Comparison of hypofractionation and standard fractionation for post-prostatectomy salvage radiotherapy in patients with persistent PSA: single institution experience

BACKGROUND

Hypofractionated post-prostatectomy radiotherapy is emerging practice, however with no randomized evidence so far to support it's use. Additionally, patients with persistent PSA after prostatectomy may have aggressive disease and respond less well on standard salvage treatment. Herein we report outcomes for conventionally fractionated (CFR) and hypofractionated radiotherapy (HFR) in patients with persistent postprostatectomy PSA who received salvage radiotherapy to prostate bed.

METHODS

Single institution retrospective chart review was performed after Institutional Review Board approval. Between May 2012 and December 2016, 147 patients received salvage postprostatectomy radiotherapy. PSA failure-free and metastasis-free survival were calculated using Kaplan-Meier method. Cox regression analysis was performed to test association of fractionation regimen and other clinical factors with treatment outcomes. Early and late toxicity was assessed using Common Terminology Criteria for Adverse Events (CTCAE) Version 4.0.

RESULTS

Sixty-nine patients who had persistent PSA (≥ 0.1 ng/mL) after prostatectomy were identified. Median follow-up was 67 months (95% CI 58-106 months, range, 8-106 months). Thirty-six patients (52.2%) received CFR, 66 Gy in 33 fractions, 2 Gy per fraction, and 33 patients (47.8%) received HFR, 52.5 Gy in 20 fractions, 2.63 Gy per fraction. Forty-seven (68%) patients received androgen deprivation therapy (ADT). 5-year PSA failure- and metastasis-free survival rate was 56.9% and 76.9%, respectively. Thirty patients (43%) experienced biochemical failure after salvage radiotherapy and 16 patients (23%) experienced metastatic relapse. Nine patients (13%) developed metastatic castration-resistant disease and died of advanced prostate cancer. Median PSA failure-free survival was 72 months (95% CI; 41-72 months), while median metastasis-free survival was not reached. Patients in HFR group were more likely to experience shorter PSA failure-free survival when compared to CFR group (HR 2.2; 95% CI 1.0-4.6, p = 0.04). On univariate analysis, factors significantly associated with PSA failure-free survival were radiotherapy schedule (CFR vs HFR, HR 2.2, 95% CI 1.0-4.6, p = 0.04), first postoperative PSA (HR 1.02, 95% CI 1.0-1.04, p = 0.03), and concomitant ADT (HR 3.3, 95% CI 1.2-8.6, p = 0.02). On multivariate analysis, factors significantly associated with PSA failure-free survival were radiotherapy schedule (HR 3.04, 95% CI 1.37-6.74, p = 0.006) and concomitant ADT (HR 4.41, 95% CI 1.6-12.12, p = 0.004). On univariate analysis, factors significantly associated with metastasis-free survival were the first postoperative PSA (HR 1.07, 95% CI 1.03-1.12, p = 0.002), seminal vesicle involvement (HR 3.48, 95% CI 1.26-9.6,p = 0.02), extracapsular extension (HR 7.02, 95% CI 1.96-25.07, p = 0.003), and surgical margin status (HR 2.86, 95% CI 1.03-7.97, p = 0.04). The first postoperative PSA (HR 1.04, 95% CI 1.00-1.08, p = 0.02) and extracapsular extension (HR 4.24, 95% CI 1.08-16.55, p = 0.04) remained significantly associated with metastasis-free survival on multivariate analysis. Three patients in CFR arm (8%) experienced late genitourinary grade 3 toxicity.

CONCLUSIONS

In our experience, commonly used hypofractionated radiotherapy regimen was associated with lower biochemical control compared to standard fractionation in patients with persistent PSA receiving salvage radiotherapy. Reason for this might be lower biological dose in HFR compared to CFR group. However, this observation is limited due to baseline imbalances in ADT use, ADT duration and Grade Group distribution between two radiotherapy cohorts. In patients with persistent PSA post-prostatectomy, the first postoperative PSA is an independent risk factor for treatment failure. Additional studies are needed to corroborate our observations.

