Effect of tibolone on breast cancer recurrence: LIBERATE trial bone sub-study

Abstract #66

LIBERATE, a randomized, placebo controlled, double blind trial studied the effect of tibolone (Livial), a tissue selective hormone replacement therapy (HRT) on breast cancer (BC) recurrence, aiming to demonstrate non-inferiority of treatment compared to placebo. In the LIFT trial of osteoporotic women, tibolone prevented BC development.
 Design and Method: Women with surgically treated BC (T1-3, N0-2, M0) within the last 5 years complaining of vasomotor symptoms, were randomly assigned to tibolone 2.5mg daily or placebo treatment for a maximum of 5 years. Adequate sample size was estimated to be >1500 in each arm. A bone mineral density (BMD) sub-study of 724 patients (454 Caucasian; 270 Asian) was enrolled utilizing DXA scanning at baseline and 2 years.
 Results: Between 2002 and 2004, 3,148 women were randomized in 31 countries; 1579 to tibolone and 1569 to placebo. Mean age at randomization was 52.7 years (28.0-75.0) and mean time since surgery was 2.1 years. In total 58% of women recruited were node positive and 78% ER positive. The trial closed prematurely in July 2007, with a median follow-up of 3.1 years (0.01-4.99) per patient, because an increased risk of BC recurrence occurred on tibolone HR 1.40 (1.14-1.70; p<0.001); 15.2% (237/1556) women on tibolone recurred compared to 10.7% (165/1542) on placebo. Risk for distant recurrence on tibolone was HR 1.38 (95% CI 1.09-1.74 p=0.007).
 Aromatase inhibitor (AI) users had the highest risk of recurrence on tibolone HR 2.42 (1.01-5.79) compared to tamoxifen treated women HR 1.25 (0.98-1.59). Compared to ER positive cancers HR 1.56 (1.22-2.01), ER negative cancer had no increased risk of recurrence HR 1.15 (0.73-1.80). No differences in mortality occurred between groups.
 At entry to the bone sub-study, 298 (43%) women had normal BMD, 313 (45%) osteopenia (T-score between -1 and -2.5) and 81 (11.7%) osteoporosis. Low body mass index (<0.001), Asian race (p<0.001) and old age at menarche predicted for low bone mass after 2 years. Tibolone increased BMD by 3.5% at the lumbar spine and 2.9% at the hip compared to placebo (both p<0.001) and reduced fracture rate in the Caucasian (p=0.036) but not the Asian population. Women with normal BMD (before or at day 1) had increased recurrence on tibolone 15.1% (21/139) compared to placebo 6.9% (11/159) p=0.036, whereas no increased BC recurrence was seen in women with low BMD; 7.5% (15/201) on tibolone and 6.7% (13/193) on placebo.
 Conclusion: HRT after breast cancer treatment increases BC recurrence especially in AI treated patients. Risk of BC recurrence is elevated in BC women with normal BMD (compared to low) who take HRT.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 66.

Safety of tibolone in the treatment of vasomotor symptoms in breast cancer patients--design and baseline data 'LIBERATE' trial

Many patients with a history of breast cancer (BC) will suffer from vasomotor symptoms, which can be induced or exacerbated by treatment with tamoxifen or aromatase inhibitors. The LIBERATE trial was designed as a randomized, double-blind, multicenter trial to demonstrate that tibolone 2.5mg/day (Livial) is non-inferior to placebo regarding BC recurrence in women with vasomotor symptoms surgically treated for primary BC within the last 5 years. Secondary objectives are effects on vasomotor symptoms as well as overall survival, bone mineral density and health-related quality of life. Mean age at randomization was 52.6 years, and the mean time since surgery was 2.1 years. The mean daily number of hot flushes and sweating episodes was 7.3 and 6.1, respectively. For the primary tumor, Stage IIA or higher was reported for >70% of the patients. In subjects whose receptor status was known, 78.2% of the tumors were estrogen receptors positive. At randomization, tamoxifen was given to 66.2% of all patients and aromatase inhibitors to 7%. Chemotherapy was reported by 5% at randomization. The adjuvant tamoxifen use in LIBERATE allows a comparison with the Stockholm trial (showing no risk of BC recurrence associated with hormone therapy), which was stopped prematurely subsequent to HABITS. The LIBERATE trial is the largest, ongoing, well-controlled study for treatment of vasomotor symptoms in BC patients.

Osteopenia and osteoporosis in untreated non-Hodgkin's lymphoma patients: An important and potentially treatable survivorship issue in lymphoma

9055

Background: Alkylating agents and steroids can cause premature osteoporosis, increasing the risk of vertebral and hip fracture. The bisphosphonate pamidronate every 3 months can reduce bone loss and the risk of new vertebral fractures in lymphoma patients receiving chemotherapy.(Kim et al., 2004 Am J Med) We are conducting a randomized study of the more potent bisphosphonate zoledronic acid in untreated non-Hodgkin's lymphoma (NHL) patients to study chemotherapy induced bone loss. Methods: During the accrual period, we report the baseline bone mineral density (BMD) characteristics for screened untreated NHL patients. Exclusion criteria included bone fractures, BMD T-scores worse than -2.0, CrCl < 60 mL/min, dental problems, prior bisphosphonate or significant steroid use. Patients accrued to the study were randomized to receive either: 1) oral calcium and vitamin D (Ca+D) or 2) Ca+D and 4 mg zoledronic acid IV at baseline and at 6 months. Results: Patient characteristics: 59 males and 55 females with median age 63 (range: 18–87). Lymphoma types: B-cell n=111, T-cell 3; follicular (FL) 56, diffuse large B-cell (DLBCL) 33, mantle cell 8, and others, totaling 114 patients. Of untreated NHL individuals screened for baseline BMD to date 11/114 (10%) had osteoporosis and 62/114 (54%) had osteopenia or osteoporosis. The lowest BMD was a T-score of -4.4. Other bone, dental, and endocrine abnormalities excluded some patients from treatment randomization. Patients with T scores < -2.0 were considered for off-study treatment with bisphosphonates. Osteopenia and osteoporosis were common across lymphoma subtypes: FL 25/56 (45%), DLBCL 20/33 (61%), mantle cell 6/8 (75%), and marginal zone 5/6 (83%). The low rate of osteopenia/osteoporosis of 25% for Burkitt/Burkitt-like lymphoma may reflect fast lymphoma kinetics without associated increase in bone loss. Conclusions: Baseline testing of BMD revealed osteopenia or osteoporosis in the majority of untreated NHL patients. This widely available and non-invasive test should be considered in untreated NHL patients. Our ongoing clinical trial will address the potential role of zoledronic acid in preserving bone density for survivors of NHL. ClinicalTrials.gov Identifier: NCT00352846

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Hypocalcemia induced by bisphophonates in cancer patients with vitamin D deficiency

