Thyroid dysfunction and survival in cancer patients treated with immune checkpoint inhibitors: analyses from a large single tertiary cancer center database

PURPOSE

We aimed to assess the incidence, clinical and biochemical course of immunotherapy-induced thyroiditis and its implication on patients' survival, based on an extensive clinical experience from a tertiary cancer center.

METHODS

Analyses were based on data from the electronic medical records of cancer patients treated with CPIs. Data included demographic characteristics, cancer type, Thyroid function tests (TFT), and survival.

RESULTS

Thyroid function tests were available for 934 patients. After excluding patients with impaired baseline TFT or levothyroxine treatment, 754 euthyroid patients were included in the core analyses. Of those, 301 (39.9%) patients developed thyroid dysfunction ('thyroiditis'). Thyroiditis was more prevalent in patients with renal cell carcinoma than other types of cancer. Survival rates were comparable in patients who developed thyroiditis and in those who did not. during the 5 years follow-up period, there was a non-significant trend toward improved survival in patients who developed TD in four predefined groups: melanoma, lung cancer, renal cell carcinoma, and transitional cell carcinoma. Nevertheless, we observed a highly significant survival benefit for patients with renal cell carcinoma who developed TD (HR = 0.19, 95% CI 0.06-0.60; p = 0.005).

CONCLUSIONS

Thyroiditis is common, often asymptomatic, and is more prevalent in patients treated with combinations of nivolumab and PD-L1 inhibitors, and in patients with renal cell carcinoma. Thyroiditis was associated with a trend for a survival benefit, particularly in patients with renal cell carcinoma.

Skin exposure to UVB light induces a skin-brain-gonad axis and sexual behavior

Ultraviolet (UV) light affects endocrinological and behavioral aspects of sexuality via an unknown mechanism. Here we discover that ultraviolet B (UVB) exposure enhances the levels of sex-steroid hormones and sexual behavior, which are mediated by the skin. In female mice, UVB exposure increases hypothalamus-pituitary-gonadal axis hormone levels, resulting in larger ovaries; extends estrus days; and increases anti-Mullerian hormone (AMH) expression. UVB exposure also enhances the sexual responsiveness and attractiveness of females and male-female interactions. Conditional knockout of p53 specifically in skin keratinocytes abolishes the effects of UVB. Thus, UVB triggers a skin-brain-gonadal axis through skin p53 activation. In humans, solar exposure enhances romantic passion in both genders and aggressiveness in men, as seen in analysis of individual questionaries, and positively correlates with testosterone level. Our findings suggest opportunities for treatment of sex-steroid-related dysfunctions.

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UVB exposure increases circulating sex-steroid levels in mice and humans

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UVB exposure enhances female attractiveness and receptiveness toward males

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UVB exposure increases females’ estrus phase, HPG axis hormones, and follicle growth

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Skin p53 regulates UVB-induced sexual behavior and ovarian physiological changes

Capillary-leak syndrome: an unrecognized early immune adverse effect of checkpoint-inhibitors treatment

Capillary-leak syndrome is strongly associated with cytokine activity states. It is an ill-recognized adverse effect of checkpoint inhibitors treatment, which are typically associated with cellular immune response. We describe two patients with capillary leak syndrome following immune checkpoint inhibitors treatment. We present linking mechanisms between checkpoint inhibitors, cellular immunity, cytokine action and endothelial damage. We suggest that capillary-leak syndrome is a unique adverse effect of immunotherapy, resulting from complex interactions between cellular and cytokine activation and that its expression is probably depending on inherent host immune variabilities.

Long-Term Follow-Up of Denosumab Discontinuers with Multiple Vertebral Fractures in the Real-World: A Case Series

Denosumab discontinuation is associated with rapid reversal of bone turnover suppression and with a considerable increase in fracture risk, including a risk for multiple vertebral fractures (MVF). Long-term follow-up of patients who sustained MVF after denosumab discontinuation has not been reported. This case-series was aimed to provide a long-term follow-up on the management and outcome of denosumab discontinuers who initially presented with multiple vertebral fractures. Denosumab discontinuers were identified from a computerized database of a large healthcare provider. Baseline and follow-up clinical, laboratory, and imaging data were obtained from the computerized database and electronic medical records. The post-denosumab discontinuers MVF patients consisted of 12 women aged 71±12. Osteoporotic fractures were prevalent before denosumab discontinuation in 6 of the patients. The majority received bisphosphonates before denosumab. MVF occurred 134±76 days after denosumab discontinuation. The patients were followed for a median of 36.5 (IQR 28.2, 42.5) months after MVF. Two patients passed-away. Two patients suffered recurrent vertebral fractures. Following MVF, patients were treated inconsistently with denosumab, teriparatide, oral, and intravenous bisphosphonates, in various sequences. Two patients underwent vertebroplasty/kyphoplasty. This long-term follow-up of real-world patients with MVF following denosumab discontinuation reveals that management is inconsistent, and recurrent fractures are not uncommon. It calls for clear management guidelines for patients with MVF after denosumab discontinuation and for special attention to this high-risk group.

