 2005. Median duration of follow-up is 36 weeks (range, 16–60). Of 56 pts assessable for toxicity, serious adverse events (AEs) included aspergillus infection (gr 5, n = 1), secondary AML (gr 5, n = 1) and diverticular rupture (gr 3, n = 1). Common Gr 3 AEs were hand-foot syndrome (n = 9) and musculoskeletal pain (n = 10). Two confirmed partial responses (PRs) and 6 minor responses (23–29% decrease in sum of the longest diameter) were observed in 16 evaluable pts on Arm A. In 10 Tg-response evaluable pts on Arm A, median decrease in Tg was 70% (range, 45–90). Significant decreases in tumor perfusion and SUVs were noted in such pts. In addition, one PR and one minor response (27% decrease in sum of longest diameter; 85% reduction in Tg) have been observed among 20 pts with PTC on Arm B. Data for functional imaging and tissue correlative studies will be presented. Conclusions: BAY 43–9006 is a well-tolerated targeted therapy that has significant clinical and biologic anti-tumor activity in pts with iodine-refractory metastatic PTC.

No significant financial relationships to disclose.

In vivo imaging and radioiodine therapy following sodium iodide symporter gene transfer in animal model of intracerebral gliomas

Radioactive iodide uptake (RAIU) in thyroid follicular epithelial cells, mediated by the sodium iodide symporter (NIS), is the first rate-limiting step in iodide accumulation which provides a mechanism for effective radioiodide treatment for patients with thyroid cancer. We hypothesize that NIS gene transfer to non-thyroid tumor cells will enhance intracellular radioiodide accumulation and result in better tumor control. Here, we performed non-invasive tumor imaging and (131)I therapy studies using rats bearing intracerebral F98 gliomas that have been retrovirally transduced with human NIS. Our results show that: (1) NIS is expressed in the intracerebral F98/NIS gliomas; (2) F98/NIS gliomas can be imaged by (99m)TcO(4) (whose uptake is also mediated by NIS) and (123)I scintigraphy; (3) significant amounts of radioiodide were retained in the tumors at 24 h after (123)I injection; (4) RAIU and NIS expression in the thyroid gland can be reduced by feeding a thyroxine-supplemented diet; and (5) survival time was increased in rats bearing F98/hNIS tumors by (131)I treatment. These studies warrant further investigating tumor imaging and therapeutic strategies based on NIS gene transfer followed by radioiodide administration in a variety of human cancers.

Specificity of radioiodinated MIBG for neural crest tumors in childhood

The high sensitivity of metaiodobenzylguanidine (MIBG) scintigraphy for sympathomedullary tumors such as neuroblastoma and pheochromocytoma is well documented. The specificity of MIBG scintigraphy for these tumors is also high but has been incompletely characterized for other neural crest tumors and non-neural crest tumors of childhood.

METHODS

The medical records and MIBG scans of all children who had undergone MIBG scintigraphy for known or suspected neuroblastoma or pheochromocytoma were retrospectively reviewed at five major referral centers. Those patients found to have pathologies other than neuroblastoma or pheochromocytoma form the basis of this study.

RESULTS

One hundred children with a total of 110 lesions met the inclusion criteria. All had negative MIBG scans except 1 of 2 children with infantile myofibromatosis, 1 of 2 with neuroendocrine carcinomas, 1 of 2 with pancreaticoblastomas and 1 of 10 with primitive neuroectodermal tumors.

CONCLUSION

MIBG scintigraphy is highly specific for neuroblastoma and pheochromocytoma. Only 4% (4/100) of nonsympathomedullary tumors (non-pheochromocytoma and non-neuroblastoma) in childhood showed MIBG uptake, of which only 2% (2/100) were of non-neural crest origin.

[The therapeutic effects after the dentoalveolar compensation of skeletal open bite in adults. The skeletal and dental parameters]

In the following study 20 adult skeletal open-bite patients were analysed after they had undergone dental compensation to camouflage the underlying skeletal discrepancy. The initial and final cephalometric records were analysed to determine the factors that led to the desired goal. The results showed no significant difference in the skeletal relationship. Molar intrusion was not recorded. The open-bite was correct mostly by reclining the upper incisors and by changing their position. Significant differences existed between the obtained results and the mechano-therapy employed. The geometrical model developed on the of the above makes it possible to predict and predetermine the targeted vertical dimension. Furthermore the results show extrusion of the front teeth as another dominant factor.

Complete sequence of one copy of the psbA gene from the thermophilic cyanobacterium Synechococcus elongatus

One copy of the psbA gene which codes for the photosystem II reaction center D-1 protein from the thermophilic cyanobacterium Synechococcus elongatus has been sequenced. It is feasible that a disulfide bridge between D-1 Cys212 and D-2 Cys212 is responsible for the thermostability of the photosystem II reaction center from Synechococcus elongatus.