The impact of familial predisposition on the development of Hashimoto's thyroiditis

Objectives: Hashimoto's thyroiditis (HT) is a common autoimmune disease. Available data show that HT develops as a result of interaction between genetic susceptibility and environmental factors, but the exact pathogenesis of the disease is not yet fully understood. The aim of this investigation is to evaluate the potential relationship between family history of HT and the development of HT.Methods: Data regarding family history of all patients who were referred for a diagnostic evaluation of thyroid function for any reason between May 2014 and May 2018 was analyzed. Only first-degree relatives were considered significant, whereas the data of distant relatives was not collected.Results: A total of 39 patients with positive family history of HT were extracted (Hashimoto group). As a control group, 39 patients with negative family history of HT were randomly chosen from the same database for the final analysis. When analyzing cytological diagnoses, there were 17 patients with confirmed HT in the Hashimoto group, and 7 in the control group (p = 0.0262).Conclusion: To the best of our knowledge, this is the first study directly showing that there is genetic predisposition for the development of HT in patients with positive family history of the disease (43.59% of patients with positive family history developed HT themselves). Assessment of a patient's family history in detail should become a standard procedure when a patient with any thyroid disorder is referred for diagnostic evaluation.

Oncologist Burnout Syndrome in Eastern Europe: Results of the Multinational Survey

PURPOSE

Burnout is defined as a three-dimensional syndrome-emotional exhaustion (EE), depersonalization (DP), and reduced personal accomplishment (PA)-caused by chronic occupational stress. The aim of the current study was to investigate the prevalence of burnout among oncologists in Eastern Europe and to identify the contributing factors.

METHODS

The study was conducted as an online survey between October 2017 and March 2018. Oncologists (including medical, radiation, clinical, and surgical oncologists) from 19 countries were invited to participate. The survey consisted of 30 questions, including the standardized burnout instrument, Maslach Burnout Inventory, and eight demographic questions. Burnout risk was scored according to the scoring manual for health care workers.

RESULTS

The study included 637 oncologists. Overall, 28% were at low or intermediate risk and 72% were at high risk for burnout. Forty-four percent of participants were at high risk for EE, 28.7% for DP, and 47.3% for PA. EE risk was associated with female sex. DP risk was highest among clinical and radiation oncologists, whereas PA risk was positively correlated with years of service, percentage of cancer deaths, and availability of the number of oncologists. In multivariate logistic regression analysis, burnout was significantly associated with standardized cancer mortality and fewer years of practice.

CONCLUSION

Burnout among oncologists in Eastern Europe is high, and younger oncologists are the most vulnerable group. Preventive measures should be taken to address this issue, which negatively affects optimal care delivery and poses a threat to oncologists' health and well-being.

Burnout among Croatian physicians: a cross sectional national survey

Aim

To investigate the prevalence of burnout syndrome among physicians of all specialties, including residents and non-specialists, on a national level in Croatia.

Methods

This cross-sectional study, conducted in October 2017, used anonymous online survey based on the Maslach Burnout Inventory Human Services Survey. The Croatian version of the inventory was assessed for acceptability, factorial validity, and reliability. Key dimensions of burnout – emotional exhaustion, depersonalization, and lack of personal accomplishment were assessed. Respondents scoring high for emotional exhaustion or depersonalization were defined as burned-out.

Results

The response rate was 18% (2557/14 427). Respondents’ median age was 41 years (range 25-80), and 68% (1737/2557) were women. Good sampling adequacy and scale reliability were confirmed. Factorial validity suggested the presence of three overall factors, and no items were eliminated. Sixty-three percent of physicians were burned-out. High score on emotional exhaustion, depersonalization, and reduced personal accomplishment were found in 58%, 29%, and 52% of respondents, respectively. As many as 16% of the respondents simultaneously experienced high levels of all three burnout dimensions. Multivariate logistic regression analysis revealed that residents and physicians in tertiary or primary care were at an increased risk of burnout, while physicians working in institutes were at a decreased risk.

Conclusion

Active national measures are needed to reduce the high prevalence of burnout among Croatian physicians.

Malignancy risk with atypia of undetermined significance finding on thyroid nodule FNA: clinical experience from a tertiary institution

The Bethesda System for Reporting Thyroid Cytopathology from 2009 introduced a new category in thyroid nodule fine-needle aspiration (FNA) findings named atypia of undetermined significance (AUS), which usually appears in around 5% of FNA findings. Our study aimed to assess the utility of AUS finding in determining the risk of malignancy in thyroid nodules. In our study, 160 patients with AUS finding on initial FNA were regularly followed-up. Total and specific malignancy rates were calculated after receiving histopathologic confirmation or histopathologic/cytologic exclusion of malignancy. Eventually 80 (50%) patients were referred to surgery, with malignancy rate of 37.5% on histopathology. Another 52 (32.5%) patients were confirmed to have benign nodules on repeat FNA. After combining results obtained from histopathologic reports with those obtained from cytologic follow-up, total malignancy rate was 22.72%. However, malignancy was confirmed in only one (5.26%) of 19 patients with AUS finding on repeat FNA with surgical and histopathologic follow-up. In conclusion, FNA is an extremely useful tool for clinicians to discriminate patients to be referred to surgery and those that can be followed-up safely without the need for further invasive procedures.

