Extreme insulin resistance syndrome

Congenital extreme insulin resistance syndrome has rarely been reported in Taiwan. In 1982, a girl of a consanguineous marriage was noted to have increased body hair, an enlarged clitoris, and acanthosis nigricans at birth. Two months later, she received an operation for bilateral polycystic evaries. She was found to have diabetes at 8 years old and was treated with insulin. In March 1999, she was referred to our clinic with growth retardation and poor glycemic control. She had a characteristic face with a saddle nose, broad mouth, large low-set ears, absence of subcutaneous fat, and deformed nails. Although a very high dose of insulin (> 10 IU/kg/day) was used, her glycemic control was very poor (HbA1c 13.8%). Pediatricians should remain alert for the manifestations of extreme insulin resistance.

Evaluation of bone mineral density by quantitative ultrasound of bone in 16,862 subjects during routine health examination

Caucasians and Asians are among those with the highest risk for involutional osteoporosis. To obtain accurate data about the prevalence of osteoporosis or osteopenia in different age groups, a large epidemiological study is necessary. Quantitative ultrasound (QUS) of bone is a promising technique in assessing bone microarchitecture in addition to bone mass. This study had two aims. The first was to establish bone mineral density (BMD) using QUS in subjects with no obvious disease undergoing routine health examination. The second was to determine risk factors for osteoporosis in Taiwan in order that better prevention and treatment measures may be provided for these patients. A prospective study of the risk factors for fracture was conducted in the health examination division of Chang Gung Medical Center in Linkou, Taiwan, from January 1996 to December 1997. Broadband ultrasound attenuation of the right heel was measured with an achilles bone densitometer (Lunar, Nauheim, Germany). A total of 16,862 subjects were examined, including 9,314 women (mean age 51.5+/-11.7 years) and 7,548 men (mean age 51.1+/-12.1 years). The incidence of osteoporosis in all subjects increased from 1.13% in the 21--30-year-old age group to 54.55% in those over 80 years of age. 12.02% of the subjects had osteoporosis and 34.45% had osteopenia. From multivariate analysis, bone density evaluated by QUS showed a relationship with age, gender, body mass index, waist/hip ratio, smoking and frequency of exercise. In conclusion, BMD evaluated by QUS is not found to be higher in Taiwan than elsewhere. The role of QUS in predicting fractures in Taiwan requires further investigation.

The influence of long-term different diabetic therapies on plasma leptin in type 2 diabetic subjects

The aim of this study was to assess the effect of the long-term different diabetic therapies on the plasma leptin level in type 2 diabetic subjects. We measured plasma leptin, body fat and fasting plasma insulin in 96 type 2 diabetic male subjects. They had received the same treatment regimen for more than one year (3.5 +/- 2.3 years, mean +/- SD) and were weight-stable over the previous three months. The distribution was as follows: diet control group: 32, oral hypoglycemic agent (OHA) group: 32, and insulin group: 32. The results showed that the plasma leptin level of the different therapy groups was all positively correlated with body fat. The fasting insulin levels were significantly higher (p < 0.0001) in the insulin group than those in the other two groups. The fasting insulin of the OHA group was also greater than that of the diet group but was not statistically significant. The leptin concentrations were significantly higher in the insulin group (p < 0.001) and OHA group (p = 0.0082) than that in the diet group. The leptin concentrations of insulin group were also significantly higher (p = 0.0021) than that of the OHA group. Stepwise multiple regression analysis revealed that the significant differences in the leptin level of whole group was mainly affected by fasting insulin (p < 0.0001), followed by fat percentage (p = 0.001), fat distribution (p = 0.009) and fasting sugar (p = 0.02), whereas there was no association of leptin with age, height, glycosylated hemoglobin A1c, lipid, or blood pressure. We concluded that long-term different diabetic therapies may affect the plasma leptin level, which is mediated mainly by insulin changes. This insulin effect is independent of body fat and may be superior to the fat effect on plasma leptin in the type 2 diabetic patients.

Outcome after treatment for papillary thyroid cancer

BACKGROUND

To evaluate the results of treatment and the prognostic variables of papillary thyroid carcinoma patients after long-term follow-up.

PATIENTS AND METHODS

Retrospective review of 1,373 thyroid cancer patients. Of the 1,016 papillary thyroid cancer patients, 394 patients received follow-up for more than 5 years, including 305 women (mean age, 38.4 +/- 13.7 years) and 89 men (mean age, 44.0 +/- 13.4 years). Of these papillary thyroid carcinoma patients, 227, 76, 68, and 23 patients were categorized in clinical stages I, II, III, and IV, respectively, at the time of diagnosis.

