Could thyroid dysfunction influence outcome in sunitinib-treated metastatic renal cell carcinoma?

BACKGROUND

Sunitinib is a standard of care for metastatic renal cell carcinoma (mRCC). Hypothyroidism is frequently observed under sunitinib therapy. This study was conducted to prospectively determine the correlation between thyroid function and progression-free survival (PFS) in this population.

PATIENTS AND METHODS

One hundred and eleven mRCC patients treated with sunitinib were evaluated for serum thyroid-stimulating hormone (TSH) and T4 levels before treatment and every 6 weeks during treatment. Survival was analysed according to a landmark method with a cut-off of 6 months, excluding early progressive or early-censored patients.

RESULTS

Out of the 102 patients with normal baseline thyroid function, 53% developed thyroid dysfunction, including 95% hypothyroidisms out of which 90.9% received L-thyroxine replacement. Median time to TSH alteration was 5.4 months. Median PFS was 11.7 months for the entire population. Median PFS was not different between the groups with abnormal or normal thyroid function after 6 months of treatment (18.9 and 15.9 months, respectively, log-rank P = 0.94, hazard ratio = 1.02, 95% confidence interval = 0.54-1.93). There was no difference even after adjustment for Memorial Sloan-Kettering Cancer Centre classification and therapy line.

CONCLUSIONS

Abnormal thyroid function with hormonal substitution did not increase survival in our population, independent of initial prognosis and previous treatments. Larger comparative studies are deserved to validate these conclusions.

Prenatal and infant exposure to thimerosal from vaccines and immunoglobulins and risk of autism

OBJECTIVE

Exposure to thimerosal, a mercury-containing preservative that is used in vaccines and immunoglobulin preparations, has been hypothesized to be associated with increased risk of autism spectrum disorder (ASD). This study was designed to examine relationships between prenatal and infant ethylmercury exposure from thimerosal-containing vaccines and/or immunoglobulin preparations and ASD and 2 ASD subcategories: autistic disorder (AD) and ASD with regression.

METHODS

A case-control study was conducted in 3 managed care organizations (MCOs) of 256 children with ASD and 752 controls matched by birth year, gender, and MCO. ASD diagnoses were validated through standardized in-person evaluations. Exposure to thimerosal in vaccines and immunoglobulin preparations was determined from electronic immunization registries, medical charts, and parent interviews. Information on potential confounding factors was obtained from the interviews and medical charts. We used conditional logistic regression to assess associations between ASD, AD, and ASD with regression and exposure to ethylmercury during prenatal, birth-to-1 month, birth-to-7-month, and birth-to-20-month periods.

RESULTS

There were no findings of increased risk for any of the 3 ASD outcomes. The adjusted odds ratios (95% confidence intervals) for ASD associated with a 2-SD increase in ethylmercury exposure were 1.12 (0.83-1.51) for prenatal exposure, 0.88 (0.62-1.26) for exposure from birth to 1 month, 0.60 (0.36-0.99) for exposure from birth to 7 months, and 0.60 (0.32-0.97) for exposure from birth to 20 months.

CONCLUSIONS

In our study of MCO members, prenatal and early-life exposure to ethylmercury from thimerosal-containing vaccines and immunoglobulin preparations was not related to increased risk of ASDs.

[Robot-assisted radical prostatectomy: Perioperative complications, pathological results and functional results during the learning curve]

OBJECTIVE

We report our experiences regarding the peri- and postoperative complications as well as pathological and functional results of robot-assisted radical prostatectomy during the implementation phase and the learning curve of the technique.

MATERIAL

All clinical, paraclinical, as well as peri- and postoperative events of the first 102 patients were filed. Postoperative complications were classified according to the Clavien classification. Regarding functional results, continence was defined as the use of 0 pads or one pad for security reasons. Erectile function was classified into absence of spontaneous erections, erections insufficient for sexual intercourse and erections sufficient for sexual intercourse.

RESULTS

Median procedure time was 240min, blood-loss 400mL and transfusion rate 2%. Overall, 7.8% of all patients had perioperative complications, 13.7% had minor and 4.9% had mayor post operative complications. The overall positive surgical margin rate was 16.0%. At 12month, 87% of all patients were continent and 21.1% had spontaneous erections and 47.4% had sexual intercourse.

CONCLUSION

Patients treated during the implementation phase of robot-assisted radical prostatectomy show rates of peri- and postoperative complications, as well as pathological and functional results comparable to the results of centers of excellence published in the literature.

Tumor protein p53-induced nuclear protein (TP53INP1) expression in medullary thyroid carcinoma: a molecular guide to the optimal extent of surgery?