DIFFERENTIATED THYROID CANCER IN PEDIATRIC POPULATION (≤18 YEARS): POSTOPERATIVE TREATMENT WITH RADIOACTIVE IODINE (I-131)

The aim is to present data on the treatment and follow-up in a cohort of patients with pediatric thyroid cancer who underwent total thyroidectomy and received postoperative radioactive iodine (I-131) therapy. The study was conducted in a tertiary high-volume thyroid center, in pediatric patients with differentiated thyroid cancer who were consecutively treated during the 1965-2015 period. A total of 45 patients aged ≤18 years having undergone total thyroidectomy with or without selective neck dissection were included in the study. Decision on postoperative I-131 ablation was based on tumor characteristics, postoperative thyroglobulin level, preablative whole body scintigraphy, and/or neck ultrasound. Median age at diagnosis was 15 years. The presence of cervical lymph node metastases was significantly associated with papillary thyroid cancer, larger tumor size, involvement of two thyroid lobes, and multifocal disease. The presence of distant metastases was significantly associated with larger tumor size. None of the patients died during follow-up period, and the 5-year and 10-year overall survival rates were 100%. The 5-year and 10-year progression-free survival (PFS) rates were 87% and 73%, respectively. Male gender (p=0.046), age ≤15 years (p=0.029) and tumor size >15 mm (p=0.042) were significantly associated with inferior PFS. A significant positive trend of increase in the number of newly diagnosed patients was observed over time (p=0.011). Clinical management of pediatric thyroid cancer is challenging, especially in the light of increasing incidence in this population. Male patients younger than 15 years and with tumors of more than 15 mm in size require additional caution due to lower PFS observed.

A score derived from routine biochemical parameters increases the diagnostic accuracy of chromogranin A in detecting patients with neuroendocrine neoplasms

BACKGROUND

Chromogranin A (CgA) is a valuable biomarker for detection and follow-up of patients with neuroendocrine neoplasms (NENs). However, various comorbidities may influence serum CgA, which decreases its diagnostic accuracy. We aimed to investigate which laboratory parameters are independently associated with increased CgA in real-life setting and to develop a scoring system, which could improve the diagnostic accuracy of CgA in detecting patients with NENs.

METHODS

This retrospective study included 55 treatment naïve patients with NENs and160 patients with various comorbidities but without NEN (nonNENs). Scoring system (CgA-score) was developed based on z-scores obtained from receiver operating curve analysis for each parameter that was associated with elevated serum CgA in nonNENs.

RESULTS

CgA correlated positively with serum BUN, creatinine, α2-globulin, red-cell distribution width, erythrocyte sedimentation rate, plasma glucose and correlated inversely with hemoglobin, thrombocytes and serum albumin. Serum CgA was also associated with the presence of chronic renal failure, arterial hypertension and diabetes and the use of PPI. In the entire study population, CgA showed an area under the curve of 0.656. Aforementioned parameters were used to develop a CgA-score. In a cohort of patients with CgA-score <12.0 (N = 87), serum CgA >156.5 ng/ml had 77.8% sensitivity and 91.5% specificity for detecting NENs (AUC 0.841, 95% CI 0.713-0.969, P < 0.001). Serum CgA had no diagnostic value in detecting NENs in patients with CgA-score >12.0 (AUC 0.554, 95% CI 0.405-0.702, P = 0.430).

CONCLUSIONS

CgA-score encompasses a wide range of comorbidities and represents a promising tool that could improve diagnostic performance of CgA in everyday clinical practice.

Bethesda thyroid categories and family history of thyroid disease

OBJECTIVE

Thyroid cancer is the most common type of endocrine-related cancer worldwide. The aim of this article was to assess the relationship between thyroid diseases diagnosed by fine needle aspiration (FNA) and family history of thyroid disease.

DESIGN

The study was conducted in a tertiary high-volume thyroid cancer centre. Fine needle aspiration (FNA) of a thyroid nodule detected on neck ultrasound for any reason was performed in all included patients.

