Dosing of intra-articular triamcinolone hexacetonide for knee synovitis in chronic polyarthritis: a randomized controlled study

Objective: Intra-articular glucocorticoid (IAGC) injection treatment is an easy and effective way to treat the signs and symptoms of arthritis, but there is limited knowledge on the adequate dosing for different joints. The aim of this study was to compare the outcome between two common doses of intra-articular triamcinolone hexacetonide (THA) for knee synovitis using the relapse rate during 6 months. Methods: A total of 159 adult patients with rheumatoid arthritis (RA) or psoriatic arthritis (PsA) and active knee synovitis were randomized to IAGC injection with 20 mg or 40 mg THA. Participants were blinded to the treatment dose. The primary endpoint was relapse of arthritis. When symptoms from the treated joint recurred and signs of arthritis could be confirmed on a subsequent clinical examination, a relapse was recorded and the duration of response survival was calculated. At the end of the observation period, patients without relapse were telephoned to verify the persistence of the good treatment response. Results: The proportion of relapse after 6 months was equal in the 20 mg and 40 mg THA treatment arms (30% vs 32%, respectively, p = 0.822), and no significant differences were found in the subgroups with RA and PsA patients. Conclusion: As no difference in outcome was found between the compared doses, the lower 20 mg THA dose should be preferred in IAGC treatment for knee synovitis in chronic polyarthritis. This may also reduce pharmaceutical costs and metabolic side effects. EudraCT number: 2014-000993-20, Clinical Trials.gov identifier: NCT02437461.

Effect of Interferon on T1 Relaxation Times of Liver Metastases from Endocrine Gastrointestinal Tumours

Eight patients with liver metastases from endocrine gastrointestinal tumours were examined with magnetic resonance imaging of the liver before and during treatment with interferon. T1, T2 and tumour size were measured and compared with tumour marker levels and symptomatic improvement or deterioration. Before therapy all tumours showed a long T1 and T2, in comparison to normal liver and fat, and during therapy they all showed a decrease in T1. As no change in liver T1 and fat T1 occurred, the decreased tumour T1 is considered to be a therapy effect. This cannot be fully explained but is possibly due to a reduction in tumour growth rate during interferon treatment. There was no certain correlation between tumour T1 and tumour marker levels or symptomatic changes.

Preoperative Localization of Endocrine Pancreatic Tumours by Intra-Arterial Dynamic Computed Tomography

Eleven patients with biochemically confirmed endocrine pancreatic tumours were examined with intra-arterial (i.a.) dynamic computed tomography (CT) and angiography preoperatively. Seven of the patients suffered from the multiple endocrine neoplasia type 1 (MEN-1) syndrome. All patients were operated upon and surgical palpation and ultrasound were the peroperative localization methods. Of the 33 tumours which were found at histopathologic analysis of the resected specimens in the 11 patients, 7 tumours in 7 patients were correctly localized by both i.a. dynamic CT and angiography. Six patients with MEN-1 syndrome had multiple tumours and this group of patients together had 28 tumours, of which 5 (18%) were localized preoperatively by both CT and angiography. I.a. dynamic CT, with the technique used by us, does not seem to improve the localization of endocrine pancreatic tumours, especially in the rare group of MEN-1 patients, as compared with angiography.

Angiography, Computed Tomography, Magnetic Resonance Imaging and Ultrasonography in Detection of Liver Metastases from Endocrine Gastrointestinal Tumours

Twenty-five patients with endocrine tumours (13 with endocrine pancreatic tumours and 12 with carcinoids) were examined with angiography, computed tomography, magnetic resonance imaging and ultrasonography. Seventeen patients had liver metastases and were followed between 3 and 66 months with serial examinations during treatment with chemotherapeutic agents and interferon. The efficiency of the various techniques to detect metastases was investigated. Analysis of changes in tumour size during treatment was made to see if treatment effects could be monitored with radiologic examinations. Ultrasonography was the best non-invasive method for detection of metastases and is recommended as standard method for imaging in this group of patients. Angiography was even better showing extremely small metastases, less than 5 mm, and is recommended in selected cases. With one exception, no significant change in tumour size was noted in spite of clear laboratory and clinical signs of therapy effect indicating that tumour size determination is not useful for therapy monitoring in this type of disease.

