The influence of epidermal growth factor receptor and tumor differentiation on the response to accelerated radiotherapy of squamous cell carcinomas of the head and neck in the randomized DAHANCA 6 and 7 study

BACKGROUND AND PURPOSE

Reduction of the overall treatment time of radiotherapy has increased locoregional control and disease specific survival in squamous cell carcinomas of the head and neck (HNSCC), but the response is heterogeneous. EGFr is often overexpressed in HNSCC and has been related to the repopulation taking place during radiotherapy. The aim of the current study was to address the influence of EGFr and histopathological differentiation when the overall treatment time of radiotherapy was moderately reduced.

PATIENTS AND METHODS

Eight hundred and three patients with representative pretreatment tissue samples from the randomized DAHANCA 6 and 7 study of 5 vs. 6 fx/wk of radiotherapy. EGFr was visualized using immunohistochemistry and separated into high and low expression before correlation with clinical data.

RESULTS

Tumors with high EGFr (84%) responded better to moderately accelerated radiotherapy, than carcinomas with low EGFr, using locoregional control as endpoint and a similar pattern was seen, stratifying by well/moderate vs. poor tumor differentiation. Therefore, a combined parameter was constructed showing a more prominent separation of response: tumors with high EGFr and well/moderate differentiation did benefit from moderate acceleration of treatment regarding locoregional control, HR 0.54 (0.37-0.78), whereas such an effect was not seen in tumors with low EGFr and/or poor differentiation, HR 0.8 (0.51-1.25). These results reflected the disease specific survival as well and were confirmed in multivariable analyses.

CONCLUSIONS

Moderately accelerated fractionation is superior to conventional treatment in HNSCC but the response is heterogeneous and may be predicted by high expression of EGFr and well/moderate tumor differentiation.

The role of epidermal growth factor receptor and E-cadherin for the outcome of reduction in the overall treatment time of radiotherapy of supraglottic larynx squamous cell carcinoma

Reduction of the overall treatment time (OTT) of radiotherapy results in increased T-site control in squamous cell carcinomas of the head and neck (HNSCC). However, the response is heterogeneous and accelerated repopulation of clonogenic tumour cells during therapy may be one of the factors determining this response. The aim of the present study was to identify the influence of the epidermal growth factor receptor (EGFr) and E-cadherin for T-site control when the OTT was reduced and whether the markers add information to the histopathological grading in selecting patients for accelerated radiotherapy. A total of 209 patients from randomized DAHANCA-trials with supraglottic larynx squamous cell carcinomas treated with primary radiotherapy with different OTT of 9(1/2), 6(1/2), and 5(1/2) weeks. Available formalin-fixed paraffin embedded tumour tissues were re-evaluated for histopathological characteristics and stained for EGFr and E-cadherin. Data were correlated with patient and tumour characteristics and 5-year T-site control. EGFr and E-cadherin were not associated with patient or tumour characteristics except that EGFr correlated to carcinomas with a well to moderate histopathological feature. Tumours with high EGFr or low E-cadherin did benefit from reduced OTT, and the combination of the two (high EGFr and low E-cadherin) had the most significant acceleration of treatment effect, compared with tumours with other combinations of EGFr and E-cadherin expression. Tumours with high expression of EGFr and low expression of E-cadherin showed the most significant increase in T-site control when the overall treatment time of radiotherapy was reduced, and the markers may be useful for selecting patients who will benefit from accelerated radiotherapy.

KID Syndrome: Report of a Scandinavian Patient with Connexin‐26 Gene Mutation

Keratitis-ichthyosis-deafness syndrome is a rare genodermatosis, which has recently been connected with mutations in the connexin-26 gene, GJB2. We present a 15-year-old boy with erythroderma, hyperkeratotic plaques and deafness. Sequencing analysis showed a heterozygous missense mutation D50N (148G>A) in GJB2. The boy has not yet manifested characteristic eye lesions but his case shows that tardy development of eye signs should not preclude a clinical diagnosis of keratitis-ichthyosis-deafness syndrome. Besides the typical clinical features, the patient's height was above the 98th percentile and he displayed a delayed bone age in his hands. Additionally, he suffered from migrainoid headaches and the results of a magnetic resonance scan of the cerebrum showed he had a large cisterna magna which probably occurred independently from the syndrome. This patient is the first Danish patient in whom the keratitis-ichthyosis-deafness syndrome has been verified by mutation analysis.