19644

Background: The use of bisphosphonates for treatment of hypercalcemia, bone pain and reduction of skeletal morbidity in metastatic breast cancer is increasing. Moreover, vitamin D deficiency is commonly associated with cancer. Hypocalcemia has been reported following IV bisphosphonate use. Methods: We present the clinical and lab findings in 6 cases of bisphosphonate-induced hypocalcemia, caused by unmasked vitamin D deficiency. Results: Our 1st patient was diagnosed with breast cancer and developed metastases 6yrs later. She was given Zolendronic acid 4 mg IV with a baseline calcium level (Ca) of 9.7 mg/dl, normal albumin, and elevated alkaline phosphatase. 3 days later, she developed symptomatic severe hypocalcemia with tetany: Ca dropped to 6.1 mg/dl with recovery. After her 2nd dose of Zolendronic acid, Ca dropped again to 6 mg/dl with normal albumin, intact parathyroid hormone (PTH) of 637 pg/ml (range 10–65) and 25-hydroxy vitamin D levels (25-OHD) of 4 ng/ml (range 20–100). Our 2nd patient presented with metastatic breast cancer and was treated with Zolendronic acid for hypercalcemia with a baseline Ca of 13 mg/dl, PTH-related protein of 2.8 pmol/l (range <1.8) and PTH of 7 pg/ml. She then developed hypocalcemia with corrected Ca of 7.7 mg/dl and 25-OHD of 13 ng/ml. Our 3rd patient with breast cancer was also treated with Zolendronic acid for bone metastases and hypercalcemia. She then presented with symptomatic hypocalcemia: ionized Ca level of 1.09 mmol/l (range 1.13–1.32), PTH of 211 pg/ml and 25-OHD of 13 ng/ml. Our other 3 cases had similar presentations to the above and will be discussed in detail. All 6 cases were treated with ergocalciferol and long-term oral calcium and vitamin D therapy. All of our cases presented with symptomatic hypocalcemia with vitamin D levels less than 30ng/mL. Conclusions: Since bisphosphonate use is increasing in cancer patients and vitamin D deficiency is not an uncommon finding in this population, consideration should be given to routine checking of 25-OHD levels before initiating treatment with bisphosphonates and supplementing with calcium and vitamin D when necessary (<30ng/mL). This could potentially prevent further morbidity. Further prospective studies would be needed for early replacement with vitamin D and calcium in those with vitamin D deficiency.

No significant financial relationships to disclose.

A phase II trial of gefitinib monotherapy in patients with unresectable adrenocortical carcinoma (ACC)

15527

Background: ACC is a rare malignancy with a very poor prognosis. Surgery is the only potential curative option. Gefitinib is an oral EGFR inhibitor that may have activity in solid tumors that express EGFR. ACC over expresses EGFR in a high proportion of cases. Methods: From April 2004 through December 2006, the ACC Working Group conducted a phase II trial of Gefitinib as second line, monotherapy in patients with pathologically confirmed unresectable ACC who had progressed on mitotane or chemotherapy. All prior systemic therapy was discontinued 28 days prior to starting gefitinib. Patients were ineligible if: had received prior therapy with any EGFR inhibitor, pregnant or breast feeding, had other co-existing malignancies (other than basal cell carcinoma or cervical cancer in situ), had an ECOG PS > 2, absolute neutrophil counts < 1,500, or platelets < 20,000. Patients were not allowed concomitant use of phenytoin, carbamazepine, rifampicin, barbiturates, or St John’s Wort. Patients took gefitinib 250 mg orally once a day. Each cycle was 21 days with radiological assessment every 6 weeks.Response rate as determined by RECIST criteria was the primary endpoint. Results: 19 patients accrued to the study (18 with measurable disease and 1 without). Pt Characteristics: Female 79% (15/19); Median age 48 (range 26–74); 84% (12 female and 4 male =15/19) of the patients had steroid secreting tumors. Grade 3 toxicity was noted in 2 patients and included, hypertension and lower extremity edema and elevated liver transaminases. No grade 4 toxicities occurred. Of 19 patients evaluable, there were no complete responders, partial responders or patients with stable disease (0% response rate; 95% CI: 0%-18%). Conclusions: Gefitinib demonstrated no activity in patients with unresectable ACC. This study is now closed. This study demonstrated the ability to successfully accrue to a trial of novel agents in rare tumors in a multicenter setting.

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Chemotherapeutic management of adrenocortical carcinoma: The M. D. Anderson Cancer Center experience

14592

Background: Adrenocortical carcinoma (ACC) is a rare cancer associated with a poor prognosis. We describe our experience with the effectiveness of various chemotherapies in the treatment of ACC. Methods: We performed a detailed retrospective review of every patient diagnosed with ACC at the M.D. Anderson Cancer Center between the years 1980 and 2000. We included only those patients with a histological diagnosis of ACC who had radiologically measurable disease and received chemotherapy followed by post-treatment imaging. Patients without a pathological diagnosis, serial imaging studies, or adequate follow-up were excluded from our study. In each case, we compared radiological tumor burden after a given drug or drug combination to the radiological tumor burden preceding the treatment session. Radiologist reports were used to categorize post-treatment imaging studies as showing either a decrease in tumor burden, no change in tumor burden, or an increase in tumor burden. Patients who did not have post-treatment imaging due to rapid progressive clinical deterioration were regarded as having increased tumor burden. Results: 224 patients with a diagnosis of ACC were identified in our database, of which 62 had histological confirmation and received chemotherapy with documented radiological follow-up. 38 different chemotherapeutic regimens were reviewed. Patients given single agent fluorouracil, taxol, taxotere, trimetrexate, navelbine, and patients given combination treatment with cyclophosphamide/adriamycin/cisplatin, gemcitabine/taxotere, and mitotane/cisplatin/taxol did not show any improvement. Treatment with single agent mitotane and combination VP-16/cisplatin resulted in either no change or decrease in tumor burden in over 50% of sessions. Promising trends were seen in patients treated with single agent VP-16 and carboplatinum, and with combination adriamycin/cisplatin/ifosfamide, mitotane/cisplatin, and VP-16/adriamycin/cisplatin. Conclusions: We have identified specific drugs and drug combinations of no apparent benefit in this cohort, and have also identified select agents and combinations which offer benefit. Further prospective clinical trials should focus on the use of those agents and combinations which offer benefit.

No significant financial relationships to disclose.

Vasoactive intestinal polypeptide-secreting tumor (VIPoma) with liver metastases: dramatic and durable symptomatic benefit from hepatic artery embolization, a case report

Neuroendocrine tumors often manifest an excess production of hormones that create severe metabolic abnormalities resulting in significant patient morbidity, independent of the tumor burden itself. VIPomas are rare neuroendocrine tumors arising from the pancreas and are associated with secretory diarrhea and electrolyte disturbances. We present a patient with VIPoma and hepatic metastases who had greater than 10 loose stools a day for 4 yr since diagnosis, despite debulking surgery, multiple antidiarrheal medications, large doses of octreotide, and targeted radioisotope injections. The patient required several hospitalizations for treatment of dehydration and electrolyte disturbances, despite receiving daily intravenous fluids at home. Hepatic artery embolization (HAE) immediately stopped the patient's diarrhea and provided a return to normal formed stools without any other symptom-support measures. One year after HAE, the patient remains asymptomatic and has returned to a productive life. HAE can be a very effective and durable treatment modality for patients with metastatic VIPomas (or other neuroendocrine tumors) and who are clinically symptomatic from the effects of hormone hypersecretion.

Osteosarcoma of bone in apatient with primary hyperparathyroidism: a case report

A 69-year-old woman was diagnosed with a malignant tumor of the right proximal femur. She had primary hyperparathyroidism and chronic elevation of parathyroid hormone levels (PTH > 1,000 pg/ml). She underwent resection of the bone lesion; histological analysis showed a high-grade fibroblastic osteosarcoma. In addition, she underwent curative resection of a large left superior parathyroid adenoma. To our knowledge, this is the third reported clinical case of osteosarcoma arising in association with hyperparathyroidism.