Ultrasound-Guided Biopsies of Neuroendocrine Metastases

Twenty-five patients with known neuroendocrine tumour disease were biopsied with 1.2 mm and 0.9 mm biopsy-gun needles to evaluate the respective diagnostic accuracy of the 2 needle sizes. The influence of treatment-related fibrosis on the histopathological diagnosis was also evaluated. The overall diagnostic accuracy with the 0.9 mm needle was 69% as compared to 92% with the 1.2 mm needle. This difference, however, seems more related to needle guiding difficulties with the 0.9 mm needle than to insufficient tissue yield. When the tumour was hit with both the 0.9 and the 1.2 mm needle the tissue yield was inferior with the 0.9 mm needle in only one of 16 cases. The increased amount of fibrous tissue due to interferon treatment did not seem to negatively influence the diagnostic accuracy.

Unusual complication of a pancreatic neuroendocrine tumor presenting with malignant hypercalcemia

CONTEXT

Hypersecretion of PTHrP is a relatively common cause of malignancy-related hypercalcemia but has only been described in a few cases of neuroendocrine tumors (NET).

OBJECTIVE

The aim of this case report is to describe the clinical syndrome, complex therapeutic interventions, and unusual complications caused by persistent PTHrP hypersecretion in a patient with a pancreatic NET.

CASE ILLUSTRATION

A 58-yr-old male patient presented with nonspecific abdominal pain and was found to have severe hypercalcemia secondary to a well-differentiated NET of the pancreas associated with extensive liver metastases. Elevated ionized calcium levels accompanied by low serum PTH and remarkably elevated PTHrP concentrations were consistent with PTHrP-related hypercalcemia that proved to be resistant to various chemotherapeutic regimens and supportive therapy. Partial control of the humoral syndrome was obtained only after the application of cytoreductive interventions and the introduction of various molecular targeted therapies. Due to persistent PTHrP action, bone disease emerged in the form of brown tumors.

DISCUSSION

The manifestation of paraneoplastic syndrome due to PTHrP hypersecretion, despite its rareness in NET, should be considered in the differential diagnosis of hypercalcemia in such tumors. Moreover, the appearance of bone lesions in this setting may be in the context of metabolic bone disease and could be misdiagnosed as bone metastases.

The effects of pasireotide (SOM230) on health-related quality of life in patients with metastatic carcinoid tumors refractory or resistant to octreotide LAR

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Background: Pasireotide is a novel multi-ligand somatostatin analogue with high affinity binding for four of the five somatostatin receptor subtypes (sst1,2,3 and sst5). This Phase II clinical trial showed that pasireotide is effective in controlling the symptoms of diarrhea and flushing in 27% of patients with metastatic carcinoid tumors refractory or resistant to octreotide LAR. The impact of pasireotide therapy on health-related quality of life (HRQL) was also evaluated. Methods: Patients in this open-label, multicenter study initially received pasireotide 300 μg sc bid which was escalated to a maximum dose of 1,200 μg sc bid until clinical response was achieved. Data are reported for the Functional Assessment of Chronic Illness Therapy-Diarrhea (FACIT-D) instrument. FACIT-D comprises the Functional Assessment of Cancer Therapy-General (FACT-G) score, which measures physical, social, emotional and functional well-being, plus a symptom-specific sub-scale which measures HRQL specific to diarrhea. FACIT-D baseline assessment was obtained on day 1 immediately before dosing, and then monthly thereafter. FACIT-D sub-scale and total scores at baseline and after 1, 2, and 3 months of pasireotide treatment are described by categories of clinical response. Results: 45 patients (mean age 61 years; range 40–83) received treatment, and 44 were eligible for the efficacy and HRQL analyses. Functional well-being scores, symptom-specific scores and total FACIT-D scores of non-responders tended to be lower at baseline and during treatment than those of responders. The three sub-scale and summary FACIT-D scores exhibited relatively stable mean HRQL scores and similar patterns of variability in clinical responders and non- responders through the third month of pasireotide treatment. Conclusions: HRQL was stable during treatment with pasireotide in patients with advanced metastatic disease refractory or resistant to octreotide LAR. Additional work in HRQL study design and evaluation of HRQL endpoints in patients with carcinoid disease is indicated, and will further improve our understanding of quality of life in patients with this disease.

