[Early diagnosis, therapy, follow-up and survival in patients with thyroid malignancies]

The Aim of the paper was to give a review of an early diagnosis, therapy, follow-up and survival rate of patients with thyroid malignancy (TM). The paper presented the algorithm of early diagnosis: clinical, scintigraphic and ultrasonographic examination together with fine needle biopsy, cytologic analysis of the smear and biopsy ex tempore of the clear and suspected thyroid node to malignancy. Therapy of all TM forms was mainly surgical: postsurgical treatment was dependent on the type of malignancy: radioiodine 131-I, radiologic treatment, chemotherapy and radioimmunotherapy, (the latest one being in the phase of a clinical research). Follow-up was in accordance with the protocol and it was necessary because it contributes to the survival rate. In the presentation of survival rate for differentiated and medullar carcinomas we gave our results and literature data, while for the other malignancies only data from literature were presented.

CONCLUSION

Only an early diagnosis of the nodular goiter together with an up-to-date treatment can cure TM patients in a high percentage and prevent development of a terminal stage of the disease which is extremely severe in all forms of this malignancy.

[131-I-lipiodol in therapy of liver carcinoma--methods and case report]

INTRODUCTION

Primary malignant liver tumors are successfully treated only by means of surgery, but no more than 10% of patients are candidates for surgical intervention. The rest receive only palliative treatment which is, as a rule, unsuccessful. 131I-Lipiodol therapy (commercial label LIPIOCISTM) applied to the hepatic artery through a catheter has been used since 1984, primarily for treatment of hepatocellular carcinoma (HCC). The aim of this paper is to review the methodology of 131J-Lipiodol treatment of primary liver carcinomas. This treatment was applied for the first time in Yugoslavia.

CASE REPORT

A female patient, 46 years of age had an inoperable primary liver carcinoma. Since progression of the disease couldn't be controlled by chemotherapy, treatment with 131I-Lipiodol was indicated. After blocking the thyroid with Lugol, Sol. 2.22 GBq of 131I-Lipiodol was injected into hepatic artery via catheter, and the patient was isolated in a designated facility until discharged. Around 5 months later, second therapeutic dose of 1.11 GBq was administered. Early post-therapy complications were severe, but transient. After 131I-Lipiodol therapy, the tumor growth was stopped, but the patient's general condition slowly deteriorated. The patient died 7 months after receiving the first therapeutic dose.

CONCLUSION

In the reported patient, 131I-Lipiodol therapy stopped the tumor growth within the liver and significantly prolonged survival compared to the expected, but no improvement in quality of life was achieved. This treatment methodology is very complex. Medical staff providing care for these patients is exposed to substantial irradiation.

[Treatment of Hodgkin's disease with high-dose chemotherapy and autologous stem cell transplantation]

High dose chemotherapy (HDC) with autologous stem cell transplantation (SCT) was applied for the treatment of 13 patients (pts) with Hodgkin's disease (HD) (10 with relapsed form and 3 with conventional chemotherapy resistant form) in the Clinic for Hematology, Military Medical Academy, from May 1997 to October 1999. After the initial treatment for the reduction of tumor, burden stem cells were mobilized by cyclophosphamide 2.5-7.0 g/m2 with G-CSF 5-12 micrograms/kg body mass (BM). The average number of colected mobilized mononuclear cells (MNC) was 2.99 (1.66-5.9) x 10(8)/kg BM by the apheresis large volume from peripheral blood. All patients received BEAM (BCNU, etoposide, Cyto-Ara, and melfalan) conditioning regimen with adequate supportive therapy. Good engraftment (100%) was observed at postransplantation period: number of polymorphonuclear cells was > 0.5 x 10(9)/l, on day 13th (10-21) and number of platelets > 20 x 10(9)/l, on day 17th (11-28). One patient (7.6%) died due to infective complications at day 98th after transplantation, 9 (69.2%) patients achieved complete and 3 (23.1%) patients partial remission of the disease. Out of three patients with partial remission, one relapsed, seven months after autologous SCT, with conventional chemotherapy resistant form and two, after the applied conventional locoregional radiotherapy reached remission. One patient (7.6%) developed secondary malignancy of acute myeloid leukemia form with threelinage displasy 27 months after autologous SCT. HDC with autologous SCT contributes to more successful treatment of early relapsed and standard chemotherapy resistant forms of HD and gives the opportunity for successful quality of living for those patients.