Adrenocortical carcinoma. Clinical outcome at the end of the 20th century

BACKGROUND

Adrenocortical carcinoma remains a rare and lethal neoplasm. Effective therapies have not emerged in recent decades. However, medical advances have improved diagnostic techniques and supportive measures; these changes may have a beneficial impact on the natural history of the disease.

METHODS

The authors retrospectively analyzed the clinical outcomes of patients with adrenocortical carcinoma registered at the University of Texas M.D. Anderson Cancer Center focusing on patients who received their diagnosis since 1980 and comparing data from those patients with earlier reports.

RESULTS

Since 1980, 139 patients have registered at M.D. Anderson Cancer Center with the diagnosis of adrenocortical carcinoma. One-third had evidence of hormone hypersecretion, and one-third had localized disease at diagnosis. Men were affected as frequently as women but tended to be older and have larger tumors at diagnosis. The 5-year survival rate was 60% (Kaplan-Meier analysis). The 30 patients with the longest survival (> 5 years) and the 30 patients with the shortest survival (< 11 months) had no significant differences in age, gender, tumor size, or functionality. However, long-term survivors had significantly less extensive disease. A comparison with patients reviewed in earlier reports from the same institution showed no significant differences in gender predilection, tumor function, or extent of disease. Despite these similarities, patients whose disease was diagnosed since 1980 lived much longer than patients observed in earlier decades.

CONCLUSIONS

Despite the lack of significant improvements in early diagnosis and effective therapies, patients with adrenocortical carcinoma are living longer (5-year survival rate, 60%). It is important to revise assumptions regarding the clinical outcomes of patients with this disease.

Severe osteopenia in a young boy with Kostmann's congenital neutropenia treated with granulocyte colony-stimulating factor: suggested therapeutic approach

Kostmann's syndrome is a congenital disorder that causes an impairment of myeloid differentiation in the bone marrow characterized by severe neutropenia, which can be treated with recombinant human granulocyte colony-stimulating factor (G-CSF). We present the case of a 13-year-old boy with Kostmann's syndrome who was treated with recombinant human G-CSF from age 3.5 years. His growth and development was normal, although complicated by intermittent infections. Bone mineral density (BMD) measurement revealed severe osteopenia at the spine and hips (lumbar spine BMD 0.486 g/cm(2); Z score -3.6), and he was referred to the Endocrine Service. Relevant laboratory evaluation showed a pretreatment ionized calcium level at the upper limit of normal (1.28 mmol/L; range: 1.13-1.32 mmol/L), suppressed intact parathyroid hormone (iPTH) level (12 pg/mL; range: 10-65 pg/mL), and a low 1,25-dihydroxy vitamin D level (21 pg/mL; range: 24-65 pg/mL). He had evidence of increased bone turnover evidenced by elevated urinary deoxypyridinoline (DPD) cross-links (46.9 nmol/mmol creatinine; range: 2-34 nmol/mmol creatinine) and a simultaneous increase in markers of bone formation with elevated osteocalcin level (200 ng/mL; normal: 20-80 ng/mL) and alkaline phosphatase level (236 IU/mL; normal: 38-126 IU/mL). Because of clinical concern for his skeletal health, bisphosphonate therapy with intravenous pamidronate was initiated. One month after treatment, the iPTH and DPD cross-links were in the normal range (54 pg/mL and 17.7 nmol/mmol creatinine, respectively) and the 1,25-dihydroxy vitamin D level was elevated (111 pg/mL). Four months after treatment, there was a striking increase in BMD at the lumbar spine (+30.86%), femoral necks (left, +20.02%; right, +17.98%), and total hips (left, +18.40%; right, +15.94%). Seven months after bisphosphonate therapy, his biochemical parameters showed a return toward pretreatment levels with increasing urinary DPD cross-links (28.7 nmol/mmol creatinine) and decreasing iPTH (26 pg/mL). However, the BMD continued to increase (8 months posttreatment), but the magnitude of the increment was attenuated (lumbar-spine, +4.8%; left total hip, +1.2% and right total hip +2.4%), relative to BMD at 4 months. Eight months after the initial treatment, his iPTH was suppressed at 14 pg/mL and he again received pamidronate (at a lower dose); 3 months later, he had an additional increase in BMD (lumbar spine +7.4%, left total hip +3.9%, right total hip +2.7%), relative to the previous study. We hypothesize that prolonged administration of G-CSF as treatment for Kostmann's syndrome is associated with increased bone resorption, mediated by osteoclast activation and leading to bone loss. In children, the resulting osteopenia can be successfully managed with antisreorptive bisphosphonate therapy with significant improvement in bone density. Measurements of biochemical parameters of bone turnover can be used to monitor the magnitude and duration of the therapeutic response and the need for BMD reassessment and, perhaps, retreatment.

The development of breast carcinoma in women with thyroid carcinoma

BACKGROUND

Breast carcinoma and thyroid carcinoma are two malignancies that occur most commonly in women. An association between the incidence rates of thyroid and breast carcinoma in women after a diagnosis of the other malignancy has been suggested in a retrospective analysis of a single institution's tumor registry. In that study, an increased incidence of breast carcinoma in premenopausal women previously treated for thyroid carcinoma was observed.

METHODS

The purpose of this study was to investigate further this relation utilizing a large database, the National Cancer Institute's Surveillance, Epidemiology and End Results (SEER) database. The SEER database is maintained by the National Cancer Institute, and it represents 11 population-based cancer registries covering approximately 14% of the United States population. The study was a population-based retrospective cohort analysis using external comparisons. From 1973 to 1994, 365 women in the SEER database were identified as having both thyroid and breast carcinomas. The SEER database from 1973 to 1994 was utilized to calculate age specific and calendar year specific incidence rates for each year for thyroid and breast carcinomas. The expected number of second cancers for each age group, calendar year, and follow-up period were determined by multiplying these incidence rates by the age specific and calendar year specific number of person-years at risk. The risk ratio (RR) was calculated by dividing the observed by the expected number of second cancers. Statistical significance was determined by the Poisson test.

RESULTS

A total of 1,333,115 person-years were available for analysis. One hundred thirteen thyroid carcinoma cases were diagnosed after breast carcinoma cases (RR, 0.99; P = 0.576). Two hundred fifty-two breast carcinoma cases were diagnosed after thyroid carcinoma cases (RR, 1.18; P = 0.007). Premenopausal women (age 20-49 years) with an index thyroid carcinoma have a significantly increased risk of developing subsequent breast carcinoma (RR, 1.42; P = 0.001). Black premenopausal women with an index thyroid carcinoma do not have an increased risk of developing breast carcinoma, but the statistical power is lower due to low numbers. No women with index breast carcinoma have an increased risk of developing thyroid carcinoma.

CONCLUSIONS

Women with a history of thyroid carcinoma have a greater than expected risk of developing breast carcinoma. This risk is most pronounced in premenopausal white women. The implications of this observation with respect to breast carcinoma screening guidelines and thyroid carcinoma treatment guidelines deserve further investigation.

Interplay of pregnancy, lactation, and hyperthyroidism leading to severe osteoporosis in a young woman

OBJECTIVE

To describe the case of a young woman who had severe osteoporosis due to the compounding effects of pregnancy, lactation, and hyperthyroidism and who had a presumed metastatic lesion in the lumbar spine.

