The clinical implications of sunitinib-induced hypothyroidism: a prospective evaluation

Sunitinib is approved for the treatment of metastatic renal cell carcinoma (RCC) and imatinib-resistant or -intolerant gastrointestinal stromal tumours (GIST). Several studies have identified unexpected rates of thyroid dysfunction with sunitinib treatment. We performed a prospective observational study with the aim of more accurately defining the incidence and severity of hypothyroidism in RCC or GIST patients receiving sunitinib. Thyroid function was assessed at baseline and on days 1 and 28 of each treatment cycle. Thyroid antibodies were assessed at baseline and during follow-up if abnormal thyroid function tests were recorded. Sixteen patients (27%) developed sub- or clinical hypothyroidism and required hormone replacement and 20 patients (34%) showed at least one elevated thyroid-stimulating hormone not requiring therapeutic intervention. Twenty patients (34%) did not develop any biochemical thyroid abnormality. Thus, sunitinib can induce (sub-) clinical hypothyroidism, warranting close monitoring of thyroid function. We propose a new algorithm for managing this side effect in clinical practise.

Clinical impact of trabectedin (ecteinascidin-743) in advanced/metastatic soft tissue sarcoma

BACKGROUND

Patients with advanced or metastatic non-gastrointestinal stromal tumour soft tissue sarcoma (STS) whose disease progresses during or after chemotherapy with doxorubicin or ifosfamide have few options and very limited life expectancy. In this setting, the DNA and transcription interacting agent trabectedin (ecteinascidin-743), isolated originally from the tunicate Ecteinascidia turbinata, has encouraging activity and is now approved in the European Union.

OBJECTIVE

To review evidence for the efficacy of trabectedin in STSs.

METHODS

This review includes material known to the authors through preclinical and clinical work with trabectedin, and information from relevant papers and abstracts.

RESULTS

Pooled analysis of Phase II studies suggests that around 50% of STS patients, failing conventional chemotherapy, experienced long lasting tumour control (either objective response or stabilization of disease) when treated with trabectedin. Twenty-nine per cent of patients were alive at 2 years, and median overall survival was 10.3 months. Leiomyosarcomas and liposarcomas appear particularly sensitive to the drug. In myxoid and round-cell liposarcomas trabectedin seems exceptionally active. A link between specific translocations underlying this disease and the drug's mechanism of action is being explored. Trabectedin is also active in synovial, ewing sarcoma and other translocation-related STSs. Trabectedin is not cardio- or neurotoxic. The neutropenia and hepatic toxicity that occur are non-cumulative, reversible, and lessened by steroid premedication. The lack of cumulative toxicities could make trabectedin appropriate for prolonged treatment.

CONCLUSION

The potential of trabectedin should be further explored in STSs in general and in specific subtypes, both in combination with other cytotoxic agents and with modulators of intracellular signalling.

[TGF-beta2 involvements in open angle glaucoma]

PURPOSE

To emphasize the correlation between TGF beta2 and primary open angle glaucoma (POAG).

METHODS

Observational clinical study on two groups of patients: group I--17 patients with POAG who need surgical approach and group II--16 patients without glaucoma. The groups were homogeneous regarding age and sex. The exclusion criteria were any associated systemic pathology. The concentration of TGF beta2 in the aqueous humor of each patient of both groups was measured by ELISA method.

RESULTS AND DISCUSSIONS

After the comparative analysis we observed that TGF beta2 was more increased in patients with POAG than in patients without the disease. The changes of trabecular extra cellular matrix are induced by many factors. TGF beta2 is a special cytokine witch is believed to increase the fibronectin concentration in the trabecular meshwork and alter the extra cellular matrix turn-over with a final profibrotic effect.

[Age related macular degeneration and C-reactive protein]

C-reactive protein (CRP) is a systemic inflammatory marker associated with the cardiovascular risk profile. Some of the cardiovascular risk factors are linked with the development of age related macular degeneration (AMD), but the correlation between CRP and AMD is not yet well documented. Our current study is trying to emphasize the correlation between plasma CRP levels and the risk for AMD. In our study we used two groups of subjects homogenous by age and gender--group A formed of patients diagnosed with AMD and a group B with normal subjects to whom we measured the plasma levels of C-reactive protein using standard testing with high sensitivity. Our data suggests that there is a correlation between the elevated plasma levels of CPR and the stages of age related macular degeneration possibly implicating the inflammation in the etiopathogenic mechanism.

[Juvenile glaucoma]

We present the case of a 24 years old patient with advanced juvenile glaucoma.

The antitoxoplasma gondii antibodies incidence to the different ocular diseases patients cases of human ocular toxoplasmosis infections in Romania

Toxoplasmosis is an anthropo-zoonosis widely spread around the earth, whose ocular complications are very frequent and are often a first sign of infestation. This is a retrospective statistic research based on the clinical survey and periodic control of a lot of 135 patients with toxoplasmosis, out of which 90 presented ocular toxoplasmosis.