RESULTS

After treatment, 36 (9.1%) patients died. Only 23 (5.8%) of them died of papillary thyroid carcinoma. The 1-, 5-, 10-, and 20-year survival rates were 0.980, 0.951, 0.901, and 0.731. Mortality factors of the papillary thyroid carcinoma patients related to age, gender, tumor size, and postoperative serum thyroglobulin (Tg) levels. Twenty-four patients progressed from clinical stages I, II, and III to stage IV during the follow-up period. Of these 24 patients, 12 died during the follow-up period. In this study, age, gender, 131I accumulated dose, postoperative serum Tg levels, and the survival rate were demonstrated to be statistically significant between the patients in early stage and advanced stage groups after treatment.

CONCLUSION

Twenty-four of the 47 papillary thyroid cancer patients with distant metastases were diagnosed during the follow-up period. This study suggests that distant metastasis may occur at a serum Tg level of 2.3 ng/mL with thyroxine replacement. Postoperative long-term close follow-up of these patients is recommended.

Hyperinsulinemia and insulin resistance related metabolic syndrome

BACKGROUND

A cross-sectional study in northern Taiwan was conducted to investigate the role of serum insulin level on the development of hyperglycemia, hypertension, obesity and hyperlipidemia.

METHODS

Demographic data (age, gender), body mass index, blood pressure, and laboratory blood tests (uric acid, total cholesterol, triglycerides, glucose and immunoreactive insulin when fasting and two hours after loading 75 gm glucose) were collected. A logistic model or polychotomous model, treating each chronic disease (hyperglycemia, hypertension, obesity and hyperlipidemia) as a dependent variable, were fitted to study the effect of serum insulin level.

RESULTS

Four hundred and twenty one volunteers (women:men = 237:184) were recruited from 1991 to 1993. Women were more obese and had more hyperglycemia, while the frequency of hyperuricemia was lower than of men. Women with a higher level of the sum of fasting and 2-hour post glucose load insulin (SIRI) levels had higher frequencies of glucose intolerance, hypertension, obesity and hyperlipidemia, whereas SIRI was related to only obesity and hyperlipidemia in men. The high plasma SIRI was a risk factor for both impaired glucose tolerance (IGT) and obesity in women. Men with a high plasma SIRI showed a more than three-fold risk of obesity.

CONCLUSIONS

We have observed that a higher serum insulin level was significantly associated with the development of metabolic manifestations (glycemic status and obesity) in a suburban community in northern Taiwan. Men and women with a higher serum insulin level probably had a greater chance of developing obesity, and women had a greater chance of developing IGT.

Identifying differentially expressed genes associated with metastasis of follicular thyroid cancer by cDNA expression array

Patients with follicular thyroid carcinoma have a higher incidence of metastasis than papillary thyroid carcinoma when thyroid cancer is diagnosed. The cDNA expression array technology is utilized herein to profile differentially expressed genes from metastatic human follicular thyroid carcinoma and reveal new tumor markers as well as target genes for therapeutic intervention. Tissue samples were obtained during surgical resection of the thyroid follicular carcinoma and metastatic tissue in the brain of the same patient. Two identical Atlas human cDNA expression arrays were hybridized with 32P-labeled cDNA probes derived from RNA of either primary thyroid cancer or metastatic tissue. Parallel analysis of the hybridized signals allowed us to identify the alteration of gene expression in the metastasis process. Eighteen genes significantly overexpressed and 40 genes significantly underexpressed were identified in the metastatic thyroid cancer. Genes that displayed an altered expression were associated with the processes of cell cycle regulation, apoptosis, DNA damage response, angiogenesis, cell adhesion and mobility, invasion, and immune response. An expression profile of genes that are associated with metastasis process of follicular thyroid cancer was also discussed. Further investigation is required to understand the precise relationship between the altered expression of these genes and the metastasis process of follicular thyroid cancer.

Expression of sodium iodide symporter in benign and malignant human thyroid tissues

The extent of human sodium iodide symporter (hNIS) expression in different kinds of human thyroid cancer tissues and cell lines remains controversial. In this study, polyclonal antibodies to hNIS were used to analyze the expression of symporter protein in benign and malignant human thyroid tissues. Formalin-fixed, paraffin wax-embedded tissue sections were used. Staining was performed using primary polyclonal antibody of rabbit anti-human hNIS diluted in PBS (1:500). Results showed that 2 of 3 normal tissue, 3 of 6 nodular hyperplasia, one follicular adenoma, 3 of 11 papillary thyroid carcinoma, 1 of 5 follicular carcinoma and none of 3 metastatic thyroid epithelial tissue specimens stained positively for hNIS. A higher percentage of positive staining for symporter protein was found in benign thyroid tissues including normal thyroid tissue, nodular hyperplasia, and adenoma (60%). In contrast, papillary and follicular thyroid carcinomas demonstrated lower symporter protein expression (20%). In conclusion, although the number of tissue samples examined in this study was small, hNIS staining found a higher ratio of symporter protein expression in normal and benign thyroid tissues compared with malignant tissues. Determination of the reason for discrepancies in the expression of hNIS in in vivo and in vitro studies will require further investigation.

