Postoperative small-bowel intussusception in children with cancer

The clinical and imaging features of small-bowel intussusception as a complication of abdominal surgery are not well known. Diagnosis may be delayed because symptoms mimic common postoperative complaints. In pediatric cancer patients, the side effects of chemotherapy and symptoms related to the primary malignancy may also obscure the diagnosis. We report the clinical and radiographic features of eight children undergoing evaluation and treatment for solid tumors who developed small-bowel intussusception following laparotomy. These children represent 2.2% of all children and adolescents who underwent laparotomy at a pediatric cancer research and treatment center during a 13-year period. With prompt diagnosis and intervention, morbidity and mortality from this rare but life-threatening postoperative complication can be avoided.

Characterization of a deaminated neuraminic acid-containing glycoprotein from the skin mucus of the loach, Misgurnus anguillicaudatus

Using NMR spectroscopy and mass spectrometry, the major sialic acid of the skin mucus of the loach, Misgurnus anguillicaudatus was found to be 3-deoxy-D-glycero-D-galacto-2-nonulosonic acid (KDN). We have subsequently devised a method to isolate a KDN-containing glycoprotein preparation from loach skin mucus. The method involves the sonication of the skin mucus with 0.05 M Tris-HCl, pH 8.0, to solubilize the glycoprotein, followed by DE52-cellulose chromatography of the extract, Nuclease P1 treatment, and Sepharose CL-4B gel filtration. The purified glycoprotein preparation was found to contain 38.5% KDN, 0.4% NeuAc, 24.6% GalNAc, 3.3% Gal, and 28.2% amino acids (w/w). The amino acid composition of this glycoprotein preparation revealed that it is unusually rich in Thr, and 6 amino acids, Thr, Ser, Glu (or Gln), Pro, Gly and Ala, account for 83% of the total amino acids. This glycoprotein is extremely poor in Cys, Met, Tyr, Phe, Arg, and Trp. Treatment of this glycoprotein with alkali resulted in the destruction of 83% of Thr suggesting that most of the sugar chains in this glycoprotein are linked through Thr. Alkaline borohydride treatment of 100 mg of the glycoprotein preparation, followed by Sephadex G-25 (superfine) gel filtration, yielded two major oligosaccharide alditols, I (15.4 mg) and II (15.6 mg). Using liquid secondary ion mass spectrometry and methylation analysis, I was identified to be KDN alpha 2-->6GalNAc-ol and II, KDN alpha 2-->6(KDN alpha 2-->3)-GalNAc-o1. KDN alpha 2-->6GalNAc is structurally similar to NeuAc alpha 2-->GalNAc found in ovine submaxillary glycoprotein while II represents a novel structure which contains two sialic acids linked to a GalNAc through both alpha 2-->3 and alpha 2-->6 linkages. This structure has never been found in mucin type glycoproteins including mammalian epithelial mucin glycoproteins. This is the first report of the presence of a mucin type glycoprotein which contains KDN instead of NeuAc or NeuGc in fish skin mucus.

Synovial sarcoma in children and adolescents: the St Jude Children's Research Hospital experience

PURPOSE AND METHODS

We reviewed the clinical records and pathologic findings of 37 children and adolescents with synovial sarcoma treated at our institution over a 30-year period to evaluate the prognostic significance of tumor size, invasiveness, histology, and other features.

RESULTS

The 20 male and 17 female patients with synovial sarcoma had a median age of 13.7 years at diagnosis. Primary tumor sites were the extremities (n = 27), trunk (n = 8), and head and neck (n = 2). Disease stage (clinical group) was as follows: group I, n = 21; group II, n = 7; group III, n = 4; and group IV, n = 5. Nineteen patients had invasive (T2) lesions, 20 had tumors more than 5 cm in diameter, and 14 had histologic grade 3 lesions. The estimated 5-year survival rate (+/- SE) for patients with group I or II disease was 80% +/- 9%, compared with 17% +/- 15% for those with group III or IV tumors (P = .0003). An exact log-rank test, adjusted for clinical group, showed that tumor invasiveness and grade independently predicted overall and progression-free survival (P < .05); tumor size was significantly correlated with progression-free survival. A borderline significant relationship with overall survival was found for both tumor size and histologic subtype (P = .09).