Quantification of melanoma mRNA markers in sentinel nodes: pre-clinical evaluation of a single-step real-time reverse transcriptase-polymerase chain reaction assay

Although reverse transcriptase-polymerase chain reaction (RT-PCR) analysis of melanocyte-associated mRNA can detect sentinel node melanoma metastases, most published assays are semi-quantitative methods of unknown sensitivity and precision, unsuitable for clinical use. We describe a single-step real-time quantitative RT-PCR assay for MART-1 and tyrosinase mRNAs, suitable for sentinel node analysis in a clinical setting. Using serial dilutions of melanoma cell line SK-MEL-28 RNA in water as a calibrator, we obtained linear calibration curves covering the range 0.5 to 10,000 arbitrary units (SK-MEL-28 melanoma cell equivalents). The sensitivity limit was 0.32 (MART-1) and 5 (tyrosinase) arbitrary units. Analytical imprecision was between 11% and 34%. MART-1 PCR efficiency was unaffected when samples were diluted with negative lymph node RNA rather than water, whereas tyrosinase PCR efficiency was halved. To evaluate the clinical suitability of our assay, we quantified melanocyte mRNAs in sentinel nodes with histologically verified micrometastases (n = 10) and benign nevus inclusions (n = 10), and in sentinel nodes without evidence of intranodal melanocytes (n = 10). We found significant differences in median melanocyte-derived mRNA levels comparing the three types of lymph nodes, suggesting that this quantitative molecular protocol may increase assay precision and be useful for the clinical evaluation of sentinel nodes.

Molecular profiles as predictive marker for the effect of overall treatment time of radiotherapy in supraglottic larynx squamous cell carcinomas

BACKGROUND AND PURPOSE

Reduction of the overall treatment time of radiotherapy increases the probability of local tumour control, but it does not benefit all patients. Identification of molecular marker profiles may aid in the selection of patients likely to benefit from accelerated radiotherapy.

PATIENTS AND METHODS

Two hundred and nine patients with SCC of the supraglottic larynx received primary radiotherapy in the randomised DAHANCA trials to 66-68 Gy, 2 Gy/fx but with different overall treatment times of 9.5 week, 6.5 week and 5.5 week. Formalin-fixed paraffin embedded tumour slides were assessed by immunohistochemistry for expression of EGFr, E-cadherin, KI-67 and Bcl-2 and the TP53 mutation profile was determined using PCR-amplification, DHPLC and sequencing. The profiles were established using a hierarchical clustering algorithm with a Bayesian information criterion for cluster number optimisation.

RESULTS

Full data-set were available for 158 patients and four almost equally sized clusters were identified. One of these clusters differed significantly with respect to local control compared to the other clusters: the cluster (n=36) characterised by wild type TP53, low expression of E-cadherin and Bcl-2, moderate KI-67 and EGFr, was not influenced by a reduction in the overall treatment time (P=0.6) whereas the other clusters showed an increase in local control when the overall treatment time of radiotherapy was reduced. This was also partially seen with disease specific survival as the endpoint.

CONCLUSIONS

Molecular marker profiling may aid in the selection of patients that will benefit of a reduction in overall treatment time of radiotherapy in SCC of the supraglottic larynx.