INCREASED SERUM CALCIUM IS NOT COMMON IN HOSPITALIZED PATIENTS WITH PRIMARY HYPERPARATHYROIDISM: A RETROSPECTIVE, OBSERVATIONAL STUDY

Objective: Serum calcium levels often decrease during acute illness in patients with an intact calcium-regulating system. However, the dynamics of serum calcium levels in hospitalized patients with primary hyperparathyroidism (PHPT) have not yet been described. Methods: Clinical and laboratory data were retrospectively retrieved from the electronic medical records of patients with PHPT before, during, and after hospitalization for various reasons (excluding parathyroid surgery). Results: There were 99 nonselected patients with asymptomatic, hypercalcemic PHPT, hospitalized for various reasons; 42% were admitted for apparent infectious or septic conditions, and 58% were admitted for noninfectious conditions. Total serum calcium increased >0.5 mg/dL in 7.4% of the patients: 10.9% and 2.5% of the patients with noninfectious and infectious conditions, respectively. In 65.7% of the patients, the mean total serum calcium (TsCa), but not albumin-corrected calcium (corrCa), decreased significantly during hospitalization, down to below the upper limit of the reference range. Although prehospitalization TsCa and corrCa were similar in patients with infectious and noninfectious conditions, during hospitalization, TsCa was lower in patients with infectious conditions (P = .02). Both TsCa and albumin returned to prehospitalization levels after recovery. Conclusion: TsCa increases in a minority of hospitalized PHPT patients. In the majority of hospitalized patients with PHPT, TsCa, but not corrCa, decreases to within the normal reference range, more so in patients with infectious conditions, obscuring the major characteristic of PHPT. Therefore, it is prudent to follow calcium and corrCa during hospitalization in patients with PHPT. Abbreviations: corrCa = albumin-corrected serum calcium; IQR = interquartile range; PHPT = primary hyperparathyroidism; PTH = parathyroid hormone; TsCa = total serum calcium.

Long-term control of Paget's disease of bone with low-dose, once-weekly, oral bisphosphonate preparations, in a "real world" setting

PURPOSE

Bisphosphonates are the mainstay of the treatment of Paget's disease of bone (PDB). Clinical practice guidelines recommend treatment with intravenous zoledronic acid or high-dose oral nitrogen bisphosphonates (N-BPs). We present our long-term experience treating PDB patients with lower than recommended oral doses of N-BPs, equivalent to once-weekly doses used for treating osteoporosis.

METHODS

PDB patients were seen, between 1990 and 2015 at the endocrine clinic of an academic medical center. Diagnosis was established according to accepted criteria. Patients were initially treated with alendronate 70 mg/week or risedronate 35 mg/week. Whenever the initial dose failed to produce remission, the dosage was increased to twice a week the respective dose.

RESULTS

Patients were followed for a mean of 11.9 years (range: 1.7-24.8). Out of 96 treatment courses with N-BPs, 89% were with alendronate and 11% with risedronate. Remission was achieved in 84% of the courses with alendronate 70 mg/week. 90% of those who did not achieve remission subsequently responded to 140 mg/week. Out of the 8 treatment courses with risedronate 35 mg/week, 87% achieved remission, and the 2 patients who did not achieve remission subsequently responded to 70 mg/week. The median duration of remissions following 3-4 months courses of alendronate 70 mg/week or risedronate 35 mg/week was 8.8 months (IQR: 5.5, 14.8).

CONCLUSION

In a large proportion of "real world" PDB patients, remission can be achieved with once-weekly, "osteoporosis doses" of alendronate or risedronate.

The impact of vitamin D status and parameters of calcium metabolism in patients with primary hyperparathyroidism

BACKGROUND

There is ample evidence associating vitamin D deficiency in primary hyperparathyroidism (PHP) patients with more severe disease manifestations and increased risk of postoperative hypocalcemia. Yet, there is limited data regarding the safety of vitamin D repletion in these patients.

AIM

To assess the safety of vitamin D repletion in PHP patients in a real-world setting.

DESIGN

We included patients with asymptomatic PHP and few symptomatic patients who declined surgery, followed in our clinic, and treated on a routine basis with 2000 IU/day of vitamin D3.

METHODS

Serum calcium (sCa), PTH, 25-hydroxyvitamin D, and 24 h urinary calcium (uCa) and creatinine collections were compared between the lowest and the highest vitamin D time points.

RESULTS

There were 40 patients of a mean age was 63 ± 10 years. 25(OH)D at lowest and highest vitamin D time points was 15.5 ± 6.2 ng/ml and 33.2 ± 8, respectively (P < 0.001). Serum calcium was not affected by the changes in vitamin D levels. In none of the patients did sCa exceed 11.5 mg/dL. uCa was 220 ± 110 mg/24 h at the lowest vitamin D time point and 260 ± 140 at the highest vitamin D time point (P = 0.14). uCa exceeded 400 mg/24 h in two vs. five patients (P = 0.23) at the lowest and highest vitamin D time points, respectively. PTH was not significantly different between the different vitamin D time points.

DISCUSSION/CONCLUSION

Vitamin D repletion in PHP seems safe. Considering the documented adverse influence of vitamin D deficiency in PHP, particularly on skeletal manifestations and on the postoperative course, vitamin D repletion is warranted.