CONCLUSION

A controlled trial of adjuvant chemotherapy is merited in children with resected synovial sarcoma (clinical group I or II) who present with unfavorable clinicopathologic features such as large, invasive, or grade 3 lesions. Children with unresected or metastatic disease fare poorly despite multimodality therapy and require novel treatment approaches.

Sialyl Lewis X mimics derived from a pharmacophore search are selectin inhibitors with anti-inflammatory activity

The selectins, a family of adhesion receptors involved in leukocyte extravasation, recognize sialyl Lewis X (sLe(x); NeuAc alpha 2-3Gal beta 1-4(Fuc alpha 1-3)GlcNAc) and related oligosaccharides. We used conformational energy computations, high field NMR, and structure-function studies to define distance parameters of critical functional groups of sLe(x). This sLe(x) pharmacophore was used to search a three-dimensional data base of chemical structures. Compounds that had a similar spatial relationship of functional groups were tested as inhibitors of selectin binding. Glycyrrhizin, a triterpene glycoside, was identified and found to block selectin binding to sLe(x) in vitro. We substituted different sugars for the glucuronic acids of glycyrrhizin and found the L-fucose derivative to be the most active in vitro and in vivo. A C-fucoside derivative, synthesized on a linker designed for stability and to more closely approximate the original sLe(x) pharmacophore, resulted in an easily synthesized, effective selectin blocker with anti-inflammatory activity.

Pediatric brachytherapy. The St. Jude Children's Research Hospital experience

BACKGROUND

The use of interstitial, intracavitary, and permanent placement of radioactive isotopes has become a common practice in adult oncology patients based on numerous reports indicating improved local control and survival when used. These same irradiation techniques and treatments have been infrequently used for children with malignant disease despite known dose localization properties that allow for highly focal irradiation delivery with rapid reduction of the dose in nearby normal tissues. The noted benefit of decreased late complications noted in the adult series is also attractive, especially when considering the treatment of children.

METHODS

Between May, 1981 and December 15, 1992, 46 children with non-CNS primary malignancy received 50 brachytherapy applications for primary therapy (n = 11 sites), as a boost in conjunction with external beam irradiation (n = 16 sites), or as treatment of recurrent disease or a second malignant neoplasm in a previously irradiated region that precluded further external irradiation or for metastatic disease (n = 23 sites). The most common tumor histologies were rhabdomyosarcoma (n = 14), soft tissue sarcoma (n = 10) and retinoblastoma (n = 10). Patient age at implantation ranged from 8 weeks to 24 years; follow-up maintained in all patients and has ranged from 2-115 months (median, 39 months).

RESULTS

Forty-three of 50 sites receiving brachytherapy have maintained continuous disease free intervals, ranging from 2 to 115 months postimplantation (median, 41 months). The seven local failures occurred 2-20 months postimplant (median, 6 months). Severe complications occurred in 12 patients, two which were life threatening but resolved without further incident.

CONCLUSIONS

Based on this ongoing clinical investigation, the authors recommend brachytherapy for selected pediatric malignancies and continue to evaluate the various factors associated with local control, local failures, and complications.

Acroangiodermatitis: a study of ten cases

BACKGROUND

Acroangiodermatitis is a benign vesicular process encountered on the lower extremities that histologically resembles the superficial form of stasis dermatitis, but is clinically characterized by circumscribed violaceous, brown or dusky macules, papules, or plaques. Furthermore, unlike stasis dermatitis, acroangiodermatitis is usually associated with minimal epidermal changes and eosinophils in the inflammatory infiltrate in the dermis. Kaposi's sarcoma, pigmented purpura, vasculitis, and lichen planus are other conditions that should be considered when making a diagnosis of acroangiodermatitis.