METHODS

We present the clinical, pathologic, radiologic, and laboratory findings and describe the clinical course of our patient.

RESULTS

A 31-year-old Arabic woman was referred to the M. D. Anderson Cancer Center because of a lytic lesion in her lumbar spine, presumed to be metastatic deposits. She had a history of two consecutive pregnancies and intermittently treated hyperthyroidism. Our initial evaluation revealed that the patient had clinical and biochemical thyrotoxicosis, and we treated her with thionamides, corticosteroids, and radioiodine ablation. Radiologic studies disclosed a complex renal cyst that had increased uptake on a bone scan, which was highly suggestive of a primary malignant lesion. Ultimately, however, it proved benign on pathologic analysis after a left nephrectomy. Bone mineral density measurements identified severe osteoporosis (T-scores: lumbar spine, -3.3; right hip, -2.2; and left hip, -2.0), which had led to vertebral collapse and was misinterpreted as malignant metastatic disease. The bone mineral densities improved (+5 to +11% at the various sites) within 4 months after definitive treatment and cure of the hyperthyroidism.

CONCLUSION

The effect of pregnancies and prolonged lactation, in the milieu of other risk factors for bone depletion such as hyperthyroidism, may cause severe osteoporosis in a young patient. The resulting osteoporosis may manifest as a lesion suggestive of malignant metastatic involvement.

Corticosteroid-induced inhibition of adrenal androgen production in selected patients with prostate cancer

OBJECTIVE

To determine the effect of administration of corticosteroids on adrenal androgen production and the serologic markers of prostate cancer.

METHODS

Six patients with prostate cancer who had a serum testosterone concentration that exceeded 20 ng/dL despite treatment with medical or surgical castration were treated with dexamethasone. All patients were asymptomatic, but four were demonstrating progressive increases in serum prostate-specific antigen (PSA) concentrations. Dexamethasone, 1 mg at bedtime, was given initially and then increased to 1 mg twice daily if serum testosterone concentrations remained > or =10 ng/dL. The effect of treatment on PSA concentration was monitored.

RESULTS

The mean testosterone concentration (and standard error of the mean) was 47.5 +/- 7.9 ng/dL before administration of dexamethasone; this decreased to 5.2 +/- 3.0 ng/dL during therapy (P = 0.002). The effect was rapid (overnight) and sustainable (for 6 months). Although the duration of follow-up is limited, PSA concentrations generally stabilized (23.5 +/- 6.1 ng/mL at baseline in comparison with 15.6 +/- 1.1 ng/mL approximately 2 months after initiation of dexamethasone therapy; P = 0.24). Two patients required 1 mg of dexamethasone twice daily to suppress serum testosterone levels to <10 ng/dL.

CONCLUSION

Administration of corticosteroids in a manner opposing the normal circadian glucocorticoid production effectively and rapidly decreases adrenal androgen production in patients with prostate cancer treated with orchiectomy or luteinizing hormone-releasing hormone agonists. This reduction of androgen production was generally associated with a decrease or stabilization of PSA concentrations in all patients with increased PSA levels. Overnight dexamethasone suppression testing is useful in determining the minimal effective dose.

Hypercalcemia due to parathyroid hormone-related protein secretion by melanoma

About 1-2% of melanoma patients develop hypercalcemia. We report hypercalcemia without bone metastasis in a 46-year-old woman with advanced melanoma. The hypercalcemia was associated with elevated serum parathyroid hormone-related protein (PTHrP) levels. An even higher concentration (10 times the serum level) in pleural effusion caused by pleural metastases implied that the source of the increased circulating PTHrP was the melanoma. Immunohistochemical staining of paraffin sections, performed using a monoclonal antibody (9H7) against the peptide sequence 109-141 of human PTHrP, detected PTHrP in the cytoplasm and nucleoli of melanoma cells in an autopsy specimen but not in specimens from this patient prior to onset of hypercalcemia. Considering the evidence, it is very likely that PTHrP production by melanoma caused hypercalcemia in this patient.

Late effects of therapy in 94 patients with localized rhabdomyosarcoma of the orbit: Report from the Intergroup Rhabdomyosarcoma Study (IRS)-III, 1984-1991

BACKGROUND

We reviewed the late complications of therapy in 94 patients with localized, primary rhabdomyosarcoma of the orbit treated on the Intergroup Rhabdomyosarcoma Study (IRS)-III protocol (1984-1991).

PROCEDURE

A questionnaire was sent to the institutions that had registered 106 patients with orbital RMS on the IRS-III protocol, seeking information about vision, periocular structures, and growth and development of the 102 survivors.

RESULTS

Ninety-four questionnaires were returned. The median follow-up interval was 7.6 years. The affected eye was removed from 13 patients because of local recurrence (N = 10) or other causes (N = 3). Seventy-nine of the eighty-one remaining patients had received radiation therapy. Sixty-five of these seventy-nine patients (82%) developed a cataract, and 43 of them (66%) underwent cataract surgery. Fifty-five patients (70%) had decreased visual acuity. Twenty-four patients had a dry eye, and 22 had chronic keratitis, conjunctivitis, or corneal changes. Strabismus, diplopia, retinopathy, and uveitis were uncommon. The orbit was hypoplastic in 48 of 82 patients assessed (59%). Ptosis and enophthalmos were reported in 22 patients. Decreased statural growth was noted in 13 of the 53 irradiated patients aged 3-14 years at diagnosis with sufficient data (24%).

CONCLUSIONS

The overall survival rate was 96% (102/106). The eye was preserved in 86% of the patients, but vision was impaired in 70% of them. Other frequent complications were cataract, orbital hypoplasia, keratoconjunctivitis, and ptosis/enophthalmos. The current IRS-V study recommends decreasing the dose of irradiation and using conformal techniques in an attempt to minimize these complications.

Growth hormone deficiency in children with neurofibromatosis type 1 without suprasellar lesions

Risk factors for shortness of stature in children with neurofibromatosis type 1 (NF-1) include suprasellar lesions, which can lead to growth hormone deficiency (GHD), skeletal deformities, nutritional insufficiency, and methylphenidate use. At our Neurofibromatosis Clinic, we have observed short children growing poorly without these risk factors. This study investigated whether GHD occurs in children with NF-1 in the absence of suprasellar lesions. Of 251 children with NF-1, 112 were at or below the 25th percentile for height (68 were at or below the 10th). Of these, 51 children, 5-16 years of age were short, growing poorly, and without medical or radiologic findings to explain the poor growth. In 19 of 51, we evaluated GH secretion; 15 of 19 had GHD (peak GH level less than 5 ng/mL in most cases). These findings suggest that GHD may be relatively common in short children with NF-1 without suprasellar abnormalities, suggesting an association with NF-1 independent of organic, pituitary damage. Larger cohorts of NF-1 children should be evaluated to clarify whether NF-1 represents a novel etiology of GHD. Also, a careful assessment of GH secretion in children with NF-1 who are growing poorly in the absence of another clinical explanation is warranted.

Screening for MEN1 mutations in patients with atypical endocrine neoplasia

BACKGROUND

Most patients from typical multiple endocrine neoplasia type 1 (MEN1) kindreds harbor mutations in the MEN-1 gene, MEN1. We hypothesized that some patients with atypical endocrine neoplasia would also have mutations in MEN1.

