Tumor Markers and Lung Cancer: Guidelines in a Cost-limited Medical Organization

The aim of our study was to evaluate the cost of the tumor marker assays most widely used in pneumological practive and the effectiveness of the percentage of DRG-based reimbursements absorbed by these assays.

For this purpose we assessed the cost of lung tumor marker assays in Emilia Romagna compared to the DRG-based reimbursement of inpatients affected by lung diseases in whom the use of tumor markers is indicated.

As an example, we evaluated the cost/effectiveness of the CEA assay in the differential diagnosis of 68 pleural effusions from 46 patients (20 benign diseases, 26 malignant).

Because the CEA assay was not a substitute for cytology when this was not diagnostic, 41.3% of the resources were not efficiently spent. If the marker assay had been performed only in cases with negative cytology, we could have spared 14 of 46 tests.

Moreover, since the expense lies predominantly in the cost of reagents (81.23%), we suggest as a routine procedure to collect and store samples for tumor marker assay in all cases; the test should be performed in a selected population of patients with negative cytology and “suspect” clinical outcome.

[The 'dreams' of Cesare Augusto Levi: a pre-Freud interpretation]

On 25th February, 1887 Cesare Augusto Levi, a poet and archaeologist born in Venice in 1856, held a conference on dreams at the "Ateneo di Venezia". The conference deals with the nature of dreams, with the unconscious, with hypnosis and magnetism. Levi advocates a socially oriented version of psychiatry and he may be considered as a forerunner of Freud's theories.

Effect of a mineral water on gastric emptying of patients with idiopathic dyspepsia

The antidyspeptic property of mineral waters has for many years been based on empirical data. In the present paper we evaluated the effects of one type of mineral water, Tettuccio water from Montecatini, on gastric emptying in patients with idiopathic dyspepsia. Fourteen subjects, eight patients with idiopathic dyspepsia and delayed gastric emptying at scintigraphy and six healthy subjects with normal gastric emptying were studied. The gastric emptying of mineral water was studied with a scintigraphic method and compared with that of tap water. In patients with idiopathic dyspepsia, gastric emptying of both waters was slower than in controls but the gastric emptying of mineral water was significantly faster than that of tap water, both in dyspeptic patients and in healthy subjects. In conclusion, this mineral water stimulates gastric emptying. Further studies are needed on the possible role of this water in the management of chronic idiopathic dyspepsia.

[Changes caused by mineral water on gastrointestinal motility in patients with chronic idiopathic dyspepsia]

BACKGROUND

The antidyspeptic property of mineral waters has been based for ages on empirical data. In the present paper the effects of one of them (Tettuccio, Montecatini) on gastrointestinal motility of patients with dyspepsia has been evaluated.

METHODS

The study was carried out on 24 patients with idiopathic dyspepsia and delayed gastric emptying at scintigraphy and 18 healthy subjects with normal gastric emptying. The gastric emptying of this mineral water was studied with a scintigraphic method in comparison with tap water, while its effects on gastroduodenal contractions were evaluated by of manometry.

RESULTS

The gastric emptying of this mineral water was significantly faster than that of tap water, both in dyspeptic patients and in normals. Manometric examination showed that the administration of mineral water induced a brief decrease of phasic motor activity, followed by a progressive increase, which in some cases ended in an activity front of the Migrating Motor Complex.

CONCLUSIONS

This mineral water has a stimulating effect on both gastric emptying and interdigestive cyclic motor activity of the gastroduodenal tract. Both these effects could be useful in the treatment of chronic idiopathic dyspepsia and impaired gut clearing.

111In-octreotide scintigraphy in endocrine tumors. Preliminary data

A large number of endocrine tumors express somatostatin receptors, and the use of radiolabeled somatostatin analogs has been recently introduced for their localization. Using in vivo scintigraphy with 111In-pentetreotide, primary tumor localizations were demonstrated in 3/3 carcinoids (2 intestinal carcinoids and 1 lung ACTH-secreting carcinoid; in 2 patients liver metastases larger than 1 cm were visualized), in 1/1 GH-secreting pituitary macroadenoma, and in 1/1 thyroid localization of MTC. Bone and/or lymph node metastases were imaged in 2/4 patients previously treated for MTC, with persistently high CT and CEA levels; in the other 2 patients the other scintigraphic techniques were also negative. Octreotide scintigraphy was negative in 2/2 insulinomas and in 2/2 ACT-producing pituitary adenomas. In 2 patients with carcinoid syndrome and 1 patient with Cushing syndrome due to ectopic ACTH, octreotide therapy induced a significant decrease in tumoral markers. Our preliminary data are in agreement with the results of larger series reported in literature: octreotide scintigraphy is a useful noninvasive tool to detect endocrine tumors expressing somatostatin receptors, particularly for carcinoids. It is of great use in the differential diagnosis of Cushing syndrome due to ectopic ACTH. Moreover, 111In-pentetreotide scintigraphy may be useful in selecting patients who may benefit from octreotide therapy to control hormonal hypersecretion effects.