A prospective evaluation of the relationship between bone mineral density and breast cancer

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Background: Osteoporosis and breast cancer (BC) are each mediated by circulating estrogens. Insulin and insulin growth factors 1-2 have been linked to increased bone mineral density (BMD) and BC cell growth. The relationship between BMD and BC incidence has been analyzed in a number of retrospective studies with conflicting results. We have previously reported on a study of BC risk in 15,268 women who underwent BMD testing. Women in the highest Z-score tertile at the femoral neck had a higher risk of developing BC compared to those in the lowest tertile (OR 2.15, p = 0.004). The current study was undertaken in order to determine whether there is a direct correlation between BMD and BC when evaluated prospectively. Methods: This case-control study is planned to include 400 consecutive patients (pts) with newly diagnosed BC and 800 matched controls without BC. Pts and controls undergo BMD examination using dual photon technology. Serum is obtained for vitamin D, calcium, and a panel of bone turnover markers and cytokines. Pts and controls are interviewed and a questionnaire about BC and osteoporosis risk factors is completed. Results: We present clinical and BMD data from the first 200 BC patients recruited to the study. Median age 60, interquartile range 49.5-66. Body Mass Index: 28.4 ± 5.4 (mean ± SD). Postmenopausal: 148 patients, 74%. T-scores (mean ± SD): femoral neck: -0.68 ±-1.10, total hip: -0.28 ± 1.17, L1-L4: -0.52 ± 1.39. T-score of less than minus 2.5 (cut-off for osteoporosis) at any of the 3 sites, 24 (11.9 %) pts. Estrogen receptor pos: 162 (81%).BC stage: T0-T2, 175 (87.5 %). N0: 108 (54.5%), N1-2-3: 86 (43.4%). % pts node pos (N1-2-3) in each T score range: ≤ -2.5, 20%; -2.5 < T score ≤ -1,36%; -1 < T-score ≤+ 1,50%; +1 < T-score, 60%. % pts low grade in each T score range: ≤ -2.5, 25%;-2.5 < T-score ≤ -1,35%;-1 < T-score ≤ +1,37 % ;+1 < T-score, 20%. Conclusions: Only 11.9% of the first 200 BC patients studied had osteoporosis by BMD at diagnosis.Pts with higher BMD showed a trend for more nodal involvement. Pts with T-score > +1 had fewer cases of low grade histology compared to pts with lower T-scores. These preliminary results hint that higher BMD may be associated with more aggressive BC.

[Summary of the Israeli Endocrine Society's consensus statement on the diagnosis, treatment and follow-up of well-differentiated thyroid cancer]

Well differentiated epithelial cell thyroid cancer is not classified amongst the most aggressive diseases. Notwithstanding, it can potentially both impair quality of life and affect life expectancy. Appropriate treatment has been shown to be crucial in obtaining optimal outcomes on the course of the disease. Successful treatment rests upon strict adherence to confirmed principles of diagnosis, treatment and follow-up. The aim of the position paper is to present the Israeli medical community with a set of commonly accepted principles for the diagnosis, treatment and follow-up of patients with well differentiated epithelial thyroid cancer and in addition to highlight areas of legitimate differences in approach where those differences occur. We have attempted to provide a link between the various medical disciplines involved in care of these patients: family physicians, surgeons, nuclear medicine specialists, oncologists, pathologists, radiologists and endocrinologists; and have attempted to decrease to a minimum areas of uncertainty and to offer a common approach for the best possible care of thyroid cancer patients in Israel. In addition, we find it our duty to point out those areas and resources which, in our opinion, need to be upgraded in Israel and even included in the Israeli official "health basket".

Marked secular increase in the incidence rates of osteoporotic hip fractures in women and men in southern Israel

BACKGROUND

For the last 35 years, our medical center has been the only referral center and provider of emergency medical services for a well-defined geographic area in southern Israel.

OBJECTIVES

To evaluate trends in the incidence of hip fractures in this population.

METHODS

The study was based on two surveys done approximately 20 years apart. It included women and men 50 years and older with radiographic evidence of a new hip fracture caused by low impact trauma. Only fractures that resulted from low or moderate trauma were considered for the current study. Incidence rates were calculated based on population data obtained from the official Central Bureau of Statistics.

RESULTS

There was an overall twofold increase in the incidence rate of hip fractures. However, this increase occurred almost exclusively in the over-75 year old age groups (2.5-fold increase, both in women and men). The mean (and median) age of patients with hip fractures increased significantly over the study period, corresponding to the increase in longevity between the two periods.

CONCLUSIONS

There was a marked secular increase in the incidence of proximal hip fractures in both genders, primarily because of an increase in the fracture rate in the very old. The increase in median age of fracture patients suggests that the observed increase in fracture rate can be attributed mainly to aging of the population rather than to deterioration in bone quality over the generations.

Brief report: Use and misuse of thyroid ultrasound in the initial workup of patients with suspected thyroid problems referred by primary care physicians to an endocrine clinic

BACKGROUND AND OBJECTIVES

Thyroid ultrasound (TUS) plays an important but limited role in the evaluation of some complaints related to the thyroid gland. This study was designed to examine how primary care physicians use TUS before referring patients to an endocrine clinic.

DESIGN

We audited all charts of first-time referrals for appropriateness of TUS use. Recommendations in practice guidelines and current textbooks defined appropriate indications for TUS: (1) patients with a thyroid nodule and a history of head or neck irradiation; (2) follow-up of patients with nodules not surgically removed; and (3) evaluation of patients with amiodarone-induced thyrotoxicosis.