Detection of mRNA of sodium iodide symporter in benign and malignant human thyroid tissues

Human sodium iodide symporter (hNIS) is an intrinsic membrane protein with 12 transmembrane regions, which shows homology to other sodium-dependent transporters. There is controversy as to the amount of hNIS expression in different kinds of human thyroid cancer tissues and cell lines. In this study, reverse transcription-polymerase chain reaction (RT-PCR) was used to detect mRNA of hNIS in various fresh normal, benign tissues and malignant human thyroid tissues. The forward primer was nested hNIS-5' primer containing the sequences: ACCTGGAAATGCGCTTCAGC. The reverse primer was nested hNIS-3' primer containing the sequences: AAGCATGACACCGCGTGCCA. The results revealed three of three normal tissues, six of eight nodular hyperplasia, two of two hyperthyroidism, one of three follicular adenomas, five of ten papillary thyroid carcinomas, one of one follicular carcinoma and zero of one metastatic follicular tissues demonstrated positive results for hNIS in thyroid epithelial cells. A higher percentage of positive results of the symporter mRNA were found in normal benign thyroid tissues and the thyroid tissues of hyperthyroidism, and nodular hyperplasia (84.6%); however follicular adenoma, papillary and follicular thyroid carcinomas demonstrated a lower percentage of expression in the RT-PCR studies (46.7%). Serum thyrotropin levels and the degree of differentiated components presented in cancer tissues have been mentioned as important factors for hNIS expression in the cancer tissues. The discrepancies of the expression of hNIS in in vivo and in vitro studies need further investigation. In conclusion, hNIS was found in higher ratios in normal and benign thyroid tissues than in the malignant tissues. In addition, the RT-PCR technique hNIS did not detect the transporter in most papillary thyroid cancer tissues.

Long-term effects of ketoconazole in the treatment of residual or recurrent Cushing's disease

Ketoconazole is an imidazole derivative used to treat systemic and superficial mycoses by inhibiting sterol synthesis in fungi. The drug impairs steroid hormone synthesis by blocking mitochondrial P450-dependent enzyme systems. Because of its potent inhibitory effects on adrenal steroidogenesis, ketoconazole is valuable in controlling hypercortisolism. We investigated the effects of long-term treatment of this drug on three patients who had residual or recurrent Cushing's disease after surgical treatment. Ketoconazole was administered orally and adjusted according to individual response and 24-hour urinary free cortisol excretion levels. All three patients had good clinical and biochemical responses to ketoconazole therapy without adverse effects. The 24-hour urinary free cortisol levels were kept around 114.8+/-52.4 microg/24 h, 143.0+/-59.9 microg/24 h, and 122.9+/-79.9 microg/24 h, respectively (reference range, 35 to 120 microg/24 h). All three patients had follow-up magnetic resonance imaging or computed tomography of the pituitary gland, which revealed no significant changes in the sellar region. Daily ketoconazole doses ranged from 200 to 1200 mg per day. Follow-up periods were 65, 86, and 83 months, respectively. In conclusion, ketoconazole is valuable in the long-term treatment of residual or recurrent Cushing's disease when surgical treatment is contraindicated or unsuccessful.

The effects of glurenorm on plasma glucose and lipids in patients with type 2 diabetes mellitus

BACKGROUND

The effects of sulfonylureas on plasma glucose, lipids, and macrovascular complications are of interest. This study was designed to investigate the effects of glurenorm on plasma glucose and lipids in patients with type 2 diabetes mellitus.

METHODS

Nineteen patients, 15 men and 4 women, with an age range of 38-69 years, and with type 2 diabetes mellitus, were studied. Plasma glucose, glycated hemoglobin, and lipids were compared before and 3 months after glurenorm treatment.