[Second allogenic bone marrow transplantation after late graft rejection in a patient with severe aplastic anemia]

Allogeneic bone marrow transplantation (BMT) is the treatment of choice in young patients (pts) with severe aplastic anemia (SAA) who have an HLA identical sibling donor. Late graft rejection to following allogeneic BMT for SAA is a significant clinical problem and is associated with a high risk of mortality. The optimal treatment strategy for patients with late graft rejection after first BMT is still an open question. We report 12-year-old patient with acquired SAA who underwent BMT from his HLA identical sister. BMT was first-line treatment within 3 months of diagnosis. Preparative therapy was Cyclophosphamide (Cy) 200 mg/kg body mass (BM) during 4 days. Graft versus host disease (GVHD) was prevented with Methotrexate (MTX), Methylprednisolone (MPDN) and Cyclosporin A (CsA). After 17 months, during which patient was with normal blood counts and full donor chimaerism, graft rejection occurred. The patient was re-engrafted from the same donor after conditioning with Cy 200 mg/kg BM plus horse antithymocyte globulin (ATG)--2 vials (á 25 mg)/10 kg BM over 4 days. Before the collection, donor's bone marrow was activated with low dose rhGM-CSF (3 micrograms/kg one day). Following a secondary BMT engraftment has sustained. The patient is alive with full donor chimaerism 26 months from secondary transplantation, without acute or chronic GVHD.

[Secondary myelodysplastic syndrome after autologous transplantation of hematopoietic stem cells in a female patient with Hodgkin's disease]

Secondary acute myeloid leukemia with threelineage displasy (sAML/MDS) has been described as a complication of therapeutic approach with high-dose chemotherapy and autologous stem cell transplantation (SCT) in the patients with Hodgkin's disease (HD). It is not yet clear whether the sAML/MDS is a consequence of a standard therapeutic regimen, applied before transplantation, or a high-dose chemotherapy. In a female patient with initially resistant form of HD at III-B-b clinical stadium (bulky disease in neck and mediastinum) after the initial treatment (MOPPx4; ABVDx3; BEA-COPPx2), high-dose chemotherapy has been applied according to BEAM protocol with autologous SCT. In a period after transplantation, radiotherapy (RT) has been applied at initial region of the disease and a patient reached complete remission (CR), which lasted for a 27 months. After that period sAML/MDS has been observed. Application of more standard therapeutic cycles and characteristic cytogenetic findings are the facts that support the opinion that sAML/MDS is a consequence of standard treatment before transplantation, rather than high-dose chemotherapy. That finding implies the need for correct choice of the HD patients suitable for early SCT therapeutic approach.

Donor leukocyte infusion--the effect of mutual reactivity of donor's and recipient's peripheral blood mononuclear cells on hematopoietic progenitor cells growth

Donor leukocyte infusions are an effective therapy for patients who relapse with leukemia after bone marrow transplantation. We report the case of 14-year-old boy who relapsed 34 months after sibling donor bone marrow transplant for Philadelphia-positive chronic myeloid leukemia. Subsequently, he received three infusions of donor mononuclear cells (DMNC) harvested in steady state hematopoiesis and one G-CSF mobilized-peripheral blood mononuclear cells (PBMC) infusion. Simultaneously, test named as--"Test of Mixed Progenitors" (TMP) was performed for the assessment whether the outcome of donor leukocyte infusion treatment could be predicted. Prior to DMNC infusions, the CFU-GM and BFU-E colony assays were performed for donor's and recipient's PBMC individually, as well as for the mixture of these cells at 1:1 ratio. The cells were plated either directly in the semisolid medium or after 24 h preincubation treatment. Significantly lower values for CFU-GM derived colonies were determined in TMP in comparison to the CFU-GM values obtained for the recipient's cells. The reduced number of CFU-GM was determined both in TMP performed without preincubation treatment, app. 80% and after the 24 h preincubation, app. 55%. The reduced number of BFU-E derived colonies (app. 44%) was observed only related to recipient's cells and after the preincubation treatment of the cells. The patient did not develop GVHD and currently (40 months after the first infusion). He remained well in complete hematological, cytogenetic, molecular and clinical remission, which was the most direct evidence of the GVL effect. The novel in vitro TMP test in which the specific contribution of donor's leukocytes to the growth of recipient's hematopoietic precursor cell growth was determined, correlated with the clinical outcome.