SETTING

Endocrine referral clinic in a teaching hospital in Israel.

RESULTS

Two hundred and eight unselected referrals were reviewed. Sixty-nine (33%) of the patients presented with a TUS. Documented reasons for TUS were suspected thyroid mass (n=35, 51%), thyroid dysfunction (n=21, 30%), neck pain (n=5, 7%), dyspnea (n=4, 6%), and dysphagia (n=2, 3%). Of the 69 TUS reviewed, 64 (93%) were not appropriate.

CONCLUSIONS

Primary care clinicians obtain TUS studies in patients without recommended indications prior to referral to an endocrinologist.

Livedo reticularis: a rare manifestation of Graves hyperthyroidism associated with anticardiolipin antibodies

Livedo reticularis is a common presentation of the anticardiolipin syndrome. Although the presence of anticardiolipin (aCL) antibodies was previously reported in association with both Graves disease and Hashimoto thyroiditis, I am aware of no previous report of livedo reticularis in patients with Graves disease. A 29-year-old woman presented with very active Graves thyrotoxicosis. Physical examination revealed, in addition to signs of very active hyperthyroidism, marked livedo reticularis on both her legs. Laboratory tests confirmed the clinical impression regarding her thyroid activity and revealed prolonged prothrombin time (and partial thromboplastin time) and elevated levels of both immunoglobulin G and immunoglobulin M aCL antibodies. After methimazole-induced remission, livedo reticularis completely disappeared and the levels of aCL antibodies decreased to within the low range of normal. The literature on aCL antibodies and autoimmune thyroid diseases is reviewed and the interaction between the occurrence of aCL antibodies, disease activity, and drug therapy in Graves disease is discussed.

[Incidence of osteoporotic fractures in southern Israel]

BACKGROUND

Very little is known about the epidemiology of osteoporotic fractures in Israel.

AIM

We aimed to provide an estimate on the incidence of low-impact fractures in southern Israel.

METHODS

The study included women and men 50 years and older with radiographic evidence of a new fracture. We screened and reviewed all the emergency room and hospital charts to identify all patients with low impact fractures who attended the Soroka Hospital during the corresponding months of January and February of 1998 through 2001.

RESULTS

There were a total of 580 fracture patients (461 women and 119 men). The estimated incidence of all low-impact fractures in the entire population aged 50 and older was 1064:100,000 (95% C.I. 981: 1153) per year. The estimated incidence of low-impact fractures in women was three fold higher than in men [1526:100,000 (95% C.I. 1390: 1675) vs. 490/100,000 (95% C.I. 408: 580) per year, respectively]. Fractures of the distal forearm and proximal hip (26% each) were, by far, the most common in women, followed by fractures of the humerus (18%), ankle (12%) and pelvis (5%). In men, proximal hip fractures (39%) were the most common, followed by fractures of the humerus (18%), distal forearm (15%) and ankle (14%). Multiple concurrent fractures occurred in 2.5% of the patients.

CONCLUSIONS

Our data provides a preliminary estimate of the incidence of osteoporotic fractures, not including most vertebral collapse fractures, among women and men in southern Israel. Further studies are warranted to characterize fracture risk in other regions of the country and population sub-groups.

Plasmapheresis Rapidly Eliminates Thyroid Hormones from the Circulation, but Does Not Affect the Speed of TSH Recovery following Prolonged Suppression

OBJECTIVE

To report an attempt to shorten the preparation interval before radioactive iodine administration using plasmapheresis in a 77-year-old woman with a history of papillary thyroid carcinoma with local recurrence and lung metastases, in whom the administration of a high dose of radioactive iodine was intended as a desperate rescue procedure.

METHODS

The patient was initially started on cholestyramine. Two days later, plasmapheresis was performed.

RESULTS

Plasmapheresis rapidly decreased free tri-iodothyronine (FT(3)) and free thyroxine (FT(4)). Serum FT(4) subsequently remained low, while FT(3) recovered the next day. Thyroid-stimulating hormone (TSH) reached 25 mIU/l in 14 days, which is within the time frame required to reach the target TSH level by withdrawing levothyroxine alone.

CONCLUSION

Plasmapheresis is very effective in eliminating thyroid hormones from the circulation. However, it does not seem to accelerate thyrotroph recovery to a considerable extent after prolonged suppression.

Impact of subsidizing effective anti-osteoporosis drugs on compliance with management guidelines in patients following low-impact fractures