RESULTS

Fasting and postprandial plasma glucose, and HbA1c significantly improved after 3 months of glurenorm treatment. The mean (+/- SD) triglyceride level of 10 patients with mild to moderate hypertriglyceridemia decreased from 279 +/- 66 to 219 +/- 100 mg/dl (p = 0.054). The total cholesterol, low-density lipoprotein cholesterol (LDL-C), and high-density lipoprotein cholesterol (HDL-C) of 14 hypercholesterolemic patients did not change significantly. Their mean body weight increased significantly from 65.7 +/- 9.6 to 67.2 +/- 9.9 kg (p = 0.002).

CONCLUSION

Glurenorm was effective for glycemic control but caused weight gain in type 2 diabetic patients. Triglycerides in hypertriglyceridemic patients, and total cholesterol, LDL-C, and HDL-C in hypercholesterolemic patients did not improve after glurenorm treatment.

Trends in the clinical characteristics of patients with papillary thyroid carcinoma in Taiwan

The incidence of thyroid cancer is influenced by many factors including socioeconomic status. As economic conditions have improved in Taiwan, the increased frequency of medical examinations in the general population has led to earlier diagnosis of this indolent malignancy. The purpose of this retrospective study was to compare the clinical characteristics of cases of papillary thyroid cancer diagnosed over a 6-year period from 1993 to 1998 with those patients diagnosed from 1977 to 1992 at a single medical center. Of the 1,485 pathologically verified cases of thyroid cancer from 1977 to 1998, 1, 093 had papillary thyroid carcinoma. The mean age of these patients was 40.4 +/- 14.6 years. In order to identify trends in the characteristics of patients with thyroid cancer, patients were divided into those diagnosed before and those diagnosed after 1993. Patients diagnosed in these two time periods were also categorized into disease-free or non-disease-free groups depending on their status at the end of 1998. Actuarial survival rates were calculated using the Kaplan-Meier method. Multivariate analysis was performed to assess the independent effect of these variables using the Cox model. By December 1998, 61 (5.6%) of the 1,093 patients with papillary thyroid carcinoma had died. Among them, only 35 (3.2%) patients had died of thyroid cancer. The 5-year Greenwood survival probabilities for the groups diagnosed before and after 1993 were 0. 9412 and 0.9817, respectively. The patients diagnosed after 1993 received more aggressive surgical procedures, had smaller tumor size, lower postoperative thyroglobulin levels, less advanced clinical stage at the time of diagnosis, showed more disease-free survival, and a lower mortality rate. In conclusion, the results of this study show that patients with a diagnosis of papillary thyroid cancer after 1993 had a smaller tumor size and a better prognosis than those diagnosed before 1993. This finding emphasizes the importance of early detection in thyroid cancer.

Overexpression of thyroid hormone receptor beta1 is associated with thyrotropin receptor gene expression and proliferation in a human thyroid carcinoma cell line

To correlate the differentiation phenotype of two human thyroid cancer cell lines with their expression of various molecular markers, we analyzed the mRNA levels of four thyroid-specific genes, including thyrotropin receptor (TSHR), thyroglobulin (Tg), thyroid transcription factor-1 (TTF-1), and paired-box containing transcription factor-8 (PAX-8) genes. The results showed a differentiation-status-related pattern in which a well-differentiated cell line (WRO) expressed all the four genes, in contrast to an anaplastic cell line (ARO) that expressed TTF-1 and reduced levels of TSHR, but no Tg or PAX-8 genes. Furthermore, to verify the finding of concomitant loss of beta subtype thyroid hormone receptor (TRbeta) and TSHR gene expression in neoplastic thyroid tumors (Bronnegard et al. 1994), we examined the expression levels of TRbeta1 gene in these cell lines. Whereas the WRO cells produced an abundant amount of TRbeta1 protein detectable by immunoprecipitation, the ARO cells produced none. This new observation prompted us to investigate whether overexpression of TRbeta1 protein in ARO cells might produce changes in the differentiation phenotypes. We found that the level of expression of the TSHR gene and the proliferative index of ARO cells were significantly upregulated in the cells stably transfected with wild-type TRbeta1. These findings suggest that TRbeta1 protein overexpression can affect the differentiation phenotypes and induce more efficient cell proliferation of the anaplastic ARO cells.