Evaluation of cryopreserved murine and human hematopoietic stem and progenitor cells designated for transplantation

The influence of five different cryopreservation protocols on the quality and/or quantity of frozen cells was investigated on mouse bone marrow cells and human peripheral blood mononuclear cells (MNC). The efficiency of the protocols was evaluated on the basis of the recovery of very primitive pluripotent hematopoietic stem cells (MRA), pluripotent progenitors (CFU-Sd12), committed granulocyte-monocyte progenitors (CFU-GM) of mouse cells after thawing. The recovery of MRA, CFU-Sd12 and CFU-GM varied depending on the type of freezing procedure and cryoprotector (DMSO) concentrations used. It was shown that the controlled-rate protocol was more efficient, enabling better recovery of all categories of progenitor cells in frozen samples. The most efficient was the controlled-rate protocol of the cryopreservation designed to compensate for the release of fusion heat, which enabled the best recovery of CFU-GM (73.0 +/- 8.8%) and CFU-Sd12 (90.0 +/- 15.9%) when combined with 5% DMSO concentration (protocol 4). On the contrary, a better recovery (79.8 +/- 13.5%) of very primitive stem cells (MRA) was achieved only when the higher concentration (10%) DMSO was used in combination with a five-step protocol of cryopreservation (protocol 1). These results pointed out the adequately used controlled-rate freezing to be essential for a highly efficient cryopreservation of some of the categories of hematopoietic stem and progenitor cells. At the same time, it was obvious that a higher DMSO concentration was necessary for the cryopreservation of MRA, but not for more mature progenitor cells (CFU-S, CFU-GM). These results imply the existence of a mechanism that decreases the intracellular concentration of DMSO in MRA cells, which is not the case in less primitive progenitors. For human MNC, the recovery and viability of the cells, as well as the engraftment potential of cryopreserved cells after thawing were investigated. Cryopreservation protocol 1 resulted in better MNC recovery (82.7 +/- 10.4%) than protocol 3 (49.9 +/- 15.1%). The mean recovery of MNCs (collected from patients for autologous transplantation) was 78.5 +/- 7.3% (protocol 1) and 53.1 +/- 26.2% (protocol 3). The obtained favorable recovery of thawed cells and rapid reconstitution of hematopoiesis (on the day 11th following the transplantation) in patients confirmed that the controlled-rate freezing in combination with optimal DMSO concentration was able to obtain sufficient progenitor cryoprotection.

[In vivo study of spontaneous and therapy-induced apoptosis in patients with chronic lymphocytic leukemia treated with chlorambucil]

The efficiency of Chlorambucil in the induction of apoptosis was investigated in the study, and measurable apoptosis parameters were compared to the other prognostic factors with the aim of possible prediction of clinical response to the therapy in the patients with CD5 + B-cell chronic lymphocytic leukemia (B-CLL). Seven newly diagnosed patients, initially treated with daily high-doses of Chlorambucil (HD-CLB) were analyzed. Quantitative analysis of apoptosis parameters on semi-fine sections obtained from peripheral blood was performed prior and during the first five days of therapy. The level of spontaneous apoptosis (SA) was determined, as well as the maximal response by apoptosis (MAR), and the time needed to establish maximal response by apoptosis (TMAR), respectively. The results revealed that the level of SA in the studied group of patients was 11.39%-20.50%. In three patients with achieved criteria for complete remission (CR) was observed high level of SA, TMAR 2-4 days and MAR 23.42-26.36%, respectively. All patients with CR were with negative LDT, non-diffuse involvement of bone marrow and clinical stage B. Criteria for partial remission (PR) were achieved in 4 patients. Within this group, all three measurable parameters of apoptosis could have been determined in only one patient, while in the rest was noticed the increased percentage of apoptotic cells on the last day of follow-up. In all patients was observed negative LDT, diffuse bone marrow involvement, and 2 out of 4 patients had CLPL of cytomorphological type and clinical stage B. By comparing the obtained values of measurable apoptotic parameters with the clinical response to the applied therapy with HD-CLB, it is possible to divide our patients into two groups: patients who have achieved CR have the highest percentage of cells dying due to the therapy-induced apoptosis, as well as the higher values of measurable parameters compared to the certain parameters of the patients with the criteria for PR. Our preliminary results of therapeutic response to the apoptosis might be useful for the timely decision upon the duration of therapy and change of modality of treatment for every patient during the follow-up period.