PATIENTS

A total of 10 709 patients were included in the study.

MEASUREMENTS

Correlation of cytological findings classified according to the Bethesda system and family history was calculated using Fisher's exact test.

RESULTS

There were 2580 (24.09%) patients with non-malignant thyroid diseases in the family and 198 (1.85%) patients who had a history of thyroid cancer in the family. A total of 2778 (25.94%) patients had positive family history of thyroid diseases, and 7931 (74.06%) patients had negative family history. In patients with papillary thyroid carcinoma in family history, the difference between those with benign (Bethesda 2) and malignant thyroid FNA diagnosis (Bethesda 6) was found to be statistically significant (P = .0432).

CONCLUSIONS

Family history plays a significant role in the development of thyroid cancer, and having first-degree relatives with not only medullary, but also papillary thyroid cancer strongly predicts the risk of developing the malignant thyroid disease. In contrast, benign thyroid disorders in family history do not lead to the development of thyroid cancer.

The Role of the Acute Octreotide Suppression Test in Detecting Patients with Neuroendocrine Neoplasms

BACKGROUND

Serum chromogranin A (CgA) is routinely used as a biomarker in patients with neuroendocrine neoplasms (NENs). Several conditions and comorbidities may be associated with falsely elevated CgA, often leading to extensive diagnostic evaluation, which may be costly and harmful. The aim of this study was to analyze the effectiveness of the acute octreotide suppression test (AOST) in differentiating falsely elevated serum CgA.

METHODS

Our prospective study enrolled 45 patients from two different patient cohorts: (1) 29 patients with suspicion or presence of NENs (extensive workup and subsequent biopsy confirmed 16 NENs); (2) 16 consecutive patients admitted via the Emergency Department without NENs (non-NENs). AOST was performed after an overnight fast. Baseline CgA was measured, after which 0.25 mg of octreotide was administered subcutaneously. CgA was measured 3 and 6 h after administration.

RESULTS

Baseline CgA levels were similar in NENs and non-NENs. At the end of the AOST, CgA decreased by a median of 83.3% (41.0-127.4) in non-NENs and 13.8% (0.0-43.6) in NENs (p < 0.001). In patients with increased baseline CgA, a decrease in CgA at the 6th hour of < 51.3% had 90.0% sensitivity and 88.9% specificity in detecting NENs. In patients with normal baseline serum CgA, a decrease in CgA at the 3rd hour of < 17.6% had 83.3% sensitivity and 81.8% specificity in detecting patients with NENs. The diagnostic accuracy of the AOST in the entire study population was 86.7%.

CONCLUSIONS

AOST is a promising tool to increase the diagnostic accuracy of serum CgA.

The Impact of Hyperosmolarity on Long-Term Outcome in Patients Presenting with Severe Hyperglycemic Crisis: A Population Based Study

AIMS

We compared characteristics of patients with hyperglycemic hyperosmolar state (HHS) and patients with severe hyperglycemia without the signs of hyperosmolarity and ketoacidosis; analyzed long-term all-cause mortality and potential prognostic factors.

METHODS

The studied population included 261 749 adults. HHS was diagnosed in patients with plasma glucose >33.0 mmol/L, ketonuria <1+, and serum osmolarity >320 mmol/L. Patients with plasma glucose >33.0 mmol/L, ketonuria <1+ and serum osmolarity <320 mmol/L were considered as controls (nHHS).

RESULTS

During the 5-year period, we observed 68 episodes of HHS in 66 patients and 51 patients with nHHS. Patients with HHS were significantly older, had lower BMI, higher serum C-reactive protein and used diuretics and benzodiazepines more frequently. Mortality rates one, three and 12 months after admission were 19.0, 32.1 and 35.7% in the HHS group, and 4.8, 6.3 and 9.4% in the nHHS group (P<0.001). However, after adjustment for patient age, these differences were not statistically significant. In multivariate Cox regression in HHS group, mortality was positively associated with age, male gender, leukocyte count, amylase, presence of dyspnea and altered mental status, and the use of benzodiazepines, ACE inhibitors and sulphonylureas, while it was inversely associated with plasma glucose, bicarbonate, and the use of thiazides and statins. A nomogram derived from these variables had an accuracy of 89% in predicting lethal outcome.

CONCLUSIONS

Infection, use of furosemide and benzodiazepines may be important precipitating factors of HHS. Prospective clinical trials are mandatory to analyze the safety of ACE-inhibitors and benzodiazepines in elderly patients with diabetes.