Expression of integrins and E-cadherin in squamous cell carcinomas of the head and neck

Integrins and cadherins are cell adhesion molecules suggested to play an important role in malignant progression and tumour differentiation. Our aim was to characterise the pattern of expression and the relations between integrin beta1, beta4, beta6 and E-cadherin and the different histopathological features important when judging tumour differentiation, using a well-defined scoring system. Formalin-fixed paraffin-embedded pre-irradiation biopsies from 85 patients with head and neck squamous cell carcinomas (HNSCC) were stained and evaluated for the expression of integrin beta1, beta4 and beta6 and E-cadherin. The integrins were upregulated in carcinomas compared to the adjacent mucosa and E-cadherin was downregulated. However, differences were found within the tumour: Expression of E-cadherin was lost and the three integrins were upregulated at the tumour borders, compared to central parts of the tumour biopsy. Expression of the integrins did not correlate with tumour or histopathological parameters, whereas expression of E-cadherin was correlated with high degree of keratinisation, high nuclear maturation and few mitoses - factors that characterise well-differentiated carcinomas -and E-cadherin can therefore be considered as a marker of differentiation. Furthermore, loss of adhesion expressed by low E-cadherin and integrin beta4 correlated with the presence of nodal metastases at the time of diagnosis.

Alemtuzumab-induced remission of both severe paraneoplastic pemphigus and leukaemic bone marrow infiltration in a case of treatment-resistant B-cell chronic lymphocytic leukaemia

BACKGROUND

Alemtuzumab (MabCampath; ILEX Pharmaceuticals, Geneva, Switzerland) is a humanised monoclonal antibody directed against CD52. It belongs to a new group of monoclonal antibodies with anti-neoplastic effects used in chronic lymphocytic leukaemia (CLL) either as first-line treatment or in those cases resistant to alkylating drugs. Paraneoplastic pemphigus (PNP) is a severe mucocutaneus disease mostly associated with B-cell lymphoproliferative disorders. Independent of the course of the underlying malignancy, this disease is often resistant to conventional immunosuppressive treatment and may lead to death as a result of infectious complications.

CASE PRESENTATION

We report a case where an ongoing long-term remission of PNP has been induced by alemtuzumab in a patient with an underlying B-CLL. A 68-yr-old male with a 4-yr history of B-CLL presented with a widespread blistering eruption on the extremities and trunk and a severe stomatitis. The diagnosis of PNP relied on the clinical, histological and direct immunofluorescence findings. Despite intensive treatment strategies with various immunosuppressive drugs and antibiotics, blisters continued to develop and the patient was deteriorating. When treated with alemtuzumab the mucocutaneous lesions healed almost completely within a few weeks and the patients' general condition improved significantly. After 12 wk of treatment with alemtuzumab, the CLL infiltration of the bone marrow previously quantified at 75-80% remitted completely. Twelve months later, the patient was still in remission with only a small residual ulceration on the lip and one on the penis.

CONCLUSIONS

Based on this case report we recommend treatment with alemtuzumab to severe cases of PNP in CLL. However, further follow-up of this case is needed in order to assess the long-term effect of alemtuzumab treatment in PNP.

The prognostic value of epidermal growth factor receptor is related to tumor differentiation and the overall treatment time of radiotherapy in squamous cell carcinomas of the head and neck

Accelerated repopulation in head-and-neck carcinomas might be related to the expression of proliferative factors such as epidermal growth factor receptor (EGFr). The present study focuses on the prognostic value of EGFr for T-site control and the relation to tumor cell differentiation and overall treatment time. We studied 336 patients treated with primary radiotherapy using 66-68 Gy, 2 Gy per fraction and overall treatment times of 912, 612, or 512 weeks. Pretreatment biopsies were stained for EGFr.Thirty-five percent of the carcinomas had less than 50% of the area stained for EGFr. Small T-size and well-differentiated tumors was associated with a high degree of staining (p = 0.001 and p = 0.002, respectively). EGFr was of poor prognostic influence regarding local control in patients treated with 9 weeks split-course, whereas the opposite was found for patients given accelerated treatment in 5 weeks. A similar relationship between outcome, overall treatment time, and differentiation has previously been shown. The two parameters were analyzed together by separating the tumors with low EGFr and/or poor differentiation from tumors with well/moderate differentiation and high EGFr, resulting in odds ratios for T-site failure of 12 (1.43-104), 0.91 (0.51-1.65), and 0.43 (0.17-1.08), for treatment times of 912, 612, and 512 weeks, respectively. The tumor response to variations in fractionation is heterogeneous, and the prognostic impact of EGFr and differentiation might be relative and dependent on the overall treatment time of radiotherapy.