Early in 2000, proven-effective antiresorptive drugs (alendronate and raloxifene) were included in the national "health basket" in Israel. We carried out the present study to evaluate the effect of subsidizing antiosteoporosis drugs on the use of antiosteoporosis drugs in patients following low-impact fractures. The rates of dispensation of antiosteoporosis drugs, in the hospital and in the community, before and after an incident of a newly diagnosed low-impact fracture, respectively, were evaluated during January and February 1998 and 1999 ("pre-basket") and the corresponding months of 2000 and 2001 ("post-basket"). The study was carried out in a 950-bed teaching hospital, the only one serving the area, and the largest health maintenance organization in the area. Hospital charts of women and men age 50 years and older with new fractures following low- or moderate-impact trauma treated in the emergency room, or admitted to the orthopedic surgery and rehabilitation departments, were reviewed. A centralized pharmacy computerized database was used to follow antiosteoporosis drug dispensation in the community. A significant, approximately two-fold, increase in the baseline (before fracture) rate of osteoporosis drug dispensation was observed between the pre- and post-basket periods. The rate of patients treated after a fracture incident also increased significantly, 1.6 fold, in the post-basket period; however, even in the post-basket period, two-thirds of the patients remained untreated following a fracture incident, and most of those treated received only calcium and vitamin D; only 17% received potent antiosteoporosis drugs. In a multivariate analysis, female gender, hospitalization, having the incident of fracture in the post-basket period, and above all being treated for osteoporosis before the fracture incident, had the greatest effect on the likelihood of being treated following a low-impact fracture incident. The increase in the pooled use of antiosteoporosis drugs and/or calcium/vitamin D supplements was continuous, and subsidizing created no step-up effect, besides a transient increase in the use of potent antiosteoporosis drugs in the first year following the health-basket amendment. We conclude that while subsidizing may have a significant, positive effect on antiosteoporosis drug utilization, other factors may be even more important. There is an ongoing need to find ways to encourage the use of effective pharmacological interventions for primary and secondary prevention of osteoporotic fractures.

Preparation for radioactive iodine administration in differentiated thyroid cancer patients

OBJECTIVE

Because in recent years the practice of TSH suppression has changed, and thyroxine doses have been reduced significantly in the treatment of patients with low-risk differentiated thyroid cancer, the goal of this study was to determine the time needed to attain a target TSH level (of 30 mIU/l) following levothyroxine withdrawal in patients treated with thyroxine according to current guidelines, in anticipation of radioactive iodine (RAI) administration.

DESIGN

Observational study.

PATIENTS

Thirteen consecutive patients with differentiated thyroid cancer on suppressive doses of levothyroxine planned for RAI administration. Five of the patients received cholestyramine in an attempt to facilitate TSH recovery.

MEASUREMENTS

Serum TSH, free-T3 and free-T4, at 3-4-day intervals.

RESULTS

In 13 patients on suppressive doses of thyroxine, on 15 separate occasions, baseline TSH levels were between 0.01 and 0.4 mIU/l. The mean interval required to reach the target TSH concentration of at least 30 mIU/l was 17 days (95% CI 15-19; range 11-28 days). Cholestyramine had no effect on the rate of TSH recovery. Once TSH concentration became detectable, it increased exponentially; and once it reached the upper limit of normal, it rarely took more than 10 days to attain target level.

CONCLUSIONS

Attaining target TSH level before radioactive iodine administration requires a considerably shorter time than is currently recommended. Reducing preparation time might improve patients' acceptance of the procedure.

[Osteoporosis in men]

While many still consider osteoporosis a gender-specific condition of women, an increasing volume of data is accumulating on the epidemiology, pathophysiology and treatment of osteoporosis in men. The main conclusions arising from the available data indicate that the number of osteoporotic men is increasing, and is expected to continue rising due to the increase in life expectancy for men. Risk factors for osteoporotic fractures are similar in men and women. Despite some gender differences in the pathophysiology of osteoporosis, responses to available osteoporosis treatments seem to be the same. Based on available data, it is recommended to implement preventive measures (calcium and vitamin D supplementation) on aging men, similar to women, and to review the official policy on the management of osteoporosis to also include men at high risk.

Primary Bilateral Adrenal Lymphoma Relapsing as a Solid Cerebral Mass After Complete Clinical Remission

Primary adrenal lymphoma is extremely rare. Only 75 cases have been reported in the medical literature. A case of non-Hodgkin's lymphoma originating in both adrenal glands is presented. Combination chemotherapy apparently produced complete disappearance of the primary lymphomatous lesions, but subsequently a cerebral relapse was discovered 6 months later, in the form of a solid brain mass. Cranial extension of primary adrenal lymphoma is extremely unusual, and the presentation as a solid mass seems to be unique.

Long-term follow-up of patients with initially benign thyroid fine-needle aspirations

Fine-needle aspiration (FNA) is currently the most reliable diagnostic means in the clinical work-up of thyroid nodules. However, most of the available data on the diagnostic reliability of thyroid FNA derives from biopsies done just before surgery or from short-term observations, whereas data on the long-term reliability of benign FNA results, is extremely limited. Over the 17-year period between 1979 and 1996, thyroid FNA performed on 849 patients in our endocrine clinic. An initially benign result was reported in 578 patients for a total of 631 nodules. Mean follow-up period was 8.1 +/- 4.4 years (+/-standard deviation [SD]; median, 6.9 years). In order to ensure the completeness of our follow-up data, we supplemented our own patients' data with data from the Israel Cancer Registry for documentation of thyroid malignancy. Sixty-six of the patients with an initially benign FNA diagnosis were rebiopsied during follow-up. Five patients (0.85%) of all those with an initial benign FNA diagnosis, were subsequently found to have thyroid malignancy diagnosed 6 months or more after the initial evaluation. Three of the newly diagnosed malignancies were follicular and two were papillary carcinomas. Three of the patients had elements of being at high-risk: previous head irradiation, previous thyroid surgery with an occult cancer, and a growing goiter, respectively. Only 1 of 35 patients who had more than one benign FNA results was subsequently diagnosed with thyroid malignancy (follicular carcinoma). These results indicate that the rate of subsequent thyroid malignancies in patients with an initial benign FNA diagnosis is low, and thus benign thyroid FNA results provide a high level of long-term assurance. Still, repeating FNA is warranted in patients with longstanding thyroid nodules, particularly if at increased risk for cancer, or if a goiter is found to have changed its morphological characteristics over time.