Expression of sodium iodide symporter in metastatic and follicular human thyroid tissues

Active iodide uptake across the basal membrane mediated by human sodium iodide symporter (hNIS) has been shown to be a process coupled with the flow of sodium. There is still controversy as to the amount of hNIS expression present in different kinds of human thyroid cancer tissues. In this study, we present a 58-year-old women with follicular thyroid carcinoma with vertebra and skull metastases. 201Tl and 5 mCi 131I scans clearly demonstrated the metastatic lesions in the brain of this patient. Thyroid and metastatic tissues were then obtained for this study, which is aimed at comparing the iodide trapping ability in vivo and in vitro of hNIS, and then comparing their expression in both thyroid tissue and metastatic tissues. Polyclonal antibodies to hNIS and competitive RT PCR were used to analyze the symporter protein and mRNA expressed in follicular human thyroid and metastatic tissues. Positive staining of the symporter protein was performed in the follicular thyroid carcinomas, otherwise, the metastatic tissues could not have demonstrated the protein in the staining. Follicular thyroid carcinoma tissues from thyroid were revealed around 5 pg hNIS expressed in follicular thyroid carcinoma tissues from the thyroid. Otherwise, there was almost an absence of hNIS expression in the metastatic tissue. These discrepancies of the expression in hNIS in vivo and in vitro studies need further investigation.

Characteristics of thyroid carcinomas in aging patients

BACKGROUND

To investigate the clinical features of thyroid cancer in aging patients and to present the results of treatment. From this we can provide bases for earlier diagnoses and better treatment of thyroid malignancies in older patients.

MATERIALS AND METHODS

In this study a retrospective analysis was performed with 204 thyroid cancer patients aged 60 years or older (132 women, with a mean age of 68.3 +/- 6.6 years; 72 men, with a mean age of 67.0 +/- 5.3 years).

RESULTS

Of the 204 patients, 142 had well-differentiated thyroid carcinomas (96 papillary thyroid carcinomas, 43 follicular carcinomas, three Hürthle cell carcinomas) and three medullary carcinomas. Sixty-nine (33.8%) of the 204 patients died after treatment. Of these, three patients died of causes not related to thyroid cancer. For well-differentiated thyroid carcinomas, male gender, follicular carcinoma, and a larger tumour size indicated a poor prognosis. Of the 59 non-well-differentiated thyroid carcinomas, 39 were anaplastic thyroid carcinomas, nine metastatic cancers of the thyroid, seven lymphomas, and four squamous cell carcinomas. After treatment, 40 (67.8%) of the 59 patients died. In multivariant analysis of the differences in clinical parameters between aging and younger thyroid cancer patients, the current status, tumour size, follow-up period, sex, and stage at diagnosis were independent factors. From this data the delayed diagnosis of aging patients with thyroid cancer was of note when compared with younger patients.

CONCLUSION

Thyroid cancer in older patients is not a benign clinical disorder. Early diagnosis and urgent aggressive treatment are recommended courses of action for this type of cancer, especially for non-well-differentiated thyroid cancers.

Octreotide treatment for a malignant islet cell tumor with variable hormone secretion: case report

It is well known that an islet cell tumor can secrete multiple hormones depending on its cell type. We report the case of a 70-year-old woman who initially presented with peptic ulcer symptoms, an elevated serum gastrin level, and multiple liver tumors. Liver biopsy and distal pancreatectomy were performed, and the pathological diagnosis was malignant islet cell tumor. Additionally, the immunohistochemical staining revealed scattered positivity for gastrin, and then also positivity for insulin 14 months later. A subsequent hypoglycemic episode and elevated serum gastrin and insulin levels suggested that the disease had developed into a condition of multiple hormone secretion. The plasma gastrin and insulin levels decreased from 584 pg/ml and 90.8 microIU/ml to 49.1 pg/ml and 20.9 microIU/ml, respectively, 5 days after treatment with subcutaneous octreotide 100 micrograms every 6 to 8 hours. In addition, follow-up computed tomography showed shrinkage of the metastatic liver tumors. In conclusion, we found a case of malignant islet cell tumor with variable hormone secretion which could be effectively controlled with octreotide.

Factors related to the survival of papillary and follicular thyroid carcinoma patients with distant metastases