METHODS

Ten patients with acroangiodermatitis were referred to us by area physicians. Hematoxylin and eosin, periodic acid-Schiff, Pearl's (an iron stain), and an immunoperoxidase stain for Factor VIII were performed on routinely embedded paraffin sections.

RESULTS

All cases showed new vessel proliferation, perivascular inflammation of superficial and mid-dermis, consisting of lymphocytes, histiocytes, eosinophils, occasional plasma cells, extravasation of red blood cells, and hemosiderin pigment deposition. Dermal fibrosis was observed in all cases. None of the patients showed changes of vasculitis or Kaposi's sarcoma. Only one patient displayed significant epidermal changes of spongiosis and mild acanthosis.

CONCLUSIONS

Acroangiodermatitis is an uncommon entity with peculiar clinical and histologic features and should be confirmed by histologic tests.

Paratesticular rhabdomyosarcoma: delayed effects of multimodality therapy and implications for current management

BACKGROUND

The combined modalities of surgery, chemotherapy, and radiation therapy have greatly improved the survival rate in childhood paratesticular rhabdomyosarcoma, but the incidence of complications and late side effects is a cause for concern.

METHODS

We reviewed the records of 18 patients treated for paratesticular rhabdomyosarcoma at St. Jude Children's Research Hospital between 1962 and 1989. Patients with Group I disease were treated with orchiectomy, retroperitoneal lymph node dissection, and multi-agent chemotherapy; more advanced cases also received radiation therapy with concurrent chemotherapy.

RESULTS

Sequelae included esophageal and common bile duct stricture, inguinal nerve entrapment syndrome, and small bowel obstruction. Short stature was found in all children whose spines were irradiated via para-aortic fields (34-37 Gy) prior to puberty. Two of 18 patients died from treatment complications and one from progressive disease.

CONCLUSIONS

Multimodality treatment offers an excellent prognosis in paratesticular rhabdomyosarcoma, but is associated with significant morbidity and mortality rates. A discussion of therapy components and their application to disease stages suggests possible approaches to optimizing treatment for this therapy-sensitive malignancy.

Primary malignancy of the salivary gland in children

Seventeen pediatric patients with a major salivary gland malignancy (16 parotid, 1 submaxillary) were reviewed. Eight patients presented with carcinoma. The usual presentation was a mass over the affected gland. Six patients had localized disease, which was treated by excision. This was accomplished by either a total or subtotal parotidectomy or resection of the submaxillary gland. Two patients received adjuvant radiation therapy. All six patients with localized carcinoma are alive, without evidence of disease. Two patients presented with metastatic disease and died of the disease despite treatment with multiagent chemotherapy, and in one case, radiation therapy. Nine patients had rhabdomyosarcoma (RMS). The usual presentation was a mass at the angle of the mandible. Five patients had involvement of one or more cranial nerves, and two had concomitant cervical adenopathy. Eight patients had a biopsy and then were treated according to an existing prospective institutional protocol. The ninth patient initially underwent a superficial parotidectomy. Seven patients received radiation therapy. In one patient, rapid progression of the disease precluded this treatment. Seven patients died of progressive local and distant disease 2 months to 2 years (median, 6 months) from the time of diagnosis. Two patients are alive, without evidence of disease, 3 and 7 years after presentation. We conclude that carcinoma should be managed with complete excision. For RMS of the salivary gland, a biopsy should be performed, and treatment should consist of chemotherapy and radiation therapy.