Awareness of osteoporosis and compliance with management guidelines in patients with newly diagnosed low-impact fractures

A pre-existing fracture is a strong predictor of additional osteoporotic fractures. Consequently, current guidelines emphasize the need for treating patients with existing osteoporotic fractures. The present study aimed to assess the implementation of osteoporosis guidelines in routine practice. To this end, we reviewed the hospital charts of women and men aged 50 years and older with new fractures due to low or moderate impact treated in the emergency room, orthopedic surgery and rehabilitation departments. Notation of osteoporosis as a contributing cause for the fracture, performance of screening laboratory tests for possible secondary causes and treatment recommendations were abstracted from the record. In addition, we utilized the centralized pharmacy and laboratory computerized databases of the largest health maintenance organization in the area to follow dispensation of osteoporosis drugs and performance of screening laboratory tests in the community following fracture incidents. During the corresponding periods of January and February 1998 and 1999, 183 patients aged 50 years and older with low-impact fractures were treated in the emergency room only and 113 were hospitalized. Osteoporosis was rarely mentioned in the medical documentation. During the 6 month period after the fracture incident at least 70% of the emergency room patients and 62% of the hospitalized patients received no osteoporosis drugs. However, an encouraging significant trend toward increasing use of osteoporosis drugs, both prior to and after a fracture incident, was noted between the two survey periods among the emergency room fracture patients, but not among the hospitalized patients. Calcium supplements were the most commonly used osteoporosis drug. Bisphosphonates, hormone replacement therapy, raloxifene and calcitonin were rarely prescribed. Men were less likely than women to receive treatment for osteoporosis. Systematic laboratory evaluations for secondary causes of osteoporosis were not performed. We conclude that despite extensive attempts at increasing awareness among health professionals and the public at large, osteoporosis is still rarely singled out as a problem in patients with newly diagnosed low-impact fractures, and the majority of them are not managed according to guidelines. Further studies should address specific problems in physicians' and patients' attitude that may account for the present situation.

The protective effect of estrogen against chemically induced murine colon carcinogenesis is associated with decreased CpG island methylation and increased mRNA and protein expression of the colonic vitamin D receptor

Epidemiological studies suggest that estrogen prevents neoplastic transformation in the intestinal mucosa. Estrogen was shown to increase the expression of vitamin D receptors (VDR) in a variety of tissues. 1,25-Dihydroxyvitamin D [1,25-(OH)2D] and several of its analogues are known as potent antineoplastic and prodifferentiative in many cell types, including colon-derived cells. The present study was designed to examine the effect of estradiol (E2) on dimethylhydrazine (DMH)-induced colon cancer in rats, and the possibility that E2 may exert its protective effect on the colon through modulation of the vitamin D-endocrine system. The in vivo effect of E2 on DMH-induced colorectal cancer was studied in four groups of ovariectomized female rats: (I) untreated control, (II) E2 treated, (III) DMH treated, and (IV) combined E2 and DMH treated. Significantly higher uterine weights and higher colonic estrogen receptor content confirmed the effectiveness of ovariectomy and E2 replacement. The number of malignant tumors in group IV was 2.3+/-1.1 (mean +/- SE) per rat, compared with 8.1+/-1.9 in group III (P < 0.001). Exposure to estrogen was associated with a marked increase in VDR mRNA content and VDR protein expression in the normal colonic mucosa. In tumor extracts VDR protein expression was considerably lower compared with normal mucosa. Estrogen treatment did not affect serum levels of 25(OH)D, 1,25(OH)2D, and PTH. Significant CpG island methylation in the VDR gene was observed in colonic tissue DNA harvested from rats treated with DMH, but not in colonic mucosae from rats treated with DMH + E2. The highest frequency of CpG methylation in the VDR gene was detected in DNA extracted from cancer tissue rims. In summary, the protective effect of estrogen against chemically induced colonic carcinogenesis is associated with reduced methylation of the VDR gene and with upregulation of both VDR gene transcription and protein expression. We suggest that estrogen may interfere with the process of CpG DNA methylation in the colonic mucosa to prevent silencing of the VDR gene. Increased VDR activity could be one of the mechanisms by which estrogen protects against neoplastic transformation in the colon.