Evaluation of stage 4 neuroblastoma patients by means of MIBG and 99mTc-MDP scintigraphy

In a group of 22 patients with a stage 4 neuroblastoma, MIBG and 99mTc-MDP scintigraphy and radiological skeletal survey were performed at diagnosis to assess the presence of metastatic skeletal disease. In 20 out of 22 patients the MIBG scan was repeated during follow-up at a time when maximum tumoral regression was expected, i.e. after 3-4 cycles of chemotherapy; scan results were correlated to clinical and laboratory data. At diagnosis MIBG scan showed bone involvement in 19/22 patients, 99mTc-MDP in 20/22 and radiological skeletal survey in 11/22. In 1 patient only marrow aspirate revealed diffusion of disease beyond the primitive lesion. A total of 117/161 (72%) bone lesions were detected by MIBG, 89/161 (55%) by 99mTc-MDP and 47/161 (29%) by radiological skeletal survey. MIBG scintigraphy revealed bone marrow involvement in 11/22 patients in whom either marrow aspirate or bone biopsy were positive. In 5 patients 14 soft tissue lesions were also discovered and all but one primitive lesion accumulated MIBG. Although MIBG scan detected a greater number of bone lesions than 99mTc-MDP, in two patients in whom MIBG scan was negative 99mTc-MDP revealed the presence of bone involvement. Therefore we conclude that 99mTc-MDP scan is necessary to fully assess bone involvement in neuroblastoma at diagnosis. When MIBG scan was repeated after chemotherapy there was a general reduction of the number of detected lesions and in 8/17 patients both bone metastases and marrow involvement could no longer be detected.(ABSTRACT TRUNCATED AT 250 WORDS)

67Ga citrate scanning, X-ray computed tomography and chest X-ray in the study of interstitial pneumonia in patients with AIDS

Problems in the investigation of pulmonary interstitial pneumocystis carinii in AIDS patients in the early phase with 67Ga, high-resolution CT scan and chest X-ray are discussed, and a clinical study of 12 individuals is presented. The combination of the three examinations is useful in reducing false negative cases. The use of 67Ga scanning, chest X-ray and high-resolution CT is also proposed in the follow-up of AIDS patients during remission of their lung pathology.

Use of TPA in hepatology of infectious nature. Initial observations

The tissue polypeptide antigen, TPA, is a tumour-associated antigen which is synthesized during the S phase of cellular division and released later by the tissues when rapid growth takes place. For this reason, the TPA is considered to be a specific phase tumour-associated antigen. Since Björklund detected the antigen in 1957 much less has been written about research into the presence of the TPA in high concentration in the blood of subjects with tumours in different sites. The TPA can, however, be measured in moderate quantities in healthy individuals and in those with hepatic pathology (hepatitis and cirrhosis) and pathology of a viral nature. In hepatic parenchymal pathology, repeated measurements of this marker show normalization with the benign course of the disease. The aim of this work is to evaluate if the use of the TPA can be useful in hepatology of an infectious nature as an index of cytoreproduction, a phenomenon which often affects the hepatocytic cytolysis which is found in acute viral hepatitis.

Combination of tissue polypeptide antigen (TPA) and carcino embryonic antigen (CEA) in different types of cancer

Tissue polypeptide antigen (TPA) and carcino embryonic antigen (CEA) were measured in 55 patients with cancer in different locations (21 lung cancer, 133 breast cancer, 9 stomach cancer, 5 colorectal cancer, 7 cancer of unknown origin). TPA gives elevated values in all types of cancer. The statistical analysis shows that TPA is about equally sensitive for all cancer types, while CEA has a particularly high sensitivity for colorectal carcinoma. The TPA values in the group of cancer patients is significantly different from those in a group of healthy controls. TPA gives higher sensitivity than CEA in all tumour locations. By the use of combined determination of TPA and CEA the sensitivity can be further increased, to 64% for the whole patient population and 89% for the gastric tumour patients, even when the cut-off values are chosen so high that no false positives are obtained in either reference group (150 Ul-1 for TPA, 10 ng ml-1 for CEA). A limited correlation exists between the markers in tumour patients.