BACKGROUND

Medullary thyroid cancer (MTC) is characterized by early regional lymph node metastasis, the presence of which represents a critical obstacle to cure. At present no molecular markers have been successfully integrated into the clinical care of sporadic MTC. The present study was designed to evaluate TP53INP1 expression in MTC and to assess its ability to guide the surgeon to the optimal extent of surgery performed with curative intent.

METHODS

Thirty-eight patients with sporadic MTC were evaluated. TP53INP1 immunoexpression was studied on embedded paraffin material and on cytological smears.

RESULTS

TP53INP1 was expressed in normal C cells, in C-cell hyperplasia, and in 57.9% of MTC. It was possible to identify two groups of MTC according to the proportion of TP53INP1 expressing tumor cells: group 1 from 0% to <50% and group 2 from 50% to 100% of positive cells. Patients with a decreased expression of TP53INP1 (group 1) had a lower rate of nodal metastasis (18.8% versus 63.4% in group 2; P = 0.009), with only minimal lymph node involvement per N1 patient (2.7% of positive lymph nodes versus 22.9%; P < 0.001) and better outcomes (100% of biochemical cure versus 55.5%; P < 0.001). Patients with distant metastases were only observed in group 2. Cytological samples exhibit similar results to their embedded counterparts.

CONCLUSIONS

TP53INP1 immunoexpression appears to be a clinical predictor of lymph node metastasis in MTC. The evaluation of TP53INP1 expression may guide the extent of lymph node dissection in the clinically node-negative neck. These findings require prospective validation.

Alterations of natural killer cells in metastatic prostate cancer

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Background: Recently, prostate cancer (PCa) has been considered as a potential target for antitumoral immunotherapy and cells such as Natural Killer (NK) cells, with antitumoral activity are a promising candidate. NK cells activity is regulated by opposite signals delivered by inhibitory (NKRi) and activating receptors (NKRa). Primary human PCa express ligands for NKRa but the HLA class I (ligands for NKRi) expression is downregulated. Recently, our group have reported that patients with acute myeloid leukaemia have defective interactions receptor -ligand in NK cells due to a decreasing expression of Natural Cytotoxicity Receptors and it could be used as a evasion mechanism by leukaemia cells. The aim of this work was to evaluate the activating receptors expression to know if it could be used as evasion mechanism of the immune response in PCa. Methods: Activating and inhibitory receptors were analysed by flow cytometry in peripheral NK cells from 8 patients with metastatic androgen dependent prostate cancer (ADPC), 10 with metastatic androgen independent prostate cancer (AIPC), 7 patients with localized prostate cancer (LPC ) and 15 healthy donors. Results: The expression of NKp30, NKp46, and NKG2D (as determined by MFI) was significantly lower on NK cells from patients with ADPC and AIPC than in healthy donors. In ADPC patients, the ratio MFI (MFI receptor/MFI control isotype) of NKP30 (4.73 ± 1.07, p = 0.0003), of NKp46 (16.62 ± 3.42, p = 0.036) and of NKG2D (19.61 ± 6.44, p = 0.026) significantly differed from healthy donors (NKp30 26.65 ± 6.12; NKp46 39.73 ± 9.66 and NKG2D 37.97 ± 6.77). It was similar for AIPC NK cells(NKp30 6.28 ± 1.27, p = 0.0002; NKp46 16.24 ± 2.34, p = 0.014; NKG2D 13.61 ± 2.29, p = 0.0003). In ADPC and AIPC NK cells, the expression of NKRi and other NKRa did not differ from healthy donors. In LPC NK cells, the expression of NKRi and NKRa did not differ from healthy donors. Conclusions: We observed a decreased expression of principal activating receptors only in metastatic form of PCa. This could affect the interactions receptor-ligand in NK cells. Is it hormonal therapy or extension of the disease that is responsible of NK cells alterations? Moreover, this could constitute a potential mechanism for cancer cells immune escape and a possible target for therapies improving NK functions.

No significant financial relationships to disclose.