[Neurologic disorders in a patient with autoimmune hemolytic anemia]

Completely different entities might be with the same possibility in the baseline of interweaving of symptoms and signs of nervous system damage. One of them, the deficiency of vitamin B12 very frequently causes megaloblastic anemia and funicular myelosis. In the case of our patient, after the clinical picture of hemolytic anemia was revealed, by slow-progressive course was developed neurologic deficiency that, according to its features, could have the deficiency of cobalamin and folic acid in its etiologic background. On the basis of disease course, clinical finding, numerous clinical investigations so as the reaction to applied therapy it was assumed that the patient had besides confirmed autoimmune hemolytic anemia the pernicious anemia as the associated cause of anemic syndrome and the basic reason of the development of neurologic deficiency. Described is the frequent associated occurrence of pernicious anemia and antiglobulin positive hemolytic anemia, so as the significant association of pernicious anemia with the deficiency of immunoglobulins that was otherwise observed in our patient as the permanent IgA deficiency.

Mass spectral fragmentation patterns of some new 3,7-dichloro-benzo[1,2-b:4,5-b']dithiophene-2,6-dicarboxylic acid dianilides and 3,5-dichloro-dithieno[3,2-b:2',3'-d]thiophene-2,6-dicarboxylic acid dianilides. II

The electron impact mass spectra of some benzo[1,2-b:4,5-b']dithiophene-2,6-dicarboxylic acid dianilides and dithieno[3,2-b:2',3'-d]thiophene-2,6-dicarboxylic acid dianilides are discussed. Dominant peaks in these dianilides are formed by the cleavage of a C-N bond on one side of an anilino group. These ions fragment further by the cleavage of a C-C bond on the other side of an anilino group and a CONRPhR' group may be lost directly. After loss of CO, the characteristic benzodithiophene radical cation, C10H2S2Cl2[symbol: see text], at m/z 256 and the dithienothiophene radical cation, C8S3Cl2[symbol: see text], at m/z 262 are formed from their respective precursor compounds.

[Dosimetric measurements and early complications in patients with differentiated thyroid carcinomas treated with radioactive iodine]

The aim of the study was to determine the exposure dose rate during the application of radioiodine therapy (ablative or tumoral dose) given in order to treat the differentiated thyroid carcinoma, during the medical visit and examinations of those patients, to establish the safety distance from patients both for population and for medical staff and to perceive early complications after the therapy. The dosimetric measurements were performed in 10 patients. The exposure dose rate during the application of the therapy ranged from 2000 to 10000 pC/kg.s, during the visit from 528 to 15 pC/kg.s and during the examinations of patients from 5500 to 200 pC/kg.s. The average safety distance from patients for population was about 8.5 m on the day O (the very day of the therapy) and 2.0 m on the day 4, while for the medical staff it amounted to 5.0 m on the day 0 and 0.5 m on the day 4. The early complications perceived were as follows: radiation thyroiditis in 5/10 patients, stomach problems in 1/10 patients and transitorial leucopeny, forty days after the therapy, in 2/10 patients.

[Importance and diagnosis of Epstein-Barr virus infection]

The 103 serum samples have been examined for the presence of the specific antibodies against Epstein-Barr virus (EBV): IgG and IgM antibodies to viral capsid antigen (VCA), antibodies to nuclear antigen (EBNA) and antibodies to early antigen (EA). Sixty nine studied sera belonged to patients with suspected infective mononucleosis (IM) while other sera were sent with the diagnosis which could be associated with EBV infections. The results obtained have suggested the necessity of examinations of EBV markers in all states suspected of EBV infection.

Comparative chemical, biological and clinical studies of 99mtc-glucoheptonate and 99mtc-dimercaptosuccinate as used in renal scintigraphy

The renal radiopharmaceutical preparations 99mTc-DMS and 99mTc-GH were examined chemically, biologically and clinically. Both preparations are of high radiochemical purity. The biodistribution of both preparations was examined in experimental animals at different time intervals, from 15 min to 4 hr; the precentage of incorporation of 99mTc-DMS into kindeys is much higher (29.4% to 52.0%) than that of 99mTc-GH (12.80% to 22.20%). Both preparations accumulate to a greater extent in the renal cortex than in the medulla. The most suitable time for renal scintigraphy for 99mTc-DMS is 90--150 min while for 99mTc-GH it is 60--90 min. It is concluded that 99mTc-DMS is more suitable for static scintigrams on the scanner and 99mTc-GH for dynamic studies with the gamma camera.