Breast malignancy in children

In 25 years, 18 patients with breast cancer were treated at St Jude Children's Research Hospital, 16 were female and 2 were male. The patients presented with primary malignancy (2), metastatic disease (13), or secondary malignancy (3). One of the females with primary breast malignancy had alveolar rhabdomyosarcoma. She was treated with wide excision and is currently receiving chemotherapy. The other patient presented with non-Hodgkin's lymphoma of the right breast. After biopsy, she was treated with chemotherapy. Of 13 patients with metastatic disease, the primary lesion was rhabdomyosarcoma in nine. One patient each had non-Hodgkin's lymphoma, Hodgkin's lymphoma, neuroblastoma, and signet-cell adenocarcinoma. All patients with metastatic disease to the breast died of the disease. Three females presented with invasive ductal carcinoma of the breast after treatment for Hodgkin's disease. Two underwent mastectomy and are alive without evidence of disease. One patient refused therapy and died of the second malignancy. We conclude that (1) breast malignancies had three distinctly different presentations in our patients, (2) the breasts of pediatric oncology patients should be carefully and routinely examined for metastatic disease, and (3) metastatic disease in the breast of a child is a manifestation of disseminated disease and is associated with an extremely poor prognosis.

Neurofibromatosis type I and malignancy: review of 32 pediatric cases treated at a single institution

Thirty-two cases of neurofibromatosis Type I (NF1) were identified among 6,678 pediatric cancer patients treated at St. Jude Children's Research Hospital over a 29-year period. A total of 35 malignant neoplasms have been diagnosed in these patients. Two of three patients with second malignant neoplasms had colon cancer at the primary or second tumor. Of particular interest are two cases in which both NF1 and malignant peripheral nerve sheath tumors were present in multiple successive generations: a patient with colon cancer and non-Hodgkin lymphoma who has a constitutional abnormality of the p53 gene, and a patient with acute lymphoblastic leukemia with the Philadelphia chromosome and other cytogenetic abnormalities, including the t(8;14). Outcome of patients in the largest subgroup, that of malignant peripheral nerve sheath tumors, was favorable only for those patients having resectable extremity lesions. In contrast, all patients with central nervous system tumors are surviving. These cases reflect the molecular and cytogenetic abnormalities that can be present in NF1 and the variety of tumors that may result in these patients.

Postoperative analgesia following thoracotomy in children: interpleural catheters

The authors retrospectively review their experience in children with the latest addition to the postoperative analgesic armamentarium: interpleural analgesia (IPA). IPA was used in 14 children following thoracotomy. There were 9 boys and 5 girls. Patients varied in age from 2 months to 17 years 4 months (mean +/- SEM = 7.6 +/- 1.6 yr). Catheters were left in place from 10 to 72 hours (mean +/- SEM = 45.1 +/- 4.6 h). Four patients received intermittent bolus doses and 10 patients received a continuous infusion through the interpleural catheters. Adequate analgesia, as judged by both subjective responses (decreased irritability or complaints of pain) and by objective physiologic responses (decreased heart rate, respiratory rate, and systolic blood pressure), was achieved in 13 of 14 patients. Eight of the 14 children required no additional analgesic agents. One child received 2 doses of oral codeine and 4 patients received 2 to 3 doses of intravenous narcotic during IPA. IPA was not effective in one patient who required 6 doses of intravenous meperidine. Patients more than 10 years of age required significantly more (P < 0.05) intravenous narcotic supplementation than patients less than 10 years of age (1.60 +/- 0.50 v 0.14 +/- 0.11 mg meperidine/kg/d). No complications related to placement or subsequent use of IPA were identified in any of the patients. IPA provides effective postoperative analgesia following thoracotomy in children.