External validation of a nomogram predicting survival in men with metastatic hormone-refractory prostate cancer

e16066

Background: Armstrong et al. (Clin Cancer Res. 2007;13:6396–403) recently published a nomogram predicting the probability of survival in patients with hormone-refractory prostate cancer. The initial report showed a predictive accuracy of 0.69. So far, this nomogram was not yet externally validated. We validated this nomogram in a cohort of patients with hormone-refractory prostate cancer participating in five phase II trials. Methods: In our institution, 84 patients received chemotherapy for metastatic symptomatic hormone-refractory prostate cancer from September 1999 to November 2006. Follow-up was stopped in March 2008 and median follow up for all patients was 15.7 month. 75% of patients received docetaxel based chemotherapy. At the time of inclusion, median age was 69.0 years, median PSA was 40ng/ml, 93% had known bone metastases and 19% had visceral metastases. The area under the receiver operating characteristics curve was used to estimate the predictive accuracy of the nomogram and calibration plots were used for comparison between predicted and observed probabilities. Results: Of all patients, median survival was 15.5 month. The nomogram predicted median survival was 19.9 month, overestimating the true survival by roughly 30%. The predictive accuracy of the predictions at 1 year, 2 years and 5 years was 0.76, 0.69 and 0.64, respectively. The calibration plots showed departures from ideal predictions at 1 year (up to 20% of over estimation of true survival) and 5 years ( up to 19% of under estimation of true survival), whereas the predictions at 2 years showed almost perfect calibrations. Conclusions: The Armstrong et al1 nomogram provides accurate survival predictions in patients with hormone-refractory prostate cancer. The current external validation of this nomogram provides evidence that the nomogram might generally be applied to those patients in daily practice.

No significant financial relationships to disclose.

Multicystic peritoneal mesothelioma: report of three cases

Multicystic peritoneal mesothelioma is a rare lesion occurring mainly in women in a reproductive age. Its pathogenesis is unclear. We report three cases of multicystic peritoneal mesothelioma in patients that were 28, 38 and 47 years of age (one male, two females). A history of abdominal surgery was reported in two cases. Explorative laparotomy was presumptive of a pseudomyxoma peritoni in two cases, and hyperthermic intraperitoneal chemotherapy was performed. Histological examination demonstrated multicystic lesions with mesothelial cells lining confirmed by immunohistochemical analysis. Unusual findings such as hyperplasia, hobnail features, cytoplasmic vacuolisation and papillary pattern were occasionally noted. The clinical presentation, pathogenesis and pathologic features including differential diagnosis of multicystic peritoneal mesothelioma are discussed.

Risk of immune thrombocytopenic purpura after measles-mumps-rubella immunization in children

BACKGROUND

The measles-mumps-rubella vaccine has been associated with immune thrombocytopenia purpura in 2 small studies.

METHODS

By using the Vaccine Safety Datalink, we identified measles-mumps-rubella-vaccinated children aged 1 to 18. A case of immune thrombocytopenia purpura was defined as a patient with a platelet count of < or = 50,000/microL with clinical bleeding and normal red and white blood cell indices. The immune thrombocytopenia purpura incidence rates during exposed (42 days after vaccination) and unexposed time periods were determined. A retrospective cohort of vaccinated children was used to determine incident rate ratios for children aged 1 to 18 years, 12 to 23 months, and 12 to 15 months.

RESULTS

A total of 1,036,689 children received 1,107,814 measles-mumps-rubella vaccinations; there were 259 confirmed patients with immune thrombocytopenia purpura. Because only 5 exposed cases occurred after age 2, analyses were limited to children aged 12 to 23 months. Exposed patients aged 12 to 23 months had lower median platelet counts than those who were unexposed and had similar median duration of illness (11 vs 10 days). The incident rate ratio was highest for children aged 12 to 15 months at 7.10. The incident rate ratio for boys aged 12 to 15 months was 14.59, and the incident rate ratio for girls in the same age group was 3.22. Seventy-six percent of immune thrombocytopenia purpura cases in children aged 12 to 23 months were attributable to measles-mumps-rubella vaccination. This vaccine causes 1 case of immune thrombocytopenia purpura per every 40,000 doses.

CONCLUSION

Measles-mumps-rubella vaccine that is given in the second year of life is associated with an increased risk of immune thrombocytopenia purpura.

Encephalopathy after whole-cell pertussis or measles vaccination: lack of evidence for a causal association in a retrospective case-control study

BACKGROUND

Whole-cell pertussis (wP) and measles vaccines are effective in preventing disease but have also been suspected of increasing the risk of encephalopathy or encephalitis. Although many countries now use acellular pertussis vaccines, wP vaccine is still widely used in the developing world. It is therefore important to evaluate whether wP vaccine increases the risk of neurologic disorders.

METHODS

A retrospective case-control study was performed at 4 health maintenance organizations. Records from January 1, 1981, through December 31, 1995, were examined to identify children aged 0 to 6 years old hospitalized with encephalopathy or related conditions. The cause of the encephalopathy was categorized as known, unknown or suspected but unconfirmed. Up to 3 controls were matched to each case. Conditional logistic regression was used to analyze the relative risk of encephalopathy after vaccination with diphtheria-tetanus-pertussis (DTP) or measles-mumps-rubella (MMR) vaccines in the 90 days before disease onset as defined by chart review compared with an equivalent period among controls indexed by matching on case onset date.