Epidermal overexpression of interleukin-19 and -20 mRNA in psoriatic skin disappears after short-term treatment with cyclosporine a or calcipotriol

Interleukin-19, 20, and 24 are new members of the IL-10 family binding and signaling through the IL-20R1/IL-20R2 heterodimer, while IL-20 and 24 also bind to the IL-20R2/IL-22R1 heterodimer. Using in situ hybridization we have studied mRNA expression of IL-19, 20, and 24 and their related receptor chains in skin from psoriatic patients before and during short-term treatment with either oral cyclosporine A or topical calcipotriol. In untreated lesions IL-19 and IL-20 mRNA was expressed focally in epidermis above the dermal papillae, whereas IL-24 was expressed in mononuclear cells in the dermal infiltrate. The expression of IL-19 and 20 mRNA was confined to the basal and suprabasal keratinocytes. No expression of IL-19 and 20 mRNA could be detected in uninvolved psoriatic skin. Treatment with cyclosporine A and calcipotriol resulted in disappearance of the IL-19 and 20 mRNA. Expression of mRNA for the receptor chains IL-20R1 and IL-20R2 was found throughout the psoriatic epidermal layer, whereas IL-22R1 mRNA was predominantly expressed in the superficial part of the psoriatic epidermis. These findings show that IL-19 and IL-20 are synthesized by a distinct population of keratinocytes. It remains to be clarified whether IL-19 and IL-20 are implicated in the pathogenesis of psoriasis.

Sentinel lymph nodes in malignant melanoma

BACKGROUND

The optimal technique for sentinel lymph node (SN) assessment in patients with melanoma is controversial. Molecular analysis (reverse transcriptase-polymerase chain reaction) detects significantly greater numbers of SNs with suspected micrometastases (up to 71%) than does routine histopathology (approximately 20%). The authors sought to identify possible reasons for this discrepancy and to determine whether using an extended histopathologic protocol could improve diagnostic precision.

METHODS

Two hundred thirty-one SNs from 100 consecutive patients with cutaneous melanomas that measured 1-4 mm in thickness were bisected, and half of the lymph node was examined according to an extensive histopathologic protocol involving serial sectioning and immunohistochemical analysis of 3 melanocyte-associated markers (S-100, HMB-45, and Melan-A).

RESULTS

Lymph node melanocytic lesions were frequent, with micrometastases and benign nevus inclusions (BNI) found in SNs in 28% and 28% of patients, respectively (4 SNs contained both). Melan-A was the most sensitive immunohistochemical marker and was positive in all BNI-positive SNs and 97% of micrometastasis-positive SNs. Although HMB-45 showed differential labeling in micrometastases compared with BNI (82% vs. 16%), immunohistochemistry could not distinguish between those lesions. Micrometastases were already identified on the first central level in 49% of positive SNs, whereas only 23% of SNs with BNI were diagnosed on the first level.

CONCLUSIONS

Extensive serial sectioning with immunohistochemical analysis substantially increased the histopathologic detection of micrometastases and BNI in melanoma SNs to a level approaching the level reported for molecular techniques. The large number of BNIs represents an important potential source of imprecision (false positivity) in SN assays based on nonmorphologic methods.