Nonrhabdomyosarcoma in children: prognostic factors influencing survival

In approximately 90% of children with nonrhabdo soft tissue sarcoma (NRSTS) local control can be obtained by either surgery alone or with supplemental radiation. The disease-free survival is, however, only about 50%. To determine factors influencing overall survival, we undertook a retrospective review of the 154 children with NRSTS. We used the American Joint Committee on Cancer staging system (1988), using invasiveness, size, and a Pediatric Oncology Group grading system. Using this system we documented that 72 (46%) were noninvasive (T1) lesions. Of these 72 patients 50 (70%) were < or = 5 cm A, and only 9 (18%) had G3 lesions. Overall 7/72 (10%) have died. In contrast to the 82 patients with invasive (T2) lesions, 65 (79%) were > 5 cm (B), with approximately 80% G3. Of all T2 lesions, 56/82 were G3 (65%). Here, overall 58/82 (70%) have died, primarily because 49/58 had G3 lesions. Important prognostic factors include primarily G3 lesion 52/71 (73%) mortality, as compared to 13/83 (15%), G1-2 dying. Children with invasive lesions tended to have larger tumors, 50/65, most of which were higher grades. We feel that patients with histologic grade G3 and T2 lesions should be enrolled in effective chemotherapy protocols.

A "smart needle" to facilitate difficult vascular access in pediatric patients

A new Doppler probe inside a needle was evaluated in a group of infants and children to assess its suitability for subclavian venous access. While the efficient use of this device required learning a new technique, we found the device useful to accurately locate the subclavian vein and differentiate it from the artery in all patients weighing more than 3 kg. This device will be most helpful in cases of difficult access, eg, scar from previous access, obesity, or edema.

Chest tube stripping in pediatric oncology patients: an experimental study

BACKGROUND

Stripping of chest tubes to promote drainage of the thorax of postthoracotomy patients has been routine practice, based on tradition. Recent published findings indicate that significant negative pressures are generated in the tube during stripping that could cause pain, bleeding and possible damage to the patient's lung tissue.

OBJECTIVE

To determine whether pediatric oncology patients whose chest tubes were not stripped would differ in frequency of pain, fever or lung complications from patients who underwent routine tube stripping.

METHODS

Data were collected at multiple points during the first 72-hour postoperative period from 16 patients assigned to the stripped or unstripped groups. Pain was measured by the Faces Pain Scale and the Visual Analogue Scale; temperature, by electronic thermometer; and lung complications, by stethoscope and radiographs. Both groups, which were comparable for age, primary diagnosis and prior history of lung problems, received identical supportive nursing and medical care, with the physicians blind to group assignment.

RESULTS

The two groups did not differ significantly in frequency of pain, incidence of fever, breath sounds or radiographic findings across measurement points. A strong correlation was found between the pain scores using the two instruments.

DISCUSSION

Patients whose tubes were not stripped did not have an increased risk of infection or lung complications. Study findings indicated that stripping did not increase the frequency of pain.

CONCLUSIONS

Stripping of chest tubes as a routine postoperative measure is questioned.

Chest tube stripping in pediatric oncology patients: an experimental study

BACKGROUND: Stripping of chest tubes to promote drainage of the thorax of postthoracotomy patients has been routine practice, based on tradition. Recent published findings indicate that significant negative pressures are generated in the tube during stripping that could cause pain, bleeding and possible damage to the patient's lung tissue. OBJECTIVE: To determine whether pediatric oncology patients whose chest tubes were not stripped would differ in frequency of pain, fever or lung complications from patients who underwent routine tube stripping. METHODS: Data were collected at multiple points during the first 72-hour postoperative period from 16 patients assigned to the stripped or unstripped groups. Pain was measured by the Faces Pain Scale and the Visual Analogue Scale; temperature, by electronic thermometer; and lung complications, by stethoscope and radiographs. Both groups, which were comparable for age, primary diagnosis and prior history of lung problems, received identical supportive nursing and medical care, with the physicians blind to group assignment. RESULTS: The two groups did not differ significantly in frequency of pain, incidence of fever, breath sounds or radiographic findings across measurement points. A strong correlation was found between the pain scores using the two instruments. DISCUSSION: Patients whose tubes were not stripped did not have an increased risk of infection or lung complications. Study findings indicated that stripping did not increase the frequency of pain. CONCLUSIONS: Stripping of chest tubes as a routine postoperative measure is questioned.

Brain metastases in osteosarcoma. Report of a long-term survivor and review of the St. Jude Children's Research Hospital experience

BACKGROUND

Brain metastasis has been considered a rare event in osteosarcoma, although with prolonged survival an increasing incidence has been suggested. There have been no prior reports of long-term survivors among patients with this complication.