RESULTS

Four-hundred fifty-two cases were identified. Cases were no more likely than controls to have received either vaccine during the 90 days before disease onset. When encephalopathies of known etiology were excluded, the odds ratio for case children having received DTP within 7 days before onset of disease was 1.22 (95% confidence interval [CI] = 0.45-3.31, P = 0.693) compared with control children. For MMR in the 90 days before onset of encephalopathy, the odds ratio was 1.23 (95% confidence interval = 0.51-2.98, P = 0.647).

CONCLUSIONS

In this study of more than 2 million children, DTP and MMR vaccines were not associated with an increased risk of encephalopathy after vaccination.

Expression of tpo mRNA in thyroid tumors: quantitative PCR analysis and correlation with alterations of ret, Braf , ras and pax8 genes

Immunocytochemistry (ICC) of thyroid peroxidase (TPO) using the monoclonal antibody MoAb47 has been used as malignancy marker on thyroid fine needle aspiration. However, little is known about the fate of TPO in thyroid carcinoma. We performed a qualitative PCR (Q-PCR) analysis to measure the expression of variants of tpo mRNA in 13 normal tissue samples, 30 benign tumors (BT), 21 follicular carcinomas (FC), 20 classical papillary carcinomas (PCc), 12 follicular variants of papillary carcinomas (PCfv) and nine oncocytic carcinomas (OC). We also studied mutations involving the ras, Braf, ret or pax8 genes. Results of Q-PCR were closely correlated with those of ICC (P < 0.0001; R = 0.59) and showed that overall tpo expression was lower in all carcinomas than in normal and BT (P < 0.05). The ratio tpo2 or tpo3 to tpo1 was inversed in follicular tumors. Genetic mutations were observed in 90% of PCc, 61.9% of FC, 41.7% of PCfv, 0% of OC and 10% in BT. pax8-ppar gamma1 rearrangement was correlated with qualitative changes in tpo mRNA (P < 0.01). These results confirmed the decrease of TPO expression in 97% of thyroid carcinomas regardless of histological type and the overexpression of shorter splice variants in follicular tumors. Both reduction in quantity of TPO and impairment of its maturation process could account for the atypical immunohistochemical reaction of MoAb47 with TPO.

ret/PTC1 and ret/PTC3 in thyroid tumors from Chernobyl liquidators: comparison with sporadic tumors from Ukrainian and French patients

Like children exposed to Chernobyl fallout, the workers who cleaned up after the accident, also known as liquidators, have exhibited an increased incidence of thyroid cancer. A high prevalence of ret/PTC3 rearrangement has been found in pediatric post-Chernobyl thyroid tumors, but this feature has not been investigated in liquidator thyroid tumors. In this study we analyzed the prevalence of ret/PTC1 and ret/PTC3 in thyroid tumors from 21 liquidators, 31 nonirradiated adult Ukrainian patients, and 34 nonirradiated adult French patients. ret rearrangements in carcinomas were found in 83.3% of liquidators, 64.7% of Ukrainian patients, and 42.9% of French patients. The prevalence of ret/PTC1 was statistically similar in the three groups. The prevalence of ret/PTC3 was significantly higher in liquidators than in French patients (P = 0.03) but it was also high in nonirradiated Ukrainian patients who exhibited values intermediate between liquidators and French patients. In adenomas the prevalence of rearrangement was significantly higher in all Ukrainians than in French patients (P = 0.004). Like children exposed to Chernobyl fallout, liquidators showed a high prevalence of ret/PTC3. This finding suggests that irradiation had the same effect regardless of age. However, given the high rate of ret/PTC3 in nonirradiated adult Ukrainians, the possibility of genetic susceptibility or low-level exposure to radiation in that group cannot be excluded.

Lymph node involvement in macroscopic medullary thyroid carcinoma

Background

Medullary thyroid carcinoma (MTC) is a rare disease, with variable tendency to lymphatic spread. The aim of this retrospective study was to identify distinctive features of large MTC with and without nodal metastases.

Methods

Between 1993 and 2003, 28 consecutive patients underwent total thyroidectomy and neck node dissection for sporadic MTC larger than 10 mm in diameter.