Towards quantitative mRNA analysis in paraffin-embedded tissues using real-time reverse transcriptase-polymerase chain reaction: a methodological study on lymph nodes from melanoma patients

Improved extraction techniques combined with sensitive real-time reverse transcriptase-polymerase chain reaction may allow detection of mRNA in formalin-fixed, paraffin-embedded (FFPE) materials, but the factors affecting mRNA quantification in clinical material using these methods have not been systematically analyzed. We designed analyses using real-time reverse transcriptase-polymerase chain reaction for quantification of MART-1, beta-actin, and beta(2)-microglobulin mRNAs. The analytical intra- and interassay imprecision (coefficient of variation) was in the range 10 to 20% for all three genes studied. Using these protocols, we studied the influence of tissue autolysis and length of formalin-fixation on mRNA detection in metastatic melanoma. Delay in freezing reduced detectable mRNA, although this was less than predicted and mostly occurred early in autolysis. MART-1, beta-actin, and beta(2)-microglobulin mRNAs were consistently detected in FFPE metastatic melanoma even after fixation for up to 3 weeks, although the total mRNA detected was markedly reduced in fixed compared with fresh tissues (up to 99%). Quantification of MART-1 was, however, possible if this was expressed relative to a housekeeping gene. The polymerase chain reaction product from FFPE tissues could be increased up to 100-fold amplifying short (<136 bp) compared with long amplicons. Variations in time before tissue processing and in fixation length seem to be less important sources of imprecision than previously assumed. Our findings suggest that quantitative analysis of mRNA in archive and routine diagnostic tissues may be possible.

Immune response in blood and tumour tissue in patients with metastatic malignant melanoma treated with IL-2, IFN alpha and histamine dihydrochloride

Interleukin-2 and interferon-alpha are pleiotropic immuno-activating cytokines with clinical efficacy in malignant melanoma. The anti-melanoma activity of these cytokines is believed to result from the triggering of lymphocyte-mediated killing of tumour cells. In ongoing clinical trials, histamine dihydrochloride is used as an adjuvant to IL-2 and IFN-alpha with a view to protecting lymphocytes from oxidative inhibition induced by tumour-infiltrating monocyte/macrophages. In this study, we have serially monitored mononuclear cells in peripheral blood and tumour biopsies from 13 patients with metastatic malignant melanoma treated under a protocol comprising histamine, IFN-alpha and low-dose IL-2. One complete and 3 partial responses were observed, while 3 patients had stable disease and 6 progressed. A trend towards a gradual increase in the absolute number of circulating CD56+/CD3- NK cells in patients maintaining stable disease during therapy was noted. In tumour tissues, the extent of leukocyte infiltration prior to treatment correlated with tumour response. Additional infiltration by NK cells (CD56+) and monocytes during treatment was seen only in responding patients. Patients with progressive disease exhibited a low density of leukocytes infiltrating tumour tissues at the onset of treatment as compared to the surrounding tissues. Our data indicate that the degree and localization of mononuclear infiltration before and during immunotherapy under this protocol may determine therapeutic anti-tumour responses.

Adipocyte tissue volume in bone marrow is increased with aging and in patients with osteoporosis

Aging of the human skeleton is characterized by decreased bone formation and bone mass and these changes are more pronounced in patients with osteoporosis. As osteoblasts and adipocytes share a common precursor cell in the bone marrow, we hypothesized that decreased bone formation observed during aging and in patients with osteoporosis is the result of enhanced adipognesis versus osteoblastogenesis from precursor cells in the bone marrow. Thus, we examined iliac crest bone biopsies obtained from 53 healthy normal individuals (age 30-100) and 26 patients with osteoporosis (age 52-92). Adipose tissue volume fraction (AV), hematopoietic tissue volume fraction (HV) and trabecular bone volume fraction (BV) were quantitated as a percentage of total tissue volume fraction (TV) (calculated as BV + AV + HV) using the point-counting method. We found an age-related increase in AV/TV (r = 0.53, P < 0.001, n = 53) and an age-related decline in BV/TV (r = -0.46, P < 0.001, n = 53) as well as in the HV/TV (r -0.318, P < 0.05, n = 53). There was an age-related inverse correlation between BV/TV and AV/TV (r = -0.58, P < 0.001). No significant correlation between the AV/TV and the body mass index (r = 0.06, n.s., n = 52) was detectable. Compared with age-matched controls, patients with osteoporosis exhibited an increased AV/TV (P < 0.05) and decreased BV/TV (P < 0.05) but no statistically significant difference in HV/TV. Our data support the hypothesis that with aging and in osteoporosis an enhanced adipogenesis is observed in the bone marrow and that these changes are inversely correlated to decreased trabecular bone volume. The cellular and molecular mechanisms mediating these changes remain to be determined.