Neurosyphilis in Anglo-American Composers and Jazz Musicians

Syphilis is a sexually transmitted, systemic disease caused by the spirochete bacterium Treponema pallidum. The most common mechanism of transmission is sexual intercourse. Although there are several hypotheses, the exact origin of the disease remains unknown. Newly published evidence suggests that the hypothesis supporting the theory of the American origin of the disease is the valid one. Among 1500 analyzed pathographies of composers and musicians, data on ten Anglo-American composers and jazz musicians having suffered from neurosyphilis (tertiary stage of the disease) were extracted for this report. In this group of Anglo-American composers and musicians, most of them died from progressive paralysis while still in the creative phase of life. Additionally, diagnoses of eleven other famous neurosyphilitic composers, as well as basic biographic data on ten less known composers that died from neurosyphilis-progressive paralysis are also briefly mentioned. In conclusion, neurosyphilis can cause serious neurological damage, as well as permanent disability or death, preventing further work and skill improvement.

Clinical and prognostic significance of anisocytosis measured as a red cell distribution width in patients with colorectal cancer

PURPOSE

: colorectal cancer (CRC) is the third most commonly diagnosed cancer worldwide, and detection of new prognostic markers is mandatory for patients to receive optimal oncological treatment. The aim of the study was to assess clinical and prognostic value of red cell distribution width (RDW) in patients with CRC.

METHODS

: RDW values in 90 patients with CRC undergoing surgery for primary disease were analyzed in pre- and postoperative setting, and correlated with clinical and hematological parameters.

RESULTS

: Both pre- and postoperative RDW measurements were found to be associated with features of iron deficiency anemia, inflammatory response to tumor, advanced age and depth of tumor invasion. Optimal cutoff points were calculated to be 14% for preoperative and 13.6% for postoperative RDW measurements. Elevations in both pre- and postoperative RDW values had significant effects on survival in univariate and multivariate analyses. Effects were found to be independent of tumor related features, stage of the disease, development of anemia and aberrant inflammatory response to tumor.

CONCLUSIONS

: RDW is an integrative parameter reflecting tumor specific features and shows significant association with overall survival in patients with CRC. This is especially important in patients with stage 2 disease where elevation in preoperative RDW values can contribute to recognition of higher risk patients.

Comparison of conventionally fractionated and hypofractionated schedule for post-prostatectomy salvage radiotherapy: Early results from non-randomized observational study

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Background: Data on hypofractionated radiotherapy in definitive treatment of prostate cancer are maturing; however, limited information is available for hypofractionated radiotherapy after prostatectomy. We aimed to compare hypofractionated and conventionally fractionated radiotherapy in salvage setting for biochemically recurrent prostate cancer. Methods: A retrospective analysis was performed in 106 patients with proven PSA recurrence treated to the prostate bed. Patients were non-randomly, in a alternating fashion, subjected to either 52.5 Gy in 20 fractions of 2.625 Gy over 4 weeks (N = 57, hypofractionated group) or 66 Gy in 33 fractions of 2 Gy over 6.5 weeks (N = 49, conventionally fractionated group). There was no statistically significant difference in pathologic T-stage and Gleason score distribution between the groups. In the conventionally fractionated group there were more patients with positive margins (p = 0.01), more prevalent concomitant hormonal therapy (50.9% vs 61.2%, p = 0.001), but less long-term hormonal therapy (21.4% vs 81%, p < 0.001), compared to hypofractionated group. Median follow-up was 20 months (range 6-36 months). Failure (PSA nadir+0.2) rates between the groups were compared using Cox proportional hazards model. Radiation-related side-effects were assessed using RTOG scoring scale. Results: At this early point, 13 patients (22.8%), and 6 patients (12.2%) experienced treatment failure in the hypofractionated group and conventionally fractionated group, respectively (HR 3.1, 95%CI (1.5-6.3)). More late grade 2 gastrointestinal and genitourinary side-effects were observed in conventionally fractionated group (4.1% vs 1.8%, and 2% vs 0%, p = 0.01, respectively). No grade 3 toxicities were observed. Conclusions: More initial biochemical failures were observed in hypofractionated group compared to conventionally fractionated group. However, baseline heterogeneity between the groups and short follow-up preclude any causal observation of differential efficacy between these two schedules. Randomized phase II trial is planned to prospectively compare these two regimens.