There is limited clinical information comparing presentations and results of treatment of papillary and follicular thyroid carcinoma patients with distant metastases. We retrospectively analyzed data of 1,257 thyroid cancer patients who received their treatment and follow-up at Chang Gung Memorial Hospital. We found 992 patients with papillary carcinoma and 205 patients with follicular thyroid carcinoma. Of these, 68 patients with papillary thyroid carcinoma (6.9%) had distant metastases at the time of diagnosis or during the follow-up period. Of the follicular thyroid carcinoma patients, 69 (33.7%) had distant metastases. Of the 68 patients with papillary carcinoma, only 33 were categorized as stage IV at the time of diagnosis. Nine of the patients were categorized as clinical stage I carcinoma, 10 as stage II, and 16 as stage III. Sixteen patients (23.5%) died during the study period, all but 2 of thyroid cancer. Twelve of the 68 patients were disease-free after treatment. Of the 69 patients with follicular thyroid carcinoma, 58 were categorized as stage IV at the time of diagnosis. Six of the patients were categorized as clinical stage I carcinoma, 2 as stage II, and 3 as stage III at the time of diagnosis; all of these patients deteriorated to stage IV during the follow-up period. Of the 42 patients with follicular thyroid carcinoma involving bone, 24 presented with bone metastases during the initial diagnosis. After treatment, 25 of 69 patients with follicular carcinoma died of follicular carcinoma. Only 3 patients were disease-free after the treatment. In patients with follicular carcinoma, only tumor size was an important prognostic factor. In this study, 8 patients categorized as clinical stages I to III at the time of operation had thyroglobulin (Tg) levels less than 5 ng/mL and developed distant metastases during the follow-up period. In conclusion, at diagnosis a large group of Asian patients with metastatic well-differentiated thyroid cancer was more likely to have follicular than papillary histology, and that, as expected, metastases from follicular cancer were present earlier and more frequently, were more likely to involve bone, were more likely to be associated with mortality, and were linked to tumor size but not gender. Also unlike some other reports, treatment producing a low Tg did not always produce a good outcome. More aggressive surgical procedures may be able to improve outcomes.

Diagnosis of papillary and follicular thyroid cancers

In general, thyroid cancer patients are usually presented with asymptomatic neck nodules. A differential diagnosis between malignant and benign thyroid disorder is very important for these patients. In the preoperative diagnosis, thyroid ultrasonography has been proven to be quite useful in the detection of thyroid lesions. There are two major reasons to perform thyroid ultrasonography before fine needle aspiration cytology (FNAC): to detect deep-seated small nodules, and to realize the nature of the clinically palpable nodules. Despite the limitations of aspiration cytology in the diagnosis of primary neoplasms, using this method can increase diagnostic accuracy to 92.89% in thyroid malignancy cases. Most thyroid malignancies can be diagnosed with FNAC, except for cases involving follicular thyroid cancer and Hürthle cell carcinoma. Although the serum thyroglobulin level has been used as a post-operative, well-differentiated thyroid cancer tumor marker, the assay cannot be used for preoperative diagnosis of thyroid carcinoma. Two dimensional gels electrophoresis has also been used as a diagnostic tool to elucidate tumor-specific proteins in the detection of well-differentiated thyroid cancers. The results of this technique need further investigation. In conclusion, and at the present time, FNAC is considered a useful tool in the pre-operative diagnosis of most thyroid cancers. For patients with follicular or Hürthle cell carcinomas, we need to develop further specific tumor markers for differentiating them between benign and malignant nodules.

Identification of familial hypercholesterolemia in Taiwan: report of eleven cases

BACKGROUND

Familial hypercholesterolemia is associated with a very high risk of premature coronary heart disease. In order to identify cases of familial hypercholesterolemia in Taiwan, we screened the hyperlipidemic patients in our metabolic clinics.

METHODS

Hyperlipidemic patients were screened in the metabolic outpatient department and the cases which fulfilled the clinical criteria of definitive or possible familial hypercholesterolemia were further analyzed. Their clinical characteristics, including age, gender, physical findings, past history of coronary heart disease or cerebrovascular accident (CVA), family history, and lipid profiles before and after medical treatment, were reviewed.

RESULTS

Eight women and 3 men fulfilled the diagnostic criteria. The mean age at diagnosis was 51.1 +/- 11.9 years old. Tendon xanthomas were found in 5 patients with definitive familial hypercholesterolemia. Coronary heart disease was confirmed in one patient and old CVA was noted in another 2 patients. The mean total cholesterol level was 390.3 +/- 88.9 mg/dl and the mean low density lipoprotein-cholesterol (LDL-cholesterol) level was 309.6 +/- 89.9 mg/dl before treatment. After a mean treatment duration of 45.2 months, the mean total cholesterol level and LDL-cholesterol level were 326.8 +/- 87.8 mg/dl and 249.1 +/- 91.1 mg/dl, respectively.

CONCLUSION

Clinically diagnosed familial hypercholesterolemia indeed exists in Taiwan. As compared to other reports, the mean age at diagnosis in our series was older and the majority of patients were women. Most patients were not vigorously treated and the family members were not thoroughly screened. Adequate treatment of patients with familial hypercholesterolemia in clinical practice and screening their family members are crucial in preventing new or recurrent coronary heart disease.