Estrogen controls expression and bioresponse of 1,25-dihydroxyvitamin D receptors in the rat colon

Estrogen receptors are extensively expressed in the gastrointestinal tract, however their physiological role is not clear yet. Estrogen and 1,25-dihydroxyvitamin D [1,25(OH)2D3] apparently share common activities in the intestine such as growth-suppressing effects on the colonic mucosa and positively influence intestinal calcium absorption. In view of our previous studies showing up-regulation of vitamin D receptors (VDR) in the duodenal mucosa and in osteoblasts, the present study was designed to address a possible interaction between estrogen and the vitamin D endocrine system in the colonic mucosa. Three groups of female rats were studied: sham operated ('Sham'), ovariectomized ('OVX'), and ovariectomized estrogen-treated ('OVX+E'). VDR gene expression was assessed by Northern blot analysis, VDR protein expression was assessed by ligand-binding assays, and Western-blotting. Endogenous 1,25(OH)2D3 bioactivity in colonic mucosal extracts was assessed by alkaline phosphatase activity and calbindin-9kD mRNA expression. Northern blots revealed marked increase in band intensity corresponding with the VDR mRNA product in 'Sham' or 'OVX+E' vs. 'OVX'. In ligand-binding experiments, 1,25(OH)2D3 was shown to bind specifically to a single class of receptors in extracts obtained from each of the groups (Kd--0.03 nM). The maximal VDR binding capacity of colonic mucosal extracts was 203 +/- 23 fmol/mg protein in 'Sham', 362 +/- 41 in 'OVX+E' and 102 +/- 15 in 'OVX' ('Sham' or 'OVX+E' vs. 'OVX', p < 0.001). Western-blot analysis also revealed higher VDR protein expression in the estrogen-exposed animals. Alkaline phosphatase activity and calbindin-9kD mRNA expression were significantly higher in colonic mucosal extracts from estrogen-exposed rats. Estrogen increases VDR gene transcript level, protein expression and endogenous 1,25(OH)2D3 bioactivity in colonic mucosa, which may suggest that some of the estrogen activities in the colonic mucosa, such as its growth-suppressing effect, could be mediated, at least in part, by an increase in colonic mucosa responsiveness to endogenous 1,25(OH)2D3.

Differential effect of TPA on PGE2 and cicaprost-induced cAMP synthesis in UMR-106 cells

PGE2 and prostacyclin each enhance cAMP synthesis in the osteoblast-like cell line UMR-106. The amount of cAMP induced by PGE2 was 5-7-fold greater than the amount induced by cicaprost or iloprost, stable prostacyclin analogues. Both PGE2 and the two prostacyclin analogues enhanced cAMP synthesis with similar time dependence. The EC50 values of PGE2 and cicaprost were 3 X 10(-6) and 5 x 10(-8) M, respectively. Short-term incubation of the cells with 12-o-tetradecanoylphorbol 13-acetate (TPA) markedly reduced the PGE2-induced cAMP synthesis. In contrast, cells that were incubated with the same concentrations of TPA in the presence of cicaprost or iloprost showed a 1.6-fold increase in cAMP formation. The marked disparity between the cAMP response to cicaprost and PGE2 in the presence of TPA suggests that the two prostanoids induce cAMP synthesis in the UMR-106 cells by interaction with different receptors. These observations support the idea that the osteoblastic UMR-106 cells may express specific prostacyclin receptors and suggest that prostacyclin may have a unique role in osteoblasts.

The yield of adequate and conclusive fine-needle aspiration results in thyroid nodules is uniform across functional and goiter types

Relatively little is known about the cytological characteristics of hyperfunctioning (hot) thyroid nodules. Concern has been expressed that fine-needle aspiration (FNA) identifies hot nodules as follicular tumors or indeterminate, and as a consequence patients could be unnecessarily referred for surgery. Between 1979 and 1996, thyroid FNA was performed on 829 patients. Result of thyroid scan was available in 326; 69 (21%) patients had hot, and 257 (79%) had warm or cold thyroid nodules. Nodules in each of these major groups were divided into 2 subgroups: clinically solitary nodules and dominant nodules in multinodular goiters (MNG). The frequencies of adequate versus inadequate FNA samples, and of conclusive versus indeterminate FNA results were determined separately for each of the groups and subgroups. In addition, patients with hot nodules and overt hyperthyroidism were identified and evaluated separately. Bivariate analyses were performed for the frequency of adequate versus inadequate smears and conclusive versus indeterminate results between hot, toxic, and cold-warm nodules, and between solitary nodules and MNG. The frequency of adequate aspirations and conclusive results in the various groups and subgroups was found to be statistically indistinguishable. In conclusion, the yield of adequate samples and the rate of conclusive results of FNA in thyroid nodules is similar, irrespective of the functional state or of goiter presentation. Hot thyroid nodules do not seem to produce an increase in the rate of inadequate or indeterminate FNA results, and therefore, do not affect the overall performance of thyroid FNA.

Estrogen increases 1,25-dihydroxyvitamin D receptors expression and bioresponse in the rat duodenal mucosa

Menopause and estrogen deficiency are associated with apparent intestinal resistance to vitamin D, which can be reversed by estrogen replacement. The in vivo influence of estrogens on duodenal vitamin D receptor (VDR) was studied in three groups of rats: ovariectomized (OVX), sham-operated, and ovariectomized rats treated daily with estrogen (40 microg/kg BW) for 2 weeks (OVX + E). Estrogen administration to OVX rats resulted in a 2-fold increase in VDR messenger RNA transcripts. 1,25(OH)2D3 was shown to bind specifically to one class of receptors in duodenal mucosal extracts, with a dissociation constant of 0.03 nM. Binding was significantly increased in duodenal extracts from OVX + E rats, compared with OVX rats (735 +/- 81 vs. 295 +/- 26 fmol/mg protein; P < 0.001); a comparable, 1.5- to 2-fold increase in VDR protein expression was observed in Western blot analyzes of the duodenal mucosa. Markers of VDR activity were increased in estrogen-exposed rats: calbindin-9k messenger RNA transcript content was 1.4- to 1.6-fold higher, and alkaline phosphatase activity was 1.4- to 3-fold higher in sham-operated and OVX + E, respectively, compared with OVX. 25(OH)D, 1,25(OH)2D, or PTH levels were not altered by estrogen treatment. Cumulatively, these findings suggest that estrogen up-regulates VDR expression in the duodenal mucosa and concurrently increases the responsiveness to endogenous 1,25(OH)2D. Modulation of intestinal VDR activity by estrogen, and subsequent influence on intestinal calcium absorption, could be one of the major protective mechanisms of estrogen against osteoporosis.