METHODS

DNA sequencing analysis of mutations in the coding region of MEN1 was performed with genomic DNA obtained from peripheral blood lymphocytes in a total of 21 patients who had: typical MEN1 (n = 8), clinical features suggestive of MEN1 but without a family history of endocrinopathy (n = 7), and atypical endocrine neoplasia and a family history of endocrinopathy suggestive of MEN1 (n = 6).

RESULTS

All 8 patients with typical MEN1 had mutations in MEN1. None of the 7 patients with features of MEN1, but without a family history of endocrinopathy, had a MEN1 mutation. In contrast, 4 of 6 patients with atypical endocrine neoplasia that included components of MEN1 and a family history of endocrinopathy had mutations in MEN1, including 2 patients with pheochromocytoma.

CONCLUSIONS

Genomic mutations in MEN1 may frequently be identified in patients with atypical endocrine neoplasia, especially in the setting of a family history of endocrinopathy. Atypical presentations of MEN1 may include pheochromocytoma.

Late complications of therapy in 213 children with localized, nonorbital soft-tissue sarcoma of the head and neck: A descriptive report from the Intergroup Rhabdomyosarcoma Studies (IRS)-II and - III. IRS Group of the Children's Cancer Group and the Pediatric Oncology Group

BACKGROUND

This review of children and adolescents with nonorbital soft-tissue sarcoma of the head and neck was undertaken to describe late sequelae of treatment, as manifested primarily by problems with statural growth, facial and nuchal symmetry, dentition, vision and hearing, and school performance.

PROCEDURE

Four hundred sixty-nine patients entered the IRS-II and -III protocols with localized, nonorbital soft-tissue sarcomas of the head and neck from 1978 through 1987. Their overall survival rate was 53% (250/469) at 5 years. Two hundred thirteen patients were surviving relapse-free 5 or more years after diagnosis, for whom there were serial height measurements at 2 or more years after initiation of therapy. Their median age at diagnosis was 5 years; the median length of follow-up was 7 years. All received multiple-agent chemotherapy, and all but 3 received irradiation to the primary tumor volume. Sixty-eight percent of the tumors arose in cranial parameningeal sites, 22% in nonparameningeal sites, and 10% in the neck. We reviewed flow sheets submitted to the IRS Group Statistical Office to ascertain which late sequelae were recorded.

RESULTS

One hundred sixty-four patients (77%) had one or more problems recorded. One hundred ninety of the two hundred thirteen patients (89%) were under 15 years of age at study entry, and at follow-up 92 (48%) had failed to maintain their initial height velocity, which had decreased by more than 25 percentile points from the original value. Thirty-six of the one hundred ninety patients (19%) were receiving growth hormone injections. Hypoplasia or asymmetry of tissues in the primary tumor site was reported in 74 patients, and 13 underwent reconstructive surgery. Poor dentition or malformed teeth were noted in 61 patients. Impaired vision developed in 37 patients, owing primarily to cataracts, corneal changes, and optic atrophy. Thirty-six patients had decreased hearing acuity, and 9 were fitted with hearing aids; 5 of these 9 had received cisplatin. Thirty-five patients were noted to have problems learning in school. Four patients developed a second malignancy (two sarcomas, one carcinoma, one leukemia).

CONCLUSIONS

Late sequelae affected the majority of these patients treated for soft-tissue sarcoma of the head and neck on IRS-II and -III. The potential impact of certain sequelae could be reduced by specific measures, such as surgical reconstruction and hormonal therapy. Late sequelae must be taken into account in designing future curative treatments.

Estrogen replacement therapy after localized breast cancer: clinical outcome of 319 women followed prospectively

PURPOSE

To determine whether estrogen replacement therapy (ERT) alters the development of new or recurrent breast cancer in women previously treated for localized breast cancer.

PATIENTS AND METHODS

Potential participants (n = 319) in a trial of ERT after breast cancer were observed prospectively for at least 2 years whether they enrolled onto the randomized trial or not. Of 319 women, 39 were given estrogen and 280 were not given hormones. Tumor size, number of lymph nodes, estrogen receptors, menopausal status at diagnosis, and disease-free interval at the initiation of the observation period were comparable for the trial participants (n = 62) versus nonparticipants (n = 257) and for women on ERT (n = 39) versus controls (n = 280). Cancer events were ascertained for both groups.

RESULTS

Patient and disease characteristics were comparable for the trial participants versus nonparticipants, as well as for the women on ERT versus the controls. One patient in the ERT group developed a new lobular estrogen receptor-positive breast cancer 72 months after the diagnosis of a ductal estrogen receptor-negative breast cancer and 27 months after initiation of ERT. In the control group, there were 20 cancer events: 14 patients developed new or recurrent breast cancer at a median time of 139.5 months after diagnosis and six patients developed other cancers at a median time of 122 months.

CONCLUSION

ERT does not seem to increase breast cancer events in this subset of patients previously treated for localized breast cancer. Results of randomized trials are needed before any changes in current standards of care can be proposed.

Osteopenia in young adult survivors of childhood cancer

BACKGROUND

Improved survival of children with malignant diseases is in part due to the application of intensive, multimodality therapies, including radiotherapy, surgery, glucocorticoids, and cytotoxic agents. Such interventions have the potential to induce complex hormonal, metabolic and nutritional effects that may interfere with skeletal mass acquisition during childhood and adolescence: it is possible that such childhood cancer survivors may therefore reach adulthood with diminished peak bone mass and be at increased risk for clinically significant osteoporosis later in their life.

PROCEDURE

A bone mineral density (BMD) was measured in 26 unselected former cancer patients attending the Pediatric Long-Term Clinic at M.D. Anderson Cancer Center. BMD was measured at the lumbar spine and the hip using dual X-ray absorptiometry (Hologic QDR-4500W). In addition, the patients' complete medical records were reviewed with particular attention to disease type, age modalities of treatment, and hormonal residual deficiencies.

RESULTS

The median age of patients at the time of cancer diagnosis was 8 years (range, 0.3 to 16 years). Median age at BMD determination was 23 years (range, 18 to 41 years), and the median interval since cancer diagnosis and BMD was 18 years (range, 5 to 29). Overall, their BMD was decreased relative to peak bone mass at all sites: osteopenia was especially pronounced in patients with a history of cranial irradiation who had developed evidence of pituitary insufficiency during childhood or adolescence. Overall, the median BMD T-score was -1.41 at the lumbar spine, -1.04 at the femoral neck, and -1.06 for total hip. For patients with prior cranial irradiation, T-score at the lumbar spine was -2.18 (range, -4.06 to -0.98), at the femoral neck -1.92 (range, -4.11 to +1.10), and for total hip -1.67 (range, -4.79 to +0.56); BMD for irradiated patients was significantly lower than BMD of patients without cranial irradiation. We could not discern an independent impact of other disease characteristics or treatment modalities in this small group of patients.

CONCLUSIONS

Osteopenia is a prominent finding in young adults who are survivors of childhood cancers; it is likely that antineoplastic treatments during childhood and adolescence impede peak bone mass acquisition. We suggest that systematic attention to this potential complication is needed in order to identify what subgroups of children may require regular surveillance and what interventions are required for its prevention or treatment.