99mTc-HIDA dynamic scintigraphy for the diagnosis of gastroesophageal reflux of bile

In 5 patients with partial gastric resection and esophagitis, in whom esophageal pH metry was unable to demonstrate significant gastroesophageal reflux (GER), we administered i.v. 5 mCi (185 MBq) of 99mTc-HIDA, the patient lying under a computer-assisted LFOV gamma camera. When gallbladder image was evident, caerulein was administered i.v. at a physiologic dose in order to induce gallbladder contraction, and in the subsequent 45 min the patient was asked to perform a standard series of manoeuvres that increase the intraabdominal pressure (Valsalva, etc.) and favour GER. Scintigraphic images and time/activity curves obtained from areas of interest corresponding to gastric remnant and distal esophagus showed that at least one of these manoeuvres in each case was followed by the appearance of the radiocompound in the distal esophagus, indicating a 99mTc-HIDA-tagged bile GER. Consequently, we believe that HIDA-GER dynamic scintigraphy may be more useful than esophageal pH metry in demonstrating the biliary origin of an esophagitis.

In vivo isotope study of the thyroid with 99mTcO4- in neonatal congenital hypothyroidism

Seventeen patients, screened from a neonatal programme for hypothyroidism were studied. As well as the scintigraphic investigations, serum TSH, T3, free T3, T4, free T4, and TBG were measured in all patients. Not more than 11.1 MBq (300 microCi) 99mTcO4- was administered IV. A gamma camera with a parallel-hole collimator on line with the computer was used. The method allowed good statistics to be obtained in 5-10 min in a wide field of exploration, thus reducing the problems of positioning and prolonged immobilization of the young patient. The data collected in the computer were elaborated to define better the characteristics of the thyroid image. This kind of in vivo study introduced into a screening programme, enables an 'anatomic' diagnosis of the defect to be obtained before starting the therapy. This is undoubtedly valuable from the epidemiological point of view, enables early determination of the degree of thyroid insufficiency, and contributes to the formulation of a prognosis based on the degree and on the moment in which prenatal harm occurred.

[Neonatal screening for congenital hypothyroidism. Experience at a Regional Center]

We examined 107,670 infants born in the Italian region Emilia-Romagna. Capillary blood samples for contemporary T4 and TSH radioimmunoassay were collected on the 3rd, 4th, 5th, 6th, 7th or between the 7th and the 15th day of life on filter paper. In our method the threshold value for recall for a second assay was calculated taking into account the mean - 2 SD of each session for T4, and fixing between 30 and 50 microU/ml the threshold value for TSH. The re-call percentage was 0.74%. 21 subjects confirmed to be affected by congenital hypothyroidism; this corresponds to a frequency in our region of 1 case every 5,127 infants. 12 subjects had a TBG deficiency, this corresponds to a frequency of 1 case every 8,972 infants. No cases of secondary hypothyroidism were found up to date.

[Use of radioisotopes in the evaluation of coronary disease]

A study on myocardial perfusion through scintigraphy with 201-Tl has been carried on in a group of 57 persons: among them 45 had myocardial infarction and 12 had myocardial ischemia in act. In consideration of this experience, the myocardial scintigraphy with 201-Tl seems to be a valid investigation method to support the electro-vectocardiography when evaluating, bloodlessly, ischemical cardiopathies. In general, the correlation between electro-vectorcardiographic and scintigraphic data has been satisfactory. Referring to stroken parts, we can say that also those cardiac sectors usually very difficult to be explored with other radio elements such as 131-CS and 42-K, have been adequately studied with 201-Tl. To sum up, we can say that scintigraphic investigation of myocardium with 201-Tl is certainly a valid blood-less method to diagnose ischemical cardiopathy with the advantage to be also a useful diagnostical element for the evaluation of the microcirculation.

Retained gastric antrum syndrome diagnosed by [99mTc] pertechnetate scintiphotography in man: hormonal and radioisotopic study of two cases

Retained-antrum syndrome is a rare condition, occurring in Billroth II gastrectomised patients, in which an ulcer recurs associated with high levels of circulating gastrin. Some gastrin tests are useful to differentiate a retained antrum from a gastrinoma, but a firm diagnosis is sometimes very difficult. We have studied two cases of retained-antrum syndrome both by gastrin tests and by [99mTc] pertechnetate scintiphotography. By this method a prominent area of activity was observed on the anatomic site of the duodenal stump bottom. It appeared after 20 or 30 min and lasted for the 2 hr of observation. After surgical resection, no area of activity was observed at the scintiphotographic followup. No false positive was observed out of the more than 30 subjects studied. Scintiphotography by pertechnetate seems able to demonstrate the presence and the size of retained gastric antrum in B II gastrectomised patients with recurrent ulcer.