METHODS

The authors describe a child treated for osteosarcoma who is alive and free of disease 8 years after the detection of brain metastases. Of 254 patients with primary osteosarcoma referred to St. Jude Children's Hospital between 1962 and 1989, 13 developed brain metastases, all after relapse or recurrence in another site. Concomitant active lung metastases were present in all of the patients except the one long-term survivor, whose pulmonary disease had responded to treatment with cisplatin and doxorubicin. Log-rank analyses were used to compare survival duration and the frequency of brain metastases among patients treated before and after 1982, when effective multiagent therapy was initiated.

RESULTS

Log-rank analyses comparing patients treated before and after 1982 showed that the introduction of effective modern therapy improved survival among patients at risk for brain metastases (i.e., those with recurrent and progressive disease, P = 0.007) but was not associated with a statistically significant increase in the frequency of brain metastases (15.5% versus 4.5%, P = 0.125).

CONCLUSIONS

Although the outlook for patients with this complication remains bleak, the resolution of brain metastases after eight courses of ifosfamide in the patient described in this article suggests that enrollment of selected patients in Phase II trials is merited.

Primary extracranial rhabdoid tumors. Clinicopathologic features and response to ifosfamide

BACKGROUND

Malignant rhabdoid tumor (MRT) is an aggressive, invariably lethal tumor that is resistant to multimodal therapy.

METHODS

The authors reviewed the clinicopathologic features, treatment, and outcome of 13 children (7 boys and 6 girls) with diagnoses of primary extracranial MRT at St. Jude Children's Research Hospital between 1981 and 1990.

RESULTS

The median age at diagnosis was 8 months (range, 10 weeks-18 years). Primary sites included the kidney (seven patients), liver (three patients), soft tissue of scapula, posterior mediastinum, and retroperitoneum. Seven patients had metastatic disease (lungs, six patients; cutaneous hemangioma, one patient). Ten patients had surgical resection of primary tumor (complete, nine patients; incomplete, one patient). Eleven patients had chemotherapy with multiple agents. Three of four chemotherapy responses observed were with regimens containing ifosfamide. Partial responses (PR, > 50% reduction in tumor size) were obtained in one patient who received single-agent ifosfamide during disease relapse (PR lasting 2 months), one patient who received a combination of ifosfamide, carboplatin, and etoposide at diagnosis (PR lasting 5 months), and one patient who was treated with bleomycin, cyclophosphamide, doxorubicin, and vincristine at diagnosis (PR lasting 5 months) and subsequently with ifosfamide in combination with carboplatin and etoposide during disease relapse (PR lasting 4 months). All patients died at a median period of 5 months (range, 0.5-30 months) after diagnosis.

CONCLUSIONS

Based on this review, the authors recommend using ifosfamide alone or in combination with carboplatin and etoposide in front-line therapy for malignant rhabdoid tumor.

A phase II trial of ifosfamide in previously untreated children and adolescents with unresectable rhabdomyosarcoma

BACKGROUND

Children and adolescents with unresectable rhabdomyosarcoma fare poorly when treated with contemporary chemotherapeutic regimens. Evaluation of newly developed agents in these patients is important to improve their outcome. Based on a preclinical rhabdomyosarcoma xenograft model that accurately predicted the activity of new agents, the safety and efficacy of ifosfamide was evaluated as part of a Phase II clinical trial in previously untreated children with unresectable rhabdomyosarcoma.

METHODS

Twenty-two children and adolescents (median age, 9 years) with newly diagnosed unresectable rhabdomyosarcoma (Intergroup Rhabdomyosarcoma Study Group III [n = 15] or IV [n = 7]) received two courses of ifosfamide at a dose of 1.6 g/m2 intravenously for 5 days over a 6-week period. Then the patients were evaluated for response, and additional treatment with surgery, radiation therapy, and multiagent chemotherapy (vincristine, cyclophosphamide, dactinomycin, and doxorubicin) was administered.