Primary hyperparathyroidism: bone structure, balance, and remodeling before and 3 years after surgical treatment

In 19 patients with primary hyperparathyroidism (PHPT) (14 women and 5 men; age 53 +/- 11 years, range 29-69 years), bone densitometry, biochemical markers of bone turnover, and iliac crest bone biopsies were obtained before and 3 years after successful surgical treatment. A significant increase in bone mineral content (BMC) was observed in both the lumbar spine (p < 0.001) and the proximal part of the distal forearm (p < 0.001), whereas the increase in BMC in the femoral neck was insignificant. Biochemical markers of bone formation (serum alkaline phosphatase, serum bone alkaline phosphatase and serum osteocalcin) and resorption (serum pyridinoline cross-linked telopeptide of type I collagen and urine N-telopeptide of type I collagen) all decreased following treatment. In cortical bone, relative cortical width increased following surgery (p < 0.05) and cortical porosity decreased (p < 0.01). No changes were observed in core width or cortical width. In cancellous bone, no significant changes were observed in any of the measured structural parameters. However, significant reductions in the extent of osteoid- (p < 0.01) and tetracycline-labeled surfaces (p < 0.001), and in bone formation rate (p < 0.001) and activation frequency (p < 0.001), were found. The numerical decrease in the extent of eroded surfaces did not reach significance (p = 0.057). No changes were observed in mineral appositional rate and adjusted appositional rate. The amount of bone resorbed (expressed as the resorption depth) and the amount of bone reformed (expressed as wall thickness) per remodeling cycle seemed unaffected by the treatment. Consequently, no effect on bone balance per remodeling cycle could be detected. The present study of PHPT patients showed that, within 3 years after surgery, BMC of both cancellous and cortical bone areas had increased. At the same time, bone turnover decreased markedly, as judged from biochemical as well as histomorphometric data, but no changes were seen in trabecular bone structure. In cortical bone, the relative cortical width increased and the cortical porosity decreased.

Primary hyperparathyroidism: whole-body bone mineral density in surgically treated Danish patients: a three-year follow-up study

Whole-body bone mineral density (BMD) and body composition were measured before surgery in 25 patients (20 women and 5 men, aged 53 +/- 13 years, range 26-73 years) with mild to moderate primary hyperparathyroidism (PHPT) and compared with 25 controls exactly matched with respect to age, gender, and menopausal status. Fifteen pairs of matched patients and controls were reexamined 3 years later (5 men and 10 women, aged 53 +/- 12 years in both groups). In the untreated PHPT patients, whole-body BMD was 95.4% +/- 10.5% (SD) of control BMD (p < 0.05). Body weight and height, body mass index, whole-body fat mass, and lean body mass did not differ significantly between the groups. Relative to values in matched controls, whole-body bone mineral content (BMC) and BMD increased by 4.4% and 3.0%, respectively, in PHPT patients (p < 0.005) during the 3-year follow-up. Neither whole-body BMC nor BMD differed between patients and controls after the 3-year follow-up. A positive correlation was observed between initial serum calcium levels and the 3-year increase in whole-body BMD (r(s) = 0.645, p < 0.01). Baseline serum osteocalcin, serum pyridinoline crosslinked telopeptide of Type I collagen and several histomorphometric indices of trabecular bone turnover (eroded and labeled surfaces, bone formation rate, and activation frequency) also correlated positively with the subsequent increase in whole-body BMD. Six patients disclosed transient postoperative secondary hyperparathyroidism, probably due to hungry bones. Four of these patients completed 3 years of follow-up and had higher increases in whole-body BMD than the remaining normo-parathyroid patients (7.9% +/- 4.5%, range 4.3-14.3% versus 1.9% +/- 2.1%, p < 0.01). It is concluded that Danish patients with mild to moderate PHPT only reveal small reductions in whole-body mineral density. Furthermore, within 3 years after parathyroid surgery, most of the lost bone mineral is regained even in patients with initial high bone turnover. Finally, PHPT in these patients is not associated with substantial changes in body compositions.