Results

All tumours were confirmed to be malignant with a locally invasive pattern of growth. Lymph node metastases were present in 16 patients (N1) and absent in 12 (N0). There were no statistically significant differences between patients with N0 and N1 tumours concerning age (mean 52·1 versus 53·4 years), male:female ratio (0·7 versus 1·0), basal preoperative calcitonin concentration (mean 3238 versus 3076 pg/ml) and tumour size (23·3 versus 23·9 mm). There were differences in the incidence of tumour invasion (P &lt; 0·001), vascular embolism (P = 0·011) and peritumoral thyroiditis (P = 0·039). Measurement of basal and stimulated calcitonin levels after surgery confirmed biochemical cure in all patients with N0 tumours and half of those with N1 disease (P = 0·006).

Conclusion

There were no preoperative factors that predicted node status for MTC larger than 1 cm in this series. Total thyroidectomy and nodal dissection remains the optimal treatment.

Medically recorded allergies and the risk of childhood acute lymphoblastic leukaemia

Data on five allergic conditions were abstracted from the medical records of 180 cases of childhood acute lymphoblastic leukaemia (ALL) and 718 matched controls. Odds Ratios (OR) and 95% Confidence Intervals (CI) were estimated for composite variables and for individual allergies using conditional logistic regression modelling. Allergies were divided into late and early diagnoses (those made within the year before the matched case's ALL diagnosis and those made earlier, respectively). Among the early diagnoses, atopy or hives was significantly associated with ALL (OR=2.20; 95% CI: 1.16-4.16). Significant associations were found for late diagnoses of atopy or hives (OR=3.78; 95% CI: 1.00-14.29) and of asthma (OR=3.10; 95% CI: 1.39-6.95). None of the other allergic conditions were associated with ALL. These results are contrary to those of prior studies of childhood ALL and allergy.

Risk of hospitalization because of aseptic meningitis after measles-mumps-rubella vaccination in one- to two-year-old children: an analysis of the Vaccine Safety Datalink (VSD) Project

OBJECTIVE

To assess the level of increased risk, if any, of hospitalizations for aseptic meningitis after Jeryl-Lynn mumps strain measles-mumps-rubella (MMR) vaccine in the Vaccine Safety Datalink population.

STUDY DESIGN

A possible increased risk of aseptic meningitis 8 to 14 days after receipt of MMR was observed in a preliminary screening analysis of automated data from the Vaccine Safety Datalink (VSD) project Year 2 analysis. To further evaluate this association a retrospective 10-year matched case-control study was undertaken in the four health maintenance organizations (HMOs) in the VSD project. Cases ascertained from a broad scan of the automated data were validated against a standard case definition. Two controls matched on age, sex, HMO and HMO membership were assigned per case.

RESULTS

The VSD project involves the cooperative collection of automated vaccination and medical outcome data from four large HMOs that currently have 500,000 children younger than 7 years of age under surveillance. Review of automated screening results from the first 2 years of data revealed a possible increased risk of aseptic meningitis 0 to 14 days after MMR with a relative risk of 3.61 (95% confidence interval, 1.0 to 13.1) although the total number of cases was small. Although the automated data had suggested a possible association of aseptic meningitis with MMR containing the Jeryl-Lynn strain of mumps, review of validated hospitalized cases during the observation period did not reveal evidence of an increased risk of aseptic meningitis after MMR containing the Jeryl-Lynn strain of mumps (odds ratio < 1.0 for all analyses).

CONCLUSION

Although it is recognized that hospitalized cases represent a minority of the total cases of aseptic meningitis, it is reassuring that in this evaluation no increased risk of aseptic meningitis after MMR vaccine was found.

Sequential by-passes for limb salvage

Direct revascularisation of the foot permits the healing of distal trophic lesions. This is not always possible with a by-pass on a single isolated popliteal segment. When multi-segmental occlusive arterial lesions were found in femoral, popliteal and distal arteries sequential by-pass grafting was used to improve distal runoff. During a 5 year period (1988-1992), 53 sequential by-passes were performed in 52 patients with severe ischemia manifested by rest pain (17) or trophic lesions (36). Autogenous saphenous vein was used in 36 (10 reversed, 26 in-situ), homologous saphenous in 3 and composite (PTFE+saphenous) in 14. Proximal anastomosis was performed on 29 common femoral, 20 superficial femoral and 4 popliteal arteries. Intermediary anastomosis was performed on 6 above-knee and 31 below-knee popliteal arteries and on 16 distal arteries. All distal anastomoses were performed on distal arteries (13 cases on malleolar arteries). The mean follow-up was 18 months. Thirteen patients died during this period (mean 8.5 months after the surgery). Primary and secondary patency were respectively 66 and 79% over one year and 51 and 76% over two years. Limb salvage was obtained in 89% over one year and 86% over 2 years. Sequential by-pass is a useful alternative for limb salvage. This approach offers several hemodynamic advantages and may be the best procedure in patients with poor distal runoff.