Cytokeratin 20 positive cells in blood of colorectal cancer patients as an unfavorable prognostic marker

OBJECTIVES

Cytokeratin 20 (CK20) is one of the most investigated markers for the detection of circulating colorectal cancer (CRC) cells by reverse transcription polymerase chain reaction (RT-PCR). The aim of this study was to evaluate prognostic value of RT-PCR detection of circulating CRC cells using CK20 as a marker, and to compare the value of preoperative and postoperative blood sample analysis for that purpose.

METHODS

Ribonucleic acid (RNA) was isolated from mononuclear cell fraction of blood samples taken from 95 CRC patients before and after tumor resection and from 23 healthy volunteers and assayed by real-time RT-PCR for CK20 expression.

RESULTS

In patients positive for CK20 postoperatively both progression-free survival (PFS) and overall survival were significantly shorter than in patients negative for CK20 postoperatively, while the difference between patients positive and negative for CK20 preoperatively was not statistically significant in terms of neither PFS nor overall survival.

CONCLUSION

Our results have shown prognostic value of circulating cancer cells detected in postoperative blood samples from CRC patients using CK20 as marker for RT-PCR, which has potential implications for treatment of these patients. In clinical practice, CK20 expression profile could be a factor in weighting treatment options in CRC patients. In cases where multiple treatment options are possible, patients with positive postoperative CK20 expression could be candidates to receive more aggressive treatment.

Prediction of radioactive iodine remnant ablation failure in patients with differentiated thyroid cancer: A cohort study of 740 patients

BACKGROUND

The purpose of this study was to detect parameters that could serve as predictors of radioactive iodine (I-131) ablation failure in patients with low-risk and intermediate-risk differentiated thyroid carcinoma (DTC).

METHODS

Our cohort study included 740 patients with DTC who received postoperative I-131 remnant ablation. Anthropometric, biochemical, and pathohistological parameters were analyzed and correlated with ablation outcome using multivariable logistic regression models.

RESULTS

Treatment failure rates were higher in patients <53 years, with N1a classification, and lymph node capsular invasion. In patients with N1a disease, thyroglobulin (Tg) > 2.4 ng/mL predicted treatment failure with 93.8% sensitivity and 52.5% specificity, and in patients with N1b disease, Tg > 14.9 ng/mL with 77.8% sensitivity and 92.9% specificity. I-131 activity was not associated with treatment outcome.

CONCLUSION

Patients < 53 years old, with higher Tg levels, N1a classification, and lymph node capsular invasion have a higher risk of ablation failure. Stimulated Tg is an excellent predictor of treatment failure in patients with N1 disease. © 2016 Wiley Periodicals, Inc. Head Neck 39: 109-115, 2017.

[[SATISFACTION OF YOUNG DOCTORS IN CROATIA: ARE WE HEADING IN THE RIGHT DIRECTION]?]

INTRODUCTION

The satisfaction of junior medical doctors is primarily associated with the training they receive during the residency period and working conditions. Given a considerable brain-drain of medical doctors from the Republic of Croatia, the present research focused on the evaluation of the satisfaction of junior medical doctors.

METHODOLOGY

The Junior Doctors Committee of the Croatian Medical Chamber prepared a questionnaire on the satisfaction of junior doctors. The relevant questionnaire was available for filling in online in the period from February 1 to March 20, 2016.

RESULTS

The questionnaire was completed by 1,531 persons aged between 29 and 35 (mean age 32) of which 67% were females. A 58% of respondents would leave the Republic of Croatia if offered an opportunity. The main reasons for leaving the country include better working conditions (74%), well-regulated healthcare system (64%) and higher wages (64%). In case of staying in the country, their future professional status and development would remain unaltered (44%).

CONCLUSION

The questionnaire results show a high level of dissatisfaction with the healthcare system, some segments of the specialist training and the mentor role. The analysis of factors affecting the satisfaction of junior doctors will facilitate the preparation and adoption of measures aiming to mitigate the above-mentioned trend.