Primary hyperparathyroidism: effect of parathyroidectomy on regional bone mineral density in Danish patients: a three-year follow-up study

Changes in skeletal remodeling (biochemical bone markers) and regional bone mineral density (spine, hip, and forearm bone mineral density [BMD]) were observed for 3 years in 20 patients (15 women and 5 men; age 54 +/- 11 years, range 29-69 years) after successful surgery for primary hyperparathyroidism (PHPT). Fifteen PHPT patients were compared with 15 normal controls who were exactly matched with respect to age, gender, and menopausal status (10 women and 5 men; age 53 +/- 12 years, range 29-65 years [PHPT] and 29-66 years [controls]). All bone markers (serum osteocalcin, bone alkaline phosphatase, and type I collagen telopeptide [ICTP], and urinary hydroxyproline and NTx/creatinine ratio) declined significantly and reached normal levels within 6 months. No major changes took place during the remaining 2.5 years, apart from urine hydroxyproline, which disclosed a small peak around 12 months with a further decline towards study end (p < 0.05). Bone mineral density increased significantly in all regions (p < 0.001). At all locations, except the intertrochanteric region of the hip, the increase continued from 6 months until study end (p < 0.05). The increase in BMD was unequally distributed among regions (p < 0.001). The increase at the proximal forearm was less than in the spine (p < 0.05), the trochanteric region of the hip (p < 0.05), and the distal forearm (p < 0.05). No difference in BMD increase was observed between men, and pre- and postmenopausal women. Compared with the matched control group, PHPT patients had significantly lower BMD at baseline in the proximal (p < 0.02) and distal (p < 0.05) forearm. Furthermore, during the 3-year follow-up period, the PHPT patients showed a significant increase in BMD compared with controls in the spine (p < 0.005), the trochanteric and intertrochanteric regions of the hip (p < 0.005 and p < 0.05, respectively), and the distal forearm (p < 0.005). In conclusion, bone remodeling is normalized within the first 6 months after successful parathyroid surgery, with no major changes during the following 2.5 years. Bone mineral density increases at both cancellous and cortical sites, but in predominantly cortical bone, the recovery in BMD is less than in cancellous bone-rich areas.

Primary hyperparathyroidism: short-term changes in bone remodeling and bone mineral density following parathyroidectomy

Changes in bone remodeling and bone mineral density were observed during a period of 6 months after surgery in 24 patients with primary hyperparathyroidism (20 women and 4 men; age 54+/-12 years, range 26-69 years). All bone markers declined significantly within the 6 month follow-up period, but the time course for changes in renal N-terminal telopeptide of type 1 collagen (NTx) excretion differed from those of the other markers by a steep and significant reduction (p < 0.05) after less than 1 month. During the 6 month period, bone mineral density (BMD) increased significantly at all sites measured (p < 0.05) apart from the femoral neck and the proximal and midforearm. The greatest increase of 4.2% was observed in the trochanteric region (p < 0.001). The increase in BMD in spine, trochanteric, and intertrochanteric regions of the hip correlated inversely with baseline forearm BMD values (p < 0.05). Baseline bone markers (serum alkaline phosphatase [AP], serum bone AP, serum pyridinoline crosslinked telopeptide of type 1 collagen, urinary hydroxyproline, urinary osteocalcin), as well as baseline histomorphometric indices of bone turnover (eroded and labeled surface, bone formation rate, activation frequency, and cortical porosity) were positively correlated with changes in spinal BMD over 6 months (p < 0.05). It was concluded that, within 6 months after parathyroidectomy, patients with primary hyperparathyroidism obtain normalization of bone remodeling and a substantial increase in bone mineral density in regions rich in cancellous bone but no significant changes in regions with predominantly cortical bone.

