Eosinophilic infiltration of the esophagus: gastroesophageal reflux versus eosinophilic esophagitis in children--discussion on daily practice

BACKGROUND/PURPOSE

Children presenting with persistent symptoms attributed to gastroesophaeal reflux disease (GERD) that are unresponsive to both medical and surgical therapies are commonly submitted to esophageal biopsies, the results of which show an abnormal presence of eosinophils. In this setting, eosinophilic esophagitis may be the correct diagnosis. The purpose of this report is to clarify the importance of esophageal eosinophilic infiltration, regardless of whether associated with acid reflux, ie, as an independent symptomatic entity, when treating a patient with refractory GERD.

METHODS

Two boys, aged 8 and 7 years, had the classic symptoms of GERD. They were treated with antacid without improvement of the esophagic lesions. Subsequent esophageal biopsy results showed marked eosinophilic infiltration. From this moment on, eosinophilic esophagitis started to be considered the main diagnosis.

RESULTS

Although eosinophilic infiltration caused by GERD is very frequently found in esophageal biopsy, in case of refractory drug treatment and microscopic findings of a great number of eosinophils and mast cells, eosinophilic esophagitis must be considered. This disease is better treated with corticoids instead of antacid drugs. It explains the reason some patients do not respond to antacid and surgical treatment and remain symptomatic with esophagic lesions.

CONCLUSIONS

In refractory cases of GERD, eosinophilic esophagitis must be considered before any surgical measure.

MRI assessment of prostatic ischaemia: best predictor of clinical success after prostatic artery embolisation for benign prostatic hyperplasia

AIM

To identify predictive factors of clinical success after prostatic artery embolisation (PAE) for patients with acute urinary retention (AUR) secondary to benign prostatic hyperplasia (BPH).

MATERIALS AND METHODS

Twenty-four patients with long-term indwelling urinary catheters (duration: 8±3 months) underwent PAE. Factors such as patient age, duration of urinary retention, prostate volume decrease, volume of ischaemic prostate tissue (assessed using magnetic resonance imaging [MRI]), and embolisation technique were studied as potential predictors of clinical success of PAE, defined as the ability to remove the urinary catheter (allowing spontaneous voiding) within 60 days of PAE.

RESULTS

Bilateral embolisation was performed in 21 patients, and unilateral embolisation was performed in three, due to technical challenges. Length of follow-up was 17 months (range: 3-29). No major complications were encountered. Clinical success was achieved in 15 patients (63%) with prostate volume decreasing 24% versus 16% (p=0.03) in the unsuccessful cases. Thirteen of the 15 successful cases (87%) showed ischaemic areas in the prostate on MRI obtained 30 days after embolisation, but only one unsuccessful case (11%) showed a very small area of ischaemia.

CONCLUSION

Prostatic ischaemia observed on early post-embolisation MRI appears to be the best predictor of clinical success after PAE in patients with AUR secondary to BPH.

Complexation of 188Re-phosphonates: in vitro and in vivo studies

MDP (methylenediphosphonate) and HEDP (hydroxyethylidene diphosphonate), both diphosphonates, and EDTMP (ethylenediamine tetramethylene phosphonic acid), a tetraphosphonate ligand, have been previously labeled with 188Re for use in metastatic bone-pain palliation. The aim of this study was a comparison between the three complexes 188Re-MDP, 188Re-HEDP and 188Re-EDTMP concerning the complexation conditions, in order to achieve maximum yield, stability and bone uptake. Methods: MDP was dissolved in water and HEDP and EDTMP were dissolved in NaOH 1N followed by reduction of pH with HCl 1N. To all mixtures stannous chloride and 188Re4 - were added in a nitrogen atmosphere. The preparations were heated in boiling water bath for 15min. Yield as well as radiochemical stability was estimated by ITLC. Different concentrations of phosphonates and stannous chloride were evaluated. Biodistribution studies in Swiss mice were done for the three 188Re-phosphonates that presented the best radiochemical yield. The optimal ligand concentration for maximum complexation was 85.2mM for MDP, 72.8mM for HEDP and 45.8mM for EDTMP. The best amount of SnCl2·2H2O} was 1.5mg/mL for 188Re-HEDP and 1mg/mL for both 188Re-MDP and 188Re-EDTMP. In these conditons the three complexes showed a complexation rate above 95. Reasonable radiochemical stability for 24 hours was achieved by 188Re-EDTMP when employing ascorbic acid. All products showed a great uptake by the kidneys. 188Re-EDTMP had the greatest uptake by femur (3.1±0.2 ID/g) followed by 188Re-MDP (1.2±0.1 ID/g) and 188Re-HEDP (1.0±0.1 ID/g), 4 hours post injection. 188Re-EDTMP displayed a femur bone/muscle ratio of 28.5, 188Re-MDP 4.9 and 188Re-HEDP 4.9. In conclusion 188Re-EDTMP demonstrated the best potential as a radiopharmaceutical for bone cancer pain relief, encouraging further dosimetric studies and clinical trials.

Direct labeling studies of octapeptides with rhenium-188

The somatostatin octapeptide lanreotide and octreotide were labeled with rhenium-188 by direct method. The optimization of the labeling, the in vitro stability of the complexes and the biodistribution were evaluated. Labeling efficiency was generally greater than 95. The best time for reaction was 2hours. 188Re-lanreotide gave better radiochemical yields than 188Re-octreotide, and it was stable for a longer time (24 vs. 4 hours), but the mass of lanreotide had to be larger than that for octreotide (350 vs. 250μg), and the required ratio between mass of stannous chloride and peptide was also greater for lanreotide. Use of tartrate/phthalate buffer with 188Re-octreotide gave better radiochemical results and showed more labeling stability than the use of acetate/acetic acid buffer. The results of Cys challenge for 188Re-peptides revealed higher chelation strength for 188Re-octreotide than for 188Re-lanreotide for concentrations of cysteine below 1mM. For a concentration of cysteine of 100mM the rate of transchelation of 188Re to cysteine was the same for both peptides. The CD50 value for 188Re-octreotide was 10mM of cysteine and for 188Re-lanreotide, it was 55mM.188Re-labeled peptides were distributed in the gastrointestinal tract or in the kidneys and rapid blood clearance was observed in the first hour. Results indicated that the products can be obtained with high radiochemical purity, appropriate for in vivo studies to assess their efficacy in radioimmunotherapy.