Pleural and pericardial effusions combined with ascites in a patient with severe sunitinib-induced hypothyroidism

To best of our knowledge, this is the first reported case of pericardial and pleural effusions combined with ascites, precipitated with severe sunitinib-induced hypothyroidism. A 58-year-old man presented in our emergency department due to dyspnoea and dry cough. Sixteen months earlier, the patient underwent left nephrectomy due to metastatic renal cell adenocarcinoma (RCC), and therapy with sunitinib was initiated postoperatively. Thyroid function was not assessed during the therapy. On admission, all laboratory findings were within normal range. Computed tomography of the chest detected voluminous bilateral pleural effusions and mild pericardial effusion, and echocardiography revealed pericardial effusion. Thoracocentesis was carried out three times, and cytological examination showed no signs of malignant cells. After assessment of the thyroid function, neglected hypothyroidism was registered. Substitution therapy with levothyroxine was initiated, and thyroid function normalised 2 weeks later. Few days after the last thoracocentesis, his condition suddenly got worse. Thoracocentesis was repeated, and microbiological analysis of the exudate came positive for Klebsiella pneumoniae and Streptococcus pneumoniae. Despite the implemented therapeutic measures, his clinical condition progressively deteriorated. The patient died 27 days after the admission, hospital-acquired pneumonia was identified as the cause of death. Our case emphasises the necessity of careful monitoring and management of side-effects in patients who receive sunitinib. Hypothyroidism is a known cause of pleural, pericardial and abdominal effusions, as reported in several case reports. Timely initiation of substitution levothyroxine therapy can decrease unnecessary pauses in the therapy with sunitinib, as well as prevent development of severe symptoms.

Re-ablation I-131 activity does not predict treatment success in low- and intermediate-risk patients with differentiated thyroid carcinoma

The aim of this study was to evaluate the efficacy of different radioactive iodine (I-131) activities used for re-ablation, to compare various combinations of treatment activities, and to identify predictors of re-ablation failure in low- and intermediate-risk differentiated thyroid carcinoma (DTC) patients. The study included 128 consecutive low- and intermediate-risk patients with DTC with ablation failure after total thyroidectomy. Patient characteristics, T status, tumor size, lymph node involvement, postoperative remnant size on whole-body scintigraphy, serum thyroglobulin (Tg), thyroid-stimulating hormone (TSH), anti-Tg antibody (TgAb), and Tg/TSH ratio were analyzed as potential predictors of the re-ablation success. Re-ablation was successful in 113 out of 128 patients (88.3 %). Mean first I-131 activity was 2868 ± 914 MBq (77.5 ± 24.7 mCi) and mean second I-131 activity 3004 ± 699 MBq (81.2 ± 18.9 mCi). There was no association between the first, second, and cumulative activity with re-ablation treatment outcome. Treatment failure was associated with higher Tg levels prior to re-ablation (Tg2) (OR 1.16, 95 % CI 1.05-1.29, P = 0.003) and N1a status (OR 3.89, 95 % CI 1.13-13.41, P = 0.032). After excluding patients with positive-to-negative TgAb conversion, Tg2 level of 3.7 ng/mL predicted treatment failure with a sensitivity of 75.0 %, specificity of 80.5 %, and a negative predictive value of 97.1 %. Patients with positive-to-negative TgAb conversion had higher failure rates (OR 2.96, 95 % CI 0.94-9.29). Re-ablation success was high in all subgroups of patients and I-131 activity did not influence treatment outcome. Tg may serve as a good predictor of re-ablation failure. Patients with positive-to-negative TgAb conversion represent a specific group, in whom Tg level should not be used as a predictive marker of treatment outcome.

PRIMARY FIBROSARCOMA OF THE THYROID GLAND: CASE REPORT

Due to progressive dyspnea, a male patient aged 59 underwent medical examination in 2003 in a local hospital. Neck ultrasound and fine-needle aspiration biopsy (FNAB) of a suspect lesion in the thyroid gland revealed the presence of a malignant neoplasm, i.e. mesenchymal tumor. Immunocytochemistry for epithelial membrane antigen, chromogranin A and leukocyte common antigen (CD45) was negative, while vimentin and S-100 were positive. The patient was referred to a university hospital center, where further oncologic work-up was done. Neck ultrasound revealed a tumor in the left lobe of the thyroid, with extension to the aortic arch. After repeated FNAB, cytologic diagnosis of primary thyroid fibrosarcoma was established. Due to the locally advanced and consequently inoperable disease, primary radiotherapy to the neck region (64 Gy in 32 fractions) was applied, followed by 6 cycles of chemotherapy with doxorubicin. After completion of therapy, computed tomography scan demonstrated significant regression of primary disease, but it was still not amenable to surgical treatment. Thus, the decision of the oncology board was active surveillance of the patient. During 9-year follow up, no signs of progression or activity of the disease were found.

Clinical Significance of Multinodularity in Patients with Papillary Thyroid Carcinoma

Backgroud/Aim: To assess the clinical significance of nodules in multinodular thyroid if one nodule is diagnosed as papillary carcinoma (PC), we investigated 97 patients with a multinodular thyroid and histopathological diagnosis of PC.