[Laparoscopic adrenalectomy. An alternative to open surgery of minor adrenal tumors]

In the period February 1994 to November 1995 11 laparoscopic adrenalectomies were performed at our institution (seven women, four men). A transperitoneal approach was used in both right- and left-sided operations. Results were collected retrospectively. Indications for surgery were: Conn's syndrome (four), Cushing's syndrome (two), phaecromocytoma (four), and incidentaloma (one). The operations took median 170 minutes (range 105-250 minutes). Median size of the tumour was 4 cm range 1(1/2)-5 cm). No significant peri- or postoperative complications were recorded. The patients were discharged from the surgical unit median two days after surgery. Laparoscopic operation emerges as an alternative to open operation when dealing with smaller adrenal tumours. Because of the small number of patients, these operations have to be restricted to a few centres where both internists, anaesthesiologists and surgeons with expertise in this field are found.

Primary hyperparathyroidism: biochemical markers and bone mineral density at multiple skeletal sites in Danish patients

Biochemical bone markers and bone mineral density (BMD) in spine, hip, and forearm were measured, before surgery, in 30 patients with mild to moderate primary hyperparathyroidism (PHP) (25 women and 5 men; mean age 54 +/- 12 years, range 26-73 years) and compared with normal controls. A group of 291 healthy adults (181 women and 110 men) served as controls for BMD. A smaller group of 30 normal individuals (25 women and 5 men; mean age 54 +/- 12 years; range 26-74 years) were used as matched normal controls. Parameters of bone formation (s-osteocalcin, s-alkaline phosphatase activity, and s-bone isoenzyme alkaline phosphatase activity) and bone resorption (s-type-1 collagen telopeptide) were considerably increased in patients with PHP compared with normal controls (p < 0.01 for all parameters). BMD was found to be reduced in the hip (trochanteric: 95.1 +/- 14.7% of expected, p < 0.05; intertrochanteric: 95.2 +/- 13.8% of expected, p < 0.05), and the forearm (proximal: 93.3 +/- 12.2% of expected, p < 0.05; mid: 91.8 +/- 11.6% of expected, p < 0.001; distal: 90.7 +/- 13.1% of expected, p < 0.001). Spine BMD was found significantly reduced in premenopausal (87.8 +/- 7.6% of expected, p < 0.05) but not in postmenopausal patients, and although normal women showed a decrease in spinal BMD with increasing age this was not found in the PHP women. Forearm BMD was reduced in both pre- and postmenopausal patients (distal forearm: 86.7 +/- 12.2% of expected, p < 0.05; 87.6 +/- 12.1% of expected, p < 0.01, respectively). It was concluded that Danish patients with mild or moderate PHP have only small reductions in BMD. The bone loss is mainly found in the appendicular skeleton.

Recombinant human epidermal growth factor prevents sclerotherapy-induced esophageal ulcer and stricture formations in pigs

Human epidermal growth factor (EGF), a naturally occurring protein, has been implicated in the protection of gastrointestinal mucosal integrity. The efficacy of EGF in the prevention of sclerotherapy-induced esophageal lesions was investigated in 18 minipigs with surgically induced portal hypertension. The animals underwent five weekly sessions of sclerotherapy with polidocanol 2% and were concomitantly treated with either placebo or EGF administered either paravenously or subcutaneously. EGF significantly (P < 0.05) reduced esophageal ulcerations, stricture formations, and mucosal histological damage associated with sclerotherapy. The drug was well-tolerated with no overt toxicity. These results suggest a potentially important clinical value of EGF as an adjunctive treatment with the sclerotherapy.