[Specular microscopy and pseudoexfoliative syndrome]

Focal production of pseudoexfoliative material is a stress to the endothelial cells, leading to a secondary degeneration and corneal decompensation. This typically occurs as a bilateral, asymmetrical, slowly progressive corneal endotheliopathy, more frequent in women, after the seventh decade of age. A severe decrease of endothelial cell density occurs--shown by specular microscopy. A persistent high level of the intraocular pressure and the metabolic disturbance in glaucoma affect the endothelium function. A severe decrease of the endothelial cell density occurs (up to 35%) in pseudoexfoliative keratopathy were glaucoma is associated.

[Macular involvement in glaucoma]

PURPOSE

To assess the macular structural changes in primary open angle glaucoma (POAG) patients.

METHODS

A prospective clinical study, 6 months, two groups of patients--group A--case control--healthy subjects, and group B--POAG patients, divided in B1--early glaucoma and B2--advanced glaucoma. The groups were homogeneous about age and sex distribution. In all patients we have performed Humphrey Visual Field, 24-2 Sita Standard, and macular OCT.

EXCLUSION CRITERIA

other ocular or systemic conditions.

RESULTS AND CONCLUSIONS

In POAG group, we found macular changes comparing to the case-control group. Macular assessment in glaucoma is an important element to consider in the future.

[Cataract surgery and postoperative endophthalmitis]

The purpose of this paper is to evaluate the incidence of endophthalmitis after the phacoemulsification.

MATERIAL AND METHODS

Retrospective clinical study that includes all the patients that have been operated and all cases of endophthalmitis survived after that in the period between 1.06.2007-31.05.2008 in the Central Military Hospital.

RESULTS

There were 3 cases of exogenous endophthalmitis after the cataract surgery. In all of these cases: the inflammatory reaction was limited in the anterior chamber; phacoemulsification; there were no accidents in the cataract surgery; it was performed 2.75 mm clear corneal incision; it was no suture.

CONCLUSION

There is a possibility of infections even after phacoemulsification without sutures.

Trabectedin (ET-743): evaluation of its use in advanced soft-tissue sarcoma

Trabectedin (ET-743; Yondelis®) is a novel DNA-binding agent, originally derived from the marine tunicate, Ecteinascidia turbinata, and now produced synthetically. The efficacy of trabectedin in patients with advanced soft-tissue sarcoma has been demonstrated in three Phase II studies involving 189 previously treated patients. A pooled analysis of data from these studies showed that trabectedin induced tumor control (objective responses plus disease stabilization) in approximately 50% of patients; median overall survival was 10.3 months and progression-free survival at 6 months was 19.8%, with 29.3% of patients alive at 2 years. Responses were achieved in patients who were resistant to both doxorubicin and ifosfamide. Trabectedin is generally well tolerated, with adverse events being noncumulative, reversible and manageable. Unlike other commonly used cytotoxic agents, trabectedin is not associated with cardiotoxicity or neurotoxicity and alopecia is rare. Trabectedin is an interesting new anticancer agent that offers much promise for the treatment of advanced soft-tissue sarcoma.

[Glaucoma, hydrocephaly and quadrantanopsias]

The authors present the case of a male patient who was diagnosed with juvenile glaucoma after an ophthalmologic examination. The patient had a previous diagnosis: hydrocephaly.

[Horton disease--ophthalmologic involvement]

The authors present the case of a female patient with giant cell arteritis diagnosed after an ophthalmologic examination.

[Pseudoexfoliative glaucoma]

The pseudoexfoliative syndrome is a systemic anomaly that primarily affects the eye. The presence of the pseudoexfoliative material causes important changes to the cornea, camerular angle, lens and zonules. Pseudoexfoliative glaucoma is aggressive, with great pressure differences between the two eyes, also with important circadian variations of intraocular pressure and has a poor prognostic. We present the case of a patient with pseudoexfoliative glaucoma.

[The future started: nitric oxide in glaucoma]

Nitric oxide (NO) is an important messenger intra and extra molecular implicated in vasodilatation, contractility, neurotransmission, neurotoxicity and inflammation. NO is formed from L-arginine by nitric oxide synthase (NOS). Nitric oxide synthase has three isoforms: NOS- 1 neuronal, NOS-2 inducible and NOS-3 endothelial (role in vasodilatation). Nitric oxide has a demonstrate role in many neurodegenerative diseases like: glaucoma, Alzheimer disease, multiple sclerosis and cerebral-cardio-vascular diseases.

PURPOSE

To investigate the activity of the NOS by immunohistochemistry in patients with primary open angle glaucoma (POAG).

METHODS

Observational, prospective, clinical study, during 9 months on one group of 9 patients with POAG that have underwent filtering surgery - trabeculectomy. The fragments of trabecular meshwork harvested during surgery were studied by immunohistochemistry for NOS. The exclusion criteria at the beginning of the study were any ocular or general pathology associated.

RESULTS AND CONCLUSIONS

After laboratory analyses in patients with primary open angle glaucoma we observed the presence of the activity of NOS in trabecular meshwork. The trabecular distribution of NOS suggests an important role of nitric oxide in the future therapies for the glaucoma. The increase of nitric oxide makes vasodilatation and improves contractility in the trabecular meshwork; the final effect being the decrease of intraocular pressure and on the other hand the contra-apoptotic effect giving neuroprotection.