PATIENTS AND METHODS

We assessed the following variables: age and gender, fine-needle aspiration diagnosis, PC nodule size and dominance, intraglandular dissemination (ID), regional lymph node (RLN) status, and distribution of diagnoses of the other nodules.

RESULTS

Among 97 patients with PC, additional diagnoses were: nodular goiter (NG) in 64 patients, ID in 28, Hashimoto's thyroiditis (HT) in 26, and follicular or Hürthle cell adenoma in seven.

CONCLUSION

Patients with ID, and without NG or HT more often had RLN metastases. Lower rates of RLN metastases in patients with NG and HT are probably due to smaller PC nodule sizes found during routine follow-up of these benign diseases.

DEMOGRAPHIC AND CLINICOPATHOLOGIC FEATURES OF PATIENTS WITH PRIMARY BREAST CANCER TREATED BETWEEN 1997 AND 2010: A SINGLE INSTITUTION EXPERIENCE

Breast cancer accounted for 28% of all new cancers and 18% of female cancer deaths in Europe in 2010. It is the most common type of cancer in women in Croatia, with an incidence rate of 56.9/100 000 in the year 2010, and the highest number of newly diagnosed women aged between 60 and 64. Multiple factors are associated with an increased risk of breast cancer: advancing age, family history, exposure to endogenous and exogenous reproductive hormones, dietary factors, benign breast disease, and environmental factors. To assess demographic and clinicopathologic features of primary breast cancer, we retrospectively analyzed 870 patients treated in our institution between 1997 and 2010. Data were obtained from medical documentation and a printed questionnaire regarding life habits. Most of our patients presented with a breast lump and were self-diagnosed by breast examination. This fact highlights the need of regular breast self-examination, although it should also be taken into account that most of our patients did not attend regular mammography screening (only 31%). One of the most concerning facts is that the mean time from observing the first symptom to visiting a physician was 4 months. Previous studies have identified ignorance, fear and fatalistic attitudes, poor socioeconomic conditions, and illiteracy as important factors resulting in delay. Considering these facts, education and raising awareness about the disease in the general population is one of the key weapons for lowering breast cancer mortality.

Sunitinib-induced thyrotoxicosis - a not so rare entity

BACKGROUND/AIM

The tyrosine kinase inhibitor (TKI) sunitinib malate is nowadays a standard first-line treatment option for patients with metastatic clear-cell renal cell carcinoma (mRCC). The aim of this study was to evaluate the incidence and clinical course of thyrotoxicosis in our cohort of patients treated with sunitinib.

PATIENTS AND METHODS

Medical records of all patients treated with first-line sunitinib for mRCC at our Institution between November 2008 and March 2014 were retrospectively reviewed. Thyroid function was assessed after every 2 cycles of therapy, during the 2 weeks off period.

RESULTS

Out of the 62 included patients, hypothyroidism has developed during therapy in 12 patients (19%) and it was preceded by thyrotoxicosis in 2 (3.2%).

CONCLUSION

Sunitinib-induced thyrotoxicosis (SIT), a not so rare entity, was followed by hypothyroidism. The patterns of occurrence and possible significance of SIT, as predictive marker of better treatment response to sunitinib, need to be validated in further studies.

Hypothyroidism as a predictive clinical marker of better treatment response to sunitinib therapy

BACKGROUND

Tyrosine kinase inhibitors are standard treatment in patients with metastatic renal cell carcinoma (mRCC). Several studies have indicated that side-effects including hypothyroidism may serve as potential predictive biomarkers of treatment efficacy.

PATIENTS AND METHODS

All patients with clear cell mRCC treated with sunitinib in the first-line setting in our Center between November 2008 and October 2013 were included. Thyroid function was assessed after every 2 cycles. Prognostic factors were tested using Cox proportional hazards model for univariate analysis.

RESULTS

During treatment, 29.3% developed hypothyroidism, with a median of peak TSH values of 34.4 mIU/L. Patients who had both TSH >4 mIU/L and were receiving substitution therapy with levothyroxine had prolonged PFS compared to all other patients (25.3 months vs. 9.0 months; p=0.042).

CONCLUSION

The rate of hypothyroidism as a side-effect of sunitinib in patients with mRCC is significant. Patients with symptomatic hypothyroidism experienced significantly longer PFS, but without difference in OS.