Hormone replacement therapy and breast cancer

The use of hormone replacement therapy by postmenopausal women with a history of breast cancer is a subject of considerable controversy. There are no scientific studies that have appropriately examined the issue, and current practice is often based on inferences from indirect evidence, anecdotal experience, and personal bias. Our understanding of the effects of exogenous, as well as endogenous, hormones on normal and neoplastic breast tissue provides some insights but is not an appropriate basis for clinical practice. The effects of exogenous hormone replacement on the overall health of postmenopausal women, including psychosocial issues, cardiovascular risks, and the morbidity of osteoporosis, must be understood before patients can be counseled appropriately. Treatment of patients must be individualized. The rapidly expanding area of nonhormonal therapies for the treatment of postmenopausal health risks and the treatment of symptomatic complaints in postmenopausal women has already led to a reevaluation of the use of exogenous hormones among all women. A prospective randomized trial that examines the effects of hormone replacement on women with a history of breast cancer is currently underway and will provide valuable data to address these issues. The aim of this review is to outline the scientific basis for the association between estrogen and breast cancer and to provide a framework in which individualized recommendations concerning the use of hormone replacement therapy can be made for patients with breast cancer.

Incidence of breast carcinoma in women with thyroid carcinoma

BACKGROUND

Breast carcinoma and differentiated thyroid carcinoma(the most common endocrine malignancy) occur predominantly in women. An association between the two tumors has been suggested by some investigators, but the potential impact of treatment of one of these diseases on the development of the other remains unclear. The authors examined the relation between the occurrence of these two tumors.

METHODS

There were 41,686 patients with breast carcinoma and 3662 with thyroid carcinoma who registered at The University of Texas M. D. Anderson Cancer Center between March 1944 and April 1997. Women who received both diagnoses since 1976 were identified and incidence rates and relative risks of secondary tumor development were calculated. Surveillance, Epidemiology and End Results (SEER) program data on the age-adjusted incidences of these diseases during the same time period were used for the expected incidences in the same population.

RESULTS

Among 18,931 women with a diagnosis of breast carcinoma since 1976, 11 developed differentiated thyroid carcinoma > or = 2 years after the diagnosis of breast carcinoma. These breast carcinoma patients contributed 129,336 person-years of follow-up; the observed incidence of thyroid carcinoma in this group was not different from that in a similar age group of women in the SEER database. Among 1013 women with a diagnosis of thyroid carcinoma since 1976, 24 developed breast carcinoma > or = 2 years after the diagnosis of thyroid carcinoma. These thyroid carcinoma patients contributed 8380 person-years of follow-up; the observed incidence of breast carcinoma in women ages 40-49 years was significantly higher than the expected incidence for women in the same age group in the SEER database.

CONCLUSIONS

Breast carcinoma developing after thyroid carcinoma was diagnosed more frequently than expected in young adult women seen at the study institution since 1976. This potential association and plausible mechanisms of breast carcinoma development after thyroid carcinoma should be evaluated in larger cohorts of patients.

Follicular and Hurthle cell carcinomas of the thyroid: a comparative study

University of Texas M. D. Anderson Cancer Center cases filed as Hurthle cell and follicular carcinoma were reviewed. Requirements for including a case in the study were that the diagnosis of Hurthle cell or follicular carcinoma be confirmed, that histologic material and clinical information be adequate, and that there be at least 9 years of follow-up. The study group included 18 cases of Hurthle cell carcinoma and 33 cases of follicular carcinoma. Ten of the Hurthle cell carcinomas had extrathyroid invasion, three had intrathyroid invasion, and five were encapsulated (i.e., they had intracapsular invasion only). In the follicular carcinoma group, 5 tumors had extrathyroid invasion, 14 had intrathyroid invasion, and 14 were encapsulated. When the cases were stratified according to extent of invasion in this manner, there was no statistically significant difference in rate of local recurrence, rate of metastasis (either regional lymph node or distant), or patient survival between Hurthle cell carcinoma and follicular carcinoma. Other variables including patient age and sex, treatment differences, tumor size, vascular invasion, predominant growth pattern (follicular versus solid-trabecular), nuclear size and pleomorphism, mitotic rate, and tumor necrosis did not provide significant additional prognostic information. Metastases of both Hurthle cell and follicular carcinoma were mostly distant and predominantly involved bone and lung. Behavioral differences between Hurthle cell and follicular carcinoma that were not statistically significant included a higher rate of local recurrence in Hurthle cell carcinoma with intrathyroid invasion, more frequent occurrence of regional lymph node metastasis in Hurthle cell carcinoma with extrathyroid invasion, and absence of distant metastasis and death caused by tumor in encapsulated Hurthle cell carcinoma. Five follicular carcinomas and one Hurthle cell carcinoma appeared to have arisen within an adenoma.

Differentiated thyroid cancer in children and adolescents: clinical outcome and mortality after long-term follow-up

BACKGROUND

Children and adolescents with differentiated thyroid cancer (DTC) have a good prognosis and prolonged survival even when extensive regional disease or lung metastases are present at the diagnosis; very-long-term follow-up is needed to appreciate what, if any, impact the disease may exert on the ultimate outcome.

METHODS

We retrospectively reviewed the clinical course of 112 patients with DTC who registered at M. D. Anderson Cancer Center between 1944 and 1986, were younger than 20 years old at the time of diagnosis, and were followed for at least 10 years. Surgery alone or combined with radioactive iodine or radiotherapy was used for most cases.

RESULTS

At the time of most recent contact, 99 patients remained alive and 13 had died. The 99 patients had 25 +/- 0.9 years of available follow-up (mean +/- SEM) and were 41 +/- 0.9 years of age at time of last contact; one fourth had had recurrent disease at some point since diagnosis. Among the 13 patients who died, one died of complications from coexisting diabetes mellitus, and the cause of death was not clear in one other case. Two patients died of breast cancer 13 and 15 years after thyroid cancer diagnosis. In three cases, cause of death could be considered etiologically related to initial radiotherapy: one patient developed tracheal necrosis 26 years after diagnosis and died of upper airway complications, whereas another two patients developed sarcomas of the cervical region 22 and 29 years after thyroid cancer diagnosis. Lastly, six patients died of thyroid cancer 26 +/- 3.1 years after initial diagnosis (at age 40 +/- 2.1 years). Among these cases, one patient had invasive disease and lung metastases at diagnosis and died of progressive lung metastases after 36 years. The other five patients were initially seen with local/regional disease and developed lung and skeletal metastases after a 2- to 20-year disease-free interval.

CONCLUSIONS

Our findings support the clinical impression that children and adolescents with DTC live for many years regardless of apparent extent of disease at diagnosis or development of recurrence. Indeed, overall survival was 100% at 10 years even in patients with distant metastases. However, attention to these patients' clinical course beyond the first decade indicates that a small minority (5% to 7%) of patients eventually succumb to progressive disease and that a similar number develop possibly treatment-related lethal complications or second neoplasms. We suggest lifelong surveillance for all such patients.

The role of glucagon administration in the diagnosis and treatment of patients with tumor hypoglycemia

BACKGROUND

Tumor hypoglycemia can be recurrent and severe enough to interfere with definitive antineoplastic treatment. Therefore, rapid commencement of effective therapy is essential. This is best accomplished by identifying which of the hypoglycemic processes is involved, as treatments differ. Some patients present with hypoglycemia and liver metastases; among them, only a few develop hypoglycemia as a result of a failure of hepatic glucose production. Most develop hypoglycemia as a result of an insulin-mediated process--either the secretion of insulin by an islet-cell tumor or the secretion of insulin-like growth factor-II by an extrapancreatic tumor. Administration of glucagon can rapidly make the two groups distinguishable, thus allowing institution of therapy and prompt symptomatic control of hypoglycemia.