[Cataract surgery and diurnal fluctuations of IOP in non-glaucoma patients]

PURPOSE

To study the effect of cataract surgery on diurnal IOP fluctuations.

METHODS

Three months clinical, observational, prospective study on one group of 34 patients (34 eyes) with cataract surgery (phacoemulsification technique) performed by the same surgeon. The IOP was measured, every two hours, for each patient (from 8am to 18pm) preoperative and postoperative by Goldman aplanotonometry.

EXCLUSION CRITERIA

not normal open angle in gonioscopy examination and ocular or general associated diseases. The group was homogeneous about age and sex distribution. Statistic analyse was realised by t student test.

RESULTS

Cataract surgery reduced IOP at all time points of measurement (p<0.05). The mean IOP was decreased from a preoperative level of 12.3+/-2.5mmHg to 11.2+/-2.2mmHg at follow-up (p<0.05). The maximum and minimum IOP also showed significant difference. There was no difference in the range of IOP before (3.0+/-1.5mmHg) and after surgery (2.75+/-1.5mmHg) (p<0.05).

CONCLUSION

Cataract surgery significantly decreases IOP and has no effect on diurnal IOP fluctuation.

[Systane and cataract surgery]

PURPOSE

To emphasize and measure the effect of post-cataract surgery Systane treatment.

SETTING

Eye Clinic - Central Clinical Hospital - Bucharest, Romania.

METHODS

Six months clinical, observational, prospective, double-masked study on two groups of patients with cataract surgery (phacoemulsification technique) performed by the same surgeon. Group A (19 patients) received topic treatment with Systane and group B (17 patients) topic treatment with purified water (both with the same presentation form), associated with classical postoperatively treatment. Each patient answered a standardized questionnaire about subjective symptoms of ocular discomfort Several clinical tests were performed for both groups: Schirmer 1 test, tear break-up time (TBUT) and fluorescein staining showing epithelial defects. The groups were homogeneous about the age and sex distribution.

EXCLUSION CRITERIA

any ocular or general associated disease. Statistic analyse: t-student test.

RESULTS

First examination (after one week treatment) show that 73,68% patients treated with Systane did not have subjective symptoms comparing with 47,05% patients without Systane. Final tests (3 week examination) results for subjective symptoms were improved in both groups: 94,73% group A and 70,58% group B (p<0,001). Abnormal values (under 10 mm) for Schirmer 1 test were found in 17,64% of group B patients comparing with 11,76% patients of group A at the first examination. Final Schirmer 1 test results are statistically better in group A 100%-normal values, comparing with 88,23%-normal values in group B. The stability of tear film (TBUT) is altered in 52,94% of purified water treated patients; only in 21,05% of Systane patients existing this problem at the first examination (p<0,001). After 3 weeks treatment 23,52% group B patients and 5,26% group A patients had TBUT altered. Initially fluorescein staining is present in 4 group B patients and in 1 group A patient, comparing with only 1 group B patient in final tests.

CONCLUSIONS

Cataract surgery can affect ocular tear film production and stability by many factors including postoperatively anti-inflammatory classical treatment. Systane prevents the signs and symptoms of tear film insufficiency, decrease post surgery complications and improve epithelial repair. Systane gives a higher satisfaction to the patient associated with a healthy and stable ocular surface.

[Prostaglandin analogues and central corneal thickness]

Prostaglandin analogs reduce intraocular pressure (IOP) by activation of matrixmetalloproteinase enzymes (MMP) and increasing uveoscleral outflow. MMP's were found in cornea and their activation could change the central corneal thickness (CCT).

PURPOSE

To compare the effects of different prostaglandin analogues on central corneal thickness (CCT).

METHODS

Clinical, observational, prospectively and randomised study during 3 month on 26 patients (52 eyes) newly diagnosed with primary open angle glaucoma or ocular hypertension. The patients were distributed in two groups concerning topical treatment: - group I: 15 patients treat with travoprost 0,004%; - group II: 11 patients treat with latanoprost 0,005%. The treatment was administrated daily at 9:00 pm, one drop. The CCT was measured for each patient for 3 times by ultrasound pachimetry: at the beginning of the study, at one month and three months. The groups were homogeneous concerning age and sex distribution. Exclusion criteria were: any topical eye drug usage, history of corneal disease or intraocular surgery. The statistic analyse was realised with Mann-Whitman test.

RESULTS

The mean central corneal thickness for the two groups was similar: 521,27+/-28,54 microm for group I and 522,18+/-27,52 microm for group II. A statistically significant CCT reduction was observed in both groups: 516,88+/-28,61 microm at one month and 515,04+/-27,59 microm at three month for group I; respectively 518,41+/-27,36 microm at one month and 517,98+/-27,86 microm at three month for group II.

CONCLUSIONS

The results of this study show that both classes of prostaglandin analogs reduce the mean CCT, the effect being equivalent for the both studied groups.