RESULTS

Nineteen of 22 patients (86%) had a partial response to ifosfamide given as a single agent. No complete responses to this agent alone were observed. After administration of additional chemotherapy and local control measures (radiation therapy and surgery), the estimated proportion of patients surviving progression-free at 2 years was 63% (95% confidence interval, 37-80%). Ifosfamide was tolerated well; the most frequent toxicity was nondose-limiting myelosuppression. Transient mild renal toxicity infrequently was observed, and no central nervous system toxicity occurred in this group of patients.

CONCLUSIONS

Ifosfamide appears to have significant clinical activity in untreated patients with unresectable rhabdomyosarcomas. These findings provide an accurate estimate of the response rate to single-agent ifosfamide in this group of previously untreated patients and thus provide a foundation for its rational incorporation into multiagent clinical trials. In addition, the potential benefits of this type of new drug development were demonstrated.

Postoperative outcome following thoracotomy in the pediatric oncology patient with diminished pulmonary function

Surgical resection of pulmonary metastatic disease is often indicated in pediatric malignancies. Although several adult studies document increased postoperative morbidity in adults with diminished pulmonary function, there is little information in the pediatric population or in patients with restrictive lung disease. We reviewed the postoperative course following thoracotomy in patients with diminished pulmonary function (FVC, FEV1, or TLC less than 80% predicted). Thirty-two thoracotomies were performed in 19 patients. The preoperative FVC (% predicted) was 68 +/- 3.6 with a postoperative value of 60 +/- 2.4 (P < 0.01). The preoperative FEV1 was 69 +/- 4.2 with a postoperative value of 60 +/- 3.8 (P < 0.01). Although there was a significant drop in pulmonary function tests (PFTs) following surgery, there was not a significantly greater loss when comparing patients with mild, moderate, and severe disease. When considering postoperative morbidity, there were 3 events (prolonged oxygen requirement, need for postoperative ventilation, or persistent air leak) following 20 surgeries in patients with mild preoperative respiratory dysfunction, 5 events (including one death) in the 7 patients with moderate dysfunction, and 3 events following 5 surgeries in patients with severe dysfunction. There was no correlation with a decrease in any specific PFT and the occurrence of postoperative morbidity. Our limited review suggests that aggressive surgical treatment of metastatic pulmonary disease is tolerated even in patients with severe decreases in pulmonary function.

Ferrous sulfate reduces thyroxine efficacy in patients with hypothyroidism

OBJECTIVE

To determine whether simultaneous ingestion of ferrous sulfate and thyroxine reduces the efficacy of thyroid hormone in patients with primary hypothyroidism.

DESIGN

Uncontrolled clinical trial.

SETTING

Outpatient research clinic of a tertiary care center.

PATIENTS

Fourteen patients with established primary hypothyroidism on stable thyroxine replacement.

INTERVENTION

All patients were instructed to ingest simultaneously, a 300-mg ferrous sulfate tablet and their usual thyroxine dose every day for 12 weeks.

RESULTS

After 12 weeks of ferrous sulfate ingestion with thyroxine, the mean level of serum thyrotropin (thyroid stimulating hormone, TSH) rose from 1.6 +/- 0.4 to 5.4 +/- 2.8 mU/L (P < 0.01), but the free thyroxine index did not change significantly. Subjective evaluation using a clinical score showed that nine patients had an increase in symptoms and signs of hypothyroidism; the mean score for the 14 patients changed from 0 to 1.3 +/- 0.4 (P = 0.011). When iron and thyroxine were mixed together in vitro, a poorly soluble purple complex appeared that indicated the binding of iron to thyroxine.

CONCLUSIONS

Simultaneous ingestion of ferrous sulfate and thyroxine causes a variable reduction in thyroxine efficacy that is clinically significant in some patients. The interaction is probably caused by the binding of iron to thyroxine.