Severe, diffuse osteosclerosis: A new manifestation of transitional cell carcinoma of the urinary bladder

A 56 year-old man with a 2-year history of transitional-cell carcinoma of the urinary bladder presented with back pain and diffuse radiological osteosclerosis. Laboratory studies revealed borderline-low ionized serum calcium, and markedly elevated serum alkaline phosphatase (ALP) activity and serum osteocalcin. Serum acid phosphatase and prostatic-specific antigen (PSA) were normal. Serum 25-hydroxyvitamin D and 1,25-dihydroxyvitamin D were just below the normal limit and parathyroid hormone was moderately elevated. A transiliac bone biopsy specimen revealed expanded bone trabeculae, abundance of osteoid-covered surfaces, and heavy metastatic spread. To the best of our knowledge, this is the first description of the association of osteosclerosis and metastatic transitional-cell carcinoma of the bladder.

Pregnancy-associated osteoporosis: preliminary densitometric evidence of extremely rapid recovery of bone mineral density

Pregnancy-associated osteoporosis (PAO) is considered a rare complication of pregnancy and lactation, but the actual incidence is unknown. Pregnancy-associated osteoporosis is self-limited and usually does not recur during subsequent pregnancies, but little is known about its pathogenesis or the dynamics of bone density during the evolution and recovery phases of an acute episode. We report a case of idiopathic PAO. Follow-up included repeat measurements of bone density, which revealed a striking rate of improvement during the first 6 months after delivery (50% increase) and continuous improvement, at a diminished though still relatively high rate, during the successive year. This observation provides insight into the early stages of recovery from PAO.

Familial hypocalciuric hypercalcemia in Israel: a preliminary report

Familial hypocalciuric hypercalcemia (FHH) is often considered in the differential diagnosis of hyperparathyroidism, but is rarely diagnosed. So far, FHH has not been documented in Israel. This report presents preliminary evidence for the occurrence of FHH in Israel.

'Travelers' thyrotoxicosis'. Transitory thyrotoxicosis induced by iodinated preparations for water purification

Two young adults presented with thyrotoxicosis after increased iodide ingestion in the course of backpacking trips to Central and South America, during which each of them used an iodinated preparation for water purification. In both cases, serologic tests were positive for antithyroid peroxidase antibodies, and one had a family history of immune thyroid disease. We suggest that in these two cases the condition was a variant of iodide-induced thyrotoxicosis, reflecting an inadequate response to iodide excess in association with a presumed preexisting asymptomatic immune thyroid disease. This observation adds a new consideration for travelers' consultation.

Evidence for a clinically important adverse effect of fiber-enriched diet on the bioavailability of levothyroxine in adult hypothyroid patients

To evaluate the effect of dietary fiber supplements on levothyroxine (T4) bioavailability in hypothyroid patients, dietary fiber-containing supplementation was withheld from patients requiring disproportionately high doses of T4, in whom a dietary history revealed ingestion of a dietary fiber supplement. The dose of T4 was maintained at a constant level. Serum thyrotropin (TSH) was assessed before and after removal of the dietary fiber supplements. T4 requirements, reflected by either decreased serum TSH or by decreased T4 dose, was observed in conjunction with decreased dietary fiber intake compared with T4 requirement during increased dietary fiber intake. In vitro experiments carried out to determine the mechanism of interaction between dietary fiber and T4 revealed dose dependent, nonspecific adsorption of levothyroxine by wheat bran. These results indicate a decrease in T4 bioavailability by dietary fiber through a mechanism involving nonspecific adsorption of T4 to dietary fibers. Increased intake of dietary fiber may account for the need for larger than expected doses of T4 in some hypothyroid patients.

Demographic aspects of Paget's disease of bone in the Negev of southern Israel

In a mainly retrospective but partly prospective survey of the period 1968-1993 in southern Israel, 61 cases of Paget's disease of bone were identified. Fifty six percent were of non-Afro-Asian origin and 44% originated from Afro-Asia, which is approximately the inverse of the ratio in the local general population. The largest single groups from non-Afro-Asia and Afro-Asia originated, from Romania and Tunisia, respectively, and Australia and Argentina were also disproportionately prominent as countries of origin. Israel itself was the origin of few patients. All the patients were Jews except for one Bedouin Arab, which is far different from the distribution of Bedouins and Jews in both the surveyed area and the hospital population. The differences between these groups numerically and against the background local population may well have been statistically significant had the circumstances enabled greater randomness in the collection of the data analyzed. It is surmised that in southern Israel the prevalence of Paget's disease of bone is about 1%, similar to that in southern Europe.