METHODS

The charts of seven patients with tumor hypoglycemia and liver metastases who had a glucagon stimulation test (serial glucose measurements after a 1 mg infusion of glucagon) as part of the workup for hypoglycemia were retrospectively reviewed. Those patients whose test revealed a rise in serum glucose of >30 mg/ dL were subsequently treated as outpatients, with a continuous glucagon infusion delivered by a portable pump.

RESULTS

Three patients had an insulinoma and four had non-islet cell tumor hypoglycemia (NICTH) due to hepatocellular carcinoma, colon carcinoma, meningeal sarcoma, and hemangiopericytoma, respectively. All of the patients had liver metastases. Evaluation of these patients included a glucagon stimulation test (1 mg intravenous push), which quickly provided information about the mechanism of tumor hypoglycemia and the direction towards therapy. All patients with insulinoma responded to glucagon with a rise in blood serum glucose levels, indicating adequate glycogen stores. The four patients with NICTH had mixed responses: in two patients, the response suggested that hypoglycemia was due to an insulin-like tumor product; glucose levels did not rise in the other two cases, indicating that hypoglycemia was due to poor hepatic glycogen reserve/liver failure. In all cases, a glycemic response to glucagon predicted good response to long term treatment with glucagon (0.06-0.3 mg/hour, via intravenous infusion pump).

CONCLUSIONS

The glucagon stimulation test is a simple and fast approach that serves to clarify the etiology of hypoglycemia (diagnostic use) and guide effective long term strategies for its control (therapeutic use) in patients with neoplastic diseases and liver metastases.

Pilot study of bone mineral density in breast cancer patients treated with adjuvant chemotherapy

The objective of this cross-sectional study was to determine lumbar spine bone mineral density (BMD) in breast cancer patients previously treated with adjuvant chemotherapy. Sixteen of 27 patients who received adjuvant chemotherapy became permanently amenorrheic as a result of chemotherapy. BMD was measured at the lumbar spine using dual energy X-ray absorptiometry (DEXA). Chemotherapy drugs and dosages along with a history of risk factors for reduced bone density including activity level, tobacco and/or alcohol use, metabolic bone disease, family history, and hormone exposure were identified. Results showed that women who became permanently amenorrheic as a result of chemotherapy had BMD 14% lower than women who maintained menses after chemotherapy. Chemotherapy-treated women who maintained ovarian function had normal BMD. This study suggests that women who have premature menopause as a result of chemotherapy for breast cancer are at increased risk of bone loss and may be at risk for early development of osteoporosis. Women who maintain menses do not appear to be at risk for accelerated trabecular bone loss.

Estrogen replacement therapy in women with prior diagnosis and treatment for breast cancer

We followed 49 women who underwent a minimum of 2 years estrogen replacement therapy (ERT) after diagnosis and treatment for localized breast cancer. Forty-three women were treated with oral ERT. In this group, the median age at the time of cancer diagnosis was 46 years (range 26 to 66 years), and ERT was begun a median of 84 months after diagnosis (range 0 to 286 months). The patients were followed for a median of 144 months after cancer diagnosis (range 46 to 324 months), and the median duration of ERT was 31 months (range 24 to 142 months). For six women, ERT was administered as a vaginal cream application. In this group, the median age at time of cancer diagnosis was 46 years (range 38 to 57 years), and ERT was begun a median of 49 months after diagnosis (range 24 to 61 months). The patients were followed for a median of 95 months after cancer diagnosis (range 72 to 154 months), and the median duration of ERT was 47 months (range 27 to 80 months). One patient experienced disease recurrence; she had received surgery for a stage I, estrogen receptor (ER)-positive lesion. The patient began ERT 30 months after cancer diagnosis and developed a recurrent ER-negative tumor 56 months after initiation of ERT. She remained alive without evidence of disease for 10 years since initial diagnosis of breast cancer. Despite the inherent limitations of retrospective experiential data and the need for prospective, randomized trials to assess the safety of ERT, the present observations suggest that ERT does not appear to have a pronounced adverse effect on cancer outcome. Nevertheless, until appropriate clinical trials determine that ERT is safe, caution is needed.

Estrogen replacement therapy after treatment for localized breast carcinoma. Patient responses and opinions

BACKGROUND

Women who reach menopause after receiving treatment for breast carcinoma have been advised to avoid estrogen replacement therapy (ERT), but the validity of this practice is being reappraised and the need for prospective studies is discussed. The likely response of potential participants to the tangible rather than theoretic option for ERT provides not only useful information for planning such studies but also important insights into the attitudes and expectations of breast cancer survivors.

METHODS

Women with a history of localized breast carcinoma, potentially eligible for participation in this prospective ERT study, were interviewed in person or by telephone and were asked to consider participation in a prospective, randomized study of ERT. In addition, information was obtained regarding their disease stage, estrogen receptor (ER) status, age at diagnosis, age at interview, and elapsed time since cancer treatment.

RESULTS

The authors contacted 555 women; 137 did not meet criteria for study participation. Among the 418 women eligible for the program, one-third indicated a lack of interest and cited travel, financial, or age considerations. One-third of the women were apprehensive about ERT risk and declined. Forty women (13%) were either already receiving ERT or were seeking a prescribing physician. Finally, 17% of the women enrolled in our study. There were no differences among the groups with respect to disease stage, ER status, age at diagnosis and interview, or time elapsed since cancer treatment.

CONCLUSIONS

Women with a history of breast carcinoma harbor considerable reluctance regarding ERT for the management of menopausal health concerns. However, a significant minority have already opted for ERT and up to 20% may become participants in clinical programs. Plans for large scale trials of ERT in this subset of women require careful attention to patient attitudes and concerns.

Clinical outcome of patients with papillary thyroid carcinoma who have recurrence after initial radioactive iodine therapy

BACKGROUND

Among patients with well differentiated papillary thyroid carcinoma who generally have an excellent prognosis and a near-normal lifespan, there exist subsets of patients who have significant risk for morbidity and mortality from this disease. It is important to define the patterns of disease progression and the clinical outcome of such patients to develop effective surveillance and treatment strategies. Patients with recurrence after surgery and therapeutic administration of radioactive iodine (RAI) for papillary thyroid carcinoma represent one such subset of high-risk patients.

METHODS

At the University of Texas M. D. Anderson Cancer Center, 65 patients with papillary thyroid carcinoma were diagnosed between 1970 and 1990. Their medical records were reviewed with particular attention to disease recurrence and outcome as well as RAI imaging and treatment.

RESULTS

Following diagnosis and initial therapy, 19 patients died from thyroid carcinoma after a median of 64 months; 34 had no evidence of disease for a median of 112 months of available follow-up; and 7 are alive with disease 61 to 153 months after diagnosis. Cervical lymph node metastases were present in 41 patients and extrathyroidal or extranodal tumor invasion was seen in 25 patients at the time of initial surgery; distant metastases (lung, bone, brain, liver, and adrenal) developed later in 18 patients. RAI uptake by recurrent tumor deposits in the neck was seen most frequently in patients with no direct invasion of adjacent tissues but with recurrence limited to cervical lymphadenopathy; this group of patients was the most likely to become clinically and radiologically disease free. RAI generally did not concertrate in invasive cancers with extrathyroidal or extranodal extension in the neck; patients with this type of invasive carcinoma were also more likely to die from the disease.