Recurrent fetal thyrotoxicosis in a woman with Graves' disease: case report

The thyroid stimulating immunoglobulins are generally believed to be the cause of hyperthyroidism in Graves' disease. Placental transfer of these antibodies from a mother with autoimmune thyroid disease can result in fetal thyroid disorders. We report the case of a 31-year-old woman who had a history of Graves' disease. She received thyroxine therapy for post thyroidectomy hypothyroidism. Two years after the thyroidectomy, she became pregnant. Unfortunately, intrauterine fetal death occurred in midgestation. One year later, she became pregnant again. In the 26th week of gestation, fetal thyrotoxicosis was diagnosed using clinical pictures, including fetal tachycardia and cardiomegaly, and a hormonal evaluation of a periumbilical blood sampling (T4: 18 micrograms/dl, T3: 65.3 ng/dl, TSH: < 0.03 microU/ml) was performed. Antimicrosomal antibodies were not detectable in either the maternal or fetal blood. In this case, high levels of TBII were detected during pregnancy and crossed the placenta to result in a thyrotoxic fetus in the second pregnancy. We recommend that both the regular monitoring of the thyrotropin receptor antibodies of pregnant women with a history of autoimmune thyroid disease, and routine measurements of the fetal heart rate and intrauterine growth during gestation be mandatory for the early detection of fetal thyroid disorders. Cordocentesis for measuring fetal thyroid function is helpful in reaching a definite diagnosis and for guiding therapy.

Recurrent cervical carcinoma after primary radical surgery

OBJECTIVE

This study was undertaken to investigate prognostic factors in patients with recurrent cervical carcinoma who had undergone a primary radical hysterectomy and pelvic lymphadenectomy.

STUDY DESIGN

A retrospective analysis of 177 patients with recurrent cervical carcinoma after radical hysterectomy and pelvic lymphadenectomy for stage IB to II disease at a single institution was performed to evaluate clinicopathologic parameters, time to recurrence, pattern of failure, use of salvage therapy, and survival after recurrence.

RESULTS

The 5-year survival rate from diagnosis of recurrence in this series was 10.1%. Survival after recurrence was significantly decreased in patients with pelvic lymph node metastasis at primary surgery and adenocarcinoma-adenosquamous carcinoma histologic type. Patients with extravaginal recurrences receiving chemoradiation for recurrent cervical carcinoma had significantly better outcomes than those receiving radiation alone. Six patients who had a distant relapse at a sole site had prolonged survival after salvage therapy, which was accomplished by chemoradiation, surgery plus radiotherapy, or surgery alone.

CONCLUSIONS

Our results demonstrate the benefit of adding chemotherapy to radiotherapy in the treatment of recurrent cervical carcinoma. Salvage multimodality treatment should be offered to selected patients who have isolated relapse at a single distant site.

Diagnosis and management of 34 Hürthle cell tumors

BACKGROUND

Controversies still exist around the diagnosis and management of Hürthle cell tumors. The aim of this study is to reexamine our experience to improve our methods in the future.

METHODS

We treated 34 patients with verified Hürthle cell carcinoma and adenoma at Chang Gung Memorial Hospital, Linkou from 1990 through 1996. Clinical characteristics, thyroid ultrasonogram, 131I, 201Tl, 99mTc-methoxy-isobutyl-isonitrile (MIBI) and 99mTc-thyroid scan, fine needle aspiration cytology (FNAC) and histology results were analyzed.

RESULTS

Female predominance (82.4%) was noticed among our Hürthle cell tumors. Nine (26.5%) patients had carcinoma. The median size of carcinoma was 4.0 cm, which was significantly larger than the median 3.0 cm for adenoma. No significant differences were found between gender, age, multiplicity or echogenicity between two groups. All 12 adenoma and 3 carcinoma patients who received pre-operative 99mTc and/or 131I thyroid scan showed cold nodules. The sensitivity and specificity of detection Hürthle cell carcinoma as indeterminate and malignant using FNAC was 78% and 18% respectively. These improved to 100% and 86% using frozen sections. One carcinoma patient developed neck lymph node metastasis, with normal serum thyroglobulin, negative 131I but positive 201Tl and 99mTc-MIBI whole body scans. Another one showed mediastinum metastasis with elevated serum thyroglobulin, detected using 131I scan, revealed successful regression after 131I therapeutic scan.

CONCLUSION

Tumor size of carcinoma is significantly larger than adenoma. All patients with FNAC suggestive of Hürthle cell tumors should receive surgery for histological diagnosis to differentiate carcinoma from adenoma. Therapeutic radioiodine ablation is indicated whenever there is 131I uptake by tumor cells.