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Interferon-alpha and somatostatin analog in patients with gastroenteropancreatic neuroendocrine carcinoma: single agent or combination?

In most cases gastro-enteropancreatic neuroendocrine tumors grow slowly. Interferon-alpha and somatostatin analogs have shown symptomatic, biochemical, and, in a minority of cases, antiproliferative activity. Generally, they are proposed as single-agent therapy. However, based on in vitro and in vivo evidence, the combined use of these drugs was proposed in several non-randomized trials, indicating that there is an additive effect of the combination. Nevertheless, the three randomized trials published so far did not show a statistically significant survival benefit for the combination compared to the same agents alone, even though an advantage for the combination came out in all three studies. On the other hand, data from non-randomized trials would justify the sequential use of the two drugs or the combination after progression on single agent therapy. Therefore, at present the up-front combined use of interferon-alpha and somatostatin analog is not justified, whereas it could be indicated after progression to single-agent therapy. Further larger, international, prospective, randomized, multicentric clinical trials studying homogeneous populations would be necessary to give a final answer, but the rarity and heterogeneity of this malignancy does not assure that it will be possible.

Antiserum directed against chromogranin A and B (CAB) is a useful marker for peptide hormone-producing endocrine cells and tumors

Certain proteins, such as the chromogranins, have a ubiquitous occurrence in nearly ail peptide hormone-producing cells. To date, little is known about their functional role as structural proteins, precursors of bioactive peptides, or enzymes. Such proteins may serve as markers for endocrine cells and tumors. In the present study, we have used an antiserum that recognizes both chromogranin A and B (CAB) to demonstrate peptide hormone-producing endocrine cells and tumors in humans. The antiserum demonstrated endocrine cells all along the gastrointestinal tract, most of the islet cells, the adrenomedullary cells, the thyroid C cells, scattered endocrine cells in the respiratory tract, and numerous cells in the adenohypophysis. The CAB-positive cells outnumbered those storing chromogranin A as studied in the intestines and the anterior pituitary. An array of different peptide hormone-producing tumor cells were also CAB-positive, including several types of islet cell tumors, gastric, intestinal, and bronchial carcinoids, medullary thyroid carcinomas, and pheochromocytomas. Thus, the CAB antiserum may help identify peptide hormone-producing cells and tumors.

Electron-microscopical immunocytochemical study of a pancreatic islet amyloid polypeptidoma

A 50-year-old man developed a pancreatic islet tumor with liver metastases. High levels of islet amyloid polypeptide (IAPP) were recorded in plasma-35,000 pmol/L-concomitant with the occurrence of type II diabetes mellitus (the clinical syndrome has recently been described in detail) [25]. Light microscopically, the tumor contained considerable amounts of amyloid and displayed IAPP immunoreactivity both in the tumor cells and in the amyloid stroma. Electron-microscopical examination of the liver metastases showed presence of round secretory granules in the tumor cells. The granules were immunoreactive to chromogranin A and B and IAPP but not to insulin. The amyloid deposits were mainly accumulated in the extracellular spaces but were also present in the tumor cell cytoplasm. The intracellufar amyloid fibrils were, as revealed by immunogold labeling, IAPP immunoreactive and seemed to emerge from the secretory granules in the shape of radiating threads. The results show that in this particular case, the amyloid formation started already at the intracellular level and in close proximity to the lAPP-storing secretory granules. The findings may have some significance for understanding the development of pancreatic islet B-cell-related amyloidosis in type II diabetes mellitus.