CONCLUSIONS

We suggest that among patients with recurrent papillary thyroid carcinoma, invasive cancers are less likely to concertrate RAI, whereas patients with disease confined to lymph nodes are more likely to have RAI-avid tumors and to benefit from RAI therapy.

Adrenal cortical neoplasms. A study of 56 cases

Fifty-six cases of adrenal cortical neoplasm with a minimum of 5 years follow-up are presented: 48 carcinomas and 8 adenomas. Adenomas typically had a maximal mitotic rate of fewer than 2 mitotic figures per 10 high-power fields (all cases), a prominent small nest growth pattern (7 cases), predominantly clear or foamy cytoplasm (6 cases), and no tumor necrosis (all cases), whereas carcinomas were characterized by at least 4 mitotic figures (often many more) per 10 high-power fields in the most active area (all cases), lack of a significant small nest growth pattern component (45 cases--solid or trabecular growth most common), at least a considerable proportion of cells with eosinophilic cytoplasm (all cases), and tumor necrosis (45 cases). Carcinomas were almost always larger than adenomas, but two adenomas (5.9 cm and 7 cm) overlapped in size with the four smallest carcinomas (5.5 cm, 6 cm, 7 cm, and 7 cm, respectively). The patients with adenomas were older on the average than those with carcinomas (median 58 years, range 31-71 years versus median 41 years, range 5 months-66 years). Two adenomas and 19 carcinomas were functional. No patient with adenoma had recurrence of tumor after excision, whereas all but nine carcinoma patients died of tumor, after 1 to 183 months. Among carcinoma patients, survival was significantly shorter when distant metastases were manifest at diagnosis (P = .0003). There was a trend toward shorter survival with higher mitotic rates and functional tumors, but neither these nor any other parameter had a statistically significant relationship to survival or tumor behavior when presence/absence of metastases at diagnosis was taken into account.

Surgical management, DNA content, and patient survival in adrenal cortical carcinoma

BACKGROUND

Surgical resection is the only potentially curative treatment for adrenal cortical carcinoma, yet the value of extended resection, palliative resection, and tumor DNA analysis remains unclear.

METHODS

The records of 23 patients with adrenal cortical carcinoma who underwent primary surgical resection at our institution were retrospectively reviewed. Flow cytometric DNA analysis was performed on primary tumor tissue from 14 patients.

RESULTS

Sixteen of 23 patients underwent complete resection. For these 16 patients the median follow-up was 43 months, the actuarial median survival was 46 months, and the actuarial 5-year survival rate was 46%. The seven patients who underwent incomplete resection all died of disease with a median survival of 8.5 months. Isolated local recurrence as the first site of failure occurred in two patients. Only completeness of resection (p = 0.004) and stage at presentation (p = 0.006) were significant prognostic indicators. None of the following predicted a poor prognosis in patients who underwent complete resection: (1) need for extended resection, (2) presence of renal vein or inferior vena cava tumor thrombus, or (3) tumor aneuploidy (14 of 14 tumors were aneuploid).

CONCLUSIONS

Long-term survival is possible in patients with adrenal cortical carcinoma if complete, margin-negative tumor resection can be achieved. Isolated local recurrence is uncommon after complete resection. Because adrenal cortical carcinomas are consistently aneuploid, tumor DNA content is not a useful prognostic factor.

Short stature in children and adults with neurofibromatosis

Height characteristics in 108 children and 52 adults with neurofibromatosis (NF) were analyzed. Fifty percent of the children and 54% of the adults ranked below the 25th percentile for normal age and sex-adjusted height. It can be concluded that children with NF are short and have increased risk of becoming very short adults. Primary care practitioners and specialists working with these children should recognize the possibility of future short stature and initiate measures to prevent or minimize the psychosocial problems that may result. Given the pronounced risk for shortness, it is important to avoid unrealistic adult height predictions (based on parental stature) when counseling short children with the disease.

Papillary thyroid cancer with pulmonary metastases beginning in childhood: clinical course over three decades

We present a case of childhood papillary thyroid cancer with persistent but stable pulmonary metastases for over three decades in order to highlight the natural history and clinical features of this unusual disease entity. A nine-year-old girl had thyroidectomy and cervical lymph node dissection followed by neck irradiation for invasive papillary thyroid cancer. Diffuse pulmonary metastases were present at the time of diagnosis and were treated with radioactive iodine 10 and 30 years later; both the chest radiographs and the patient remained stable throughout. This case illustrates the potential indolence of thyroid cancer when it presents during childhood.

Management of papillary thyroid cancer

Papillary thyroid cancer is predominantly a sporadic disease that usually presents as an asymptomatic thyroid mass in a euthyroid patient. Irradiation to the neck during childhood significantly increases the subsequent risk of this cancer; the prognosis for radiation-related cancers is similar to spontaneous cases. Physical examination, thyroid scanning and ultrasound, and fine-needle aspiration are used to differentiate between benign lesions and papillary thyroid cancer. Near-total thyroidectomy with postoperative radioiodine ablation is currently advocated for most patients, and has excellent results with regard to survival. In children, papillary thyroid cancer often presents with extensive regional disease as well as diffuse lung metastases. Surgery and radioiodine are very effective in such cases, and survival remains excellent. As late recurrences may occur, patients require regular long-term follow-up regardless of the extent of initial disease.

Effects of interleukin-1 alpha administration on pituitary-adrenal and pituitary-thyroid axes function of patients with ovarian cancer

We monitored pituitary, adrenal, and thyroid function in 21 women who had recurrent ovarian cancer and who received interleukin-1 alpha (IL-1 alpha) before and after carboplatin. Serum cortisol, corticotropin, thyroxine, and thyrotropin were measured in the morning before and at the end of each treatment cycle. Serum corticotropin levels were suppressed in many patients despite a normal simultaneous serum cortisol; thyrotropin tended to rise with declining thyroxine levels after prolonged IL-1 alpha administration. However, serum cortisol and thyroxine remained within the normal range at all times, in all patients. Thyroid dysfunction consistent with thyroiditis was seen in one patient. We conclude that administration of IL-1 alpha as currently used in clinical studies does not create significant thyroid or adrenocortical dysfunction.

Pleural effusion in patients with differentiated papillary thyroid cancer

Among 1,772 patients who registered at the MD Anderson Cancer Center between 1944 and 1991 with papillary thyroid cancer, 10 had malignant pleural effusion that developed during the course of the disease. At primary surgery, all 10 were found to have metastases to cervical lymph nodes. Seven of these patients also had invasion into adjacent soft tissues, 4 had lung metastases, and 1 had pleural effusion. All patients had radiologically apparent lung metastases at the time pleural effusion was found. Malignant effusion appeared 0 to 60 months after abnormal chest radiographs in 9 patients and 61 to 132 months after the initial diagnosis of thyroid cancer in 4 patients. Pleural effusions were treated with local radioisotopes or sclerosing agents, systemic radioiodine or chemotherapy, or both. All 10 patients died of thyroid cancer; overall survival time was 7 to 170 months (median, 27 months); however, appearance of pleural effusion preceded death by 1 to 20 months (median, 11 months). Malignant pleural effusion complicates the clinical course in 0.6% of adult patients with papillary thyroid cancer. It may develop many years after the initial diagnosis but is associated with greatly shortened survival time in all cases.