Detection of human papillomavirus types 16 and 18 mRNA in peripheral blood of advanced cervical cancer patients and its association with prognosis

PURPOSE

To evaluate the feasibility of detecting human papillomavirus E6 (HPVE6) gene mRNA in the peripheral blood of patients with locally advanced cervical cancer, and the relationship of the circulating HPV viral-specific mRNA with clinicopathologic factors and prognosis of locally advanced cervical cancer.

PATIENTS AND METHODS

The presence of types 16 and 18 HPVE6 gene mRNA was determined by reverse transcription followed by nested polymerase chain reaction. Thirty-five patients with locally advanced cervical cancer who were positive for HPV type 16 or 18 DNA were included in the study. All patients received external-beam radiation therapy followed by intracavitary brachytherapy.

RESULTS

Eighteen (51.4%) of 35 HPV DNA-positive cervical cancer patients had HPV-specific mRNA in their peripheral blood cells, compared with none of 17 HPV DNA-negative cervical cancer patients and none of 12 control volunteers. The presence of HPVE6 gene mRNA in peripheral blood was associated with bulky tumor volume (> 4 cm) and pelvic lymph node metastasis (tumor volume, P = .03; lymph node status, P = .03). After a median follow-up of 22 months, patients who were positive for peripheral-blood HPVE6 gene mRNA had a significantly higher risk of recurrence than those who were negative (10 of 18 v three of 17, P = .02; mean recurrent time, 20.7 months v 12.6 months, P = .02). There was also a statistically significant association of peripheral-blood HPVE6 gene mRNA positivity with distant metastasis (eight of 18 vone of 17; P = .01).

CONCLUSION

Results of this study seem to suggest that the presence of HPVE6 gene mRNA in peripheral blood may provide an early marker that identifies patients who are at risk for metastasis.

Prognostic variables of papillary and follicular thyroid carcinoma patients with lymph node metastases and without distant metastases

From 1977 through 1995, 1,013 thyroid carcinoma patients received treatment and were followed up at Chang Gung Medical Center in Taiwan. To evaluate the prognostic variables of papillary and follicular thyroid carcinomas with limited lymph node metastases, a retrospective review of these patients was performed. Of these patients, 910 had papillary or follicular thyroid carcinoma, and 119 patients were categorized as clinical stage 2 with limited neck lymph node metastases only at the time of diagnosis. The patients were categorized into two groups as no recurrence and local recurrence or distant metastasis at the end of 1997. After the operations, radioactive iodide (131I) treatments were performed in 114 patients and external radiotherapy for neck region or distant metastases in 18 patients. The median follow-up period of these patients was 5.4 years. Clinical variables were coded in our computer for statistical analysis. After the treatments, 93 patients remained disease-free; 10 were in stage 2; 5 in stage 3; and 11 aggravated to stage 4. Of the clinical variables, age, post-operative first 1311 uptake scans, and 1-month post-operative thyroglobulin levels revealed statistically significant differences between the group which improved and the group which did not. During the follow-up period, five patients died; three patients died of thyroid cancer and two died of intercurrent diseases. Patients with papillary thyroid carcinoma revealed a higher percentage of lymph node metastases. Although limited lymph node metastases did not influence survival rate, patients with poor prognostic factors need more aggressive treatment to avoid progression of the cancer.

Somatostatin and octreotide modulate the function of Kupffer cells in liver cirrhosis

In our previous studies we have shown that somatostatin and octreotide modulate the function of peritoneal macrophages and Kupffer cells in noncirrhotic livers. However, the effects of somatostatin on the Kupffer cells in cirrhotic livers are not known. In the present study, Kupffer cells, obtained from male rats with carbon tetrachloride-induced cirrhotic livers, were treated in vitro with somatostatin or octreotide and their effects on the release of nitric oxide, tumor necrosis factor-alpha (TNF-alpha) and peroxide (H2O2) determined. At concentrations of 10(-13) or 10(-10) to 10(-6) M of somatostatin or 10(-12) to 10(-10) M, or 10(-6) M of octreotide, the amount of nitric oxide released by Kupffer cells was significantly suppressed relative to that of untreated cells. Kupffer cells treated with less than 10(-12) M or greater than 10(-12) M of somatostatin or octreotide released less TNF-alpha compared to the untreated controls. In addition, zymosan-induced H2O2 release by Kupffer cells treated with 10(-9) to 10(-7) M somatostatin or with 10(-15) to 10(-13) M and 10(-9) to 10(-7) M of octreotide was greater than that of the untreated controls. These findings demonstrate that somatostatin and octreotide modulate the release of nitric oxide, TNF-alpha and H2O2 by Kupffer cells in cirrhotic livers depending on the concentrations of hormones used.