The role of radiotherapy in the management of elevated calcitonin after surgery for medullary thyroid cancer.

Among 139 patients with medullary thyroid cancer (MTC) treated at the Royal Marsden Hospital between 1957-1998, 51 had persistently elevated calcitonin levels after initial surgery in the absence of clinically or radiologically demonstrable residual disease. Of these, 24 were treated with radiotherapy because of advanced local disease at presentation; this resulted in normalization of calcitonin in only 1 patient, although 10 remained free of clinical recurrence. Surveillance alone was used in the remaining 27 patients, of whom 8 (30%) remained free of overt disease. Local relapse rate was significantly lower after radiotherapy (29% vs. 59%) but there was no significant difference in 10-year survival between the two groups (72% vs. 60%). In view of this favorable long-term survival of patients with elevated calcitonin on observation, we cannot recommend the routine use of radiotherapy. However, it does appear to have a role in those presenting with more advanced disease to reduce the incidence of loco-regional relapse.     

Diagnostic 131I whole body scanning after thyroidectomy and ablation for differentiated thyroid cancer

OBJECTIVE: To assess the value of the diagnostic whole body (131)I scan after thyroidectomy and (131)I ablation. DESIGN: Retrospective analysis of all patients with differentiated thyroid cancer treated in one centre between 1990 and 2000. RESULTS: A total of 153 consecutive patients who underwent diagnostic scanning following ablative therapy were identified. This diagnostic scan was positive in 20 patients (13%) and faintly positive in 16 patients (11%). The majority (117 patients) had negative scans. Of the 20 patients with positive scans, four received no further treatment, nine showed no abnormal uptake following a second ablative (131)I dose and seven had uptake in the thyroid bed (six) or in neck nodes (one) after repeat ablation. OUTCOME: In the group with positive scans, the four patients who received no further treatment and the nine with a negative second ablation scan remained disease free during follow-up. No patient with a positive diagnostic scan received additional (131)I therapy which would not otherwise have been given based on the clinical findings, serum thyroglobulin (Tg) values or the presence of anti-Tg antibodies. Ten of the patients with negative scans developed recurrent disease which was always detected clinically or by a rising serum Tg value. CONCLUSIONS: Diagnostic whole body (131)I scans add little extra information and in our experience do not influence patient management. They should be reserved for patients in whom serum Tg levels are unreliable because of the presence of antibodies or when there is clinical suspicion of tumour.     

Management of differentiated thyroid cancer diagnosed during pregnancy

OBJECTIVE: To assess the outcome of thyroid cancer diagnosed during pregnancy. DESIGN: Retrospective analysis of patients diagnosed between 1949 and 1997 with thyroid cancer presenting during pregnancy. RESULTS: Nine women with a median age of 28 years were identified. A thyroid nodule was discovered by the clinician during routine antenatal examination in four cases, the remainder had noted a lump in the neck. In all patients, the nodule was reported to almost double in size during the pregnancy. One patient underwent subtotal thyroidectomy during the second trimester; eight were operated on within 3 to 10 months from delivery. Total thyroidectomy was performed in five and subtotal thyroidectomy in four. All tumours were well differentiated and ranged in size from 1 to 6 cm. OUTCOME: The median follow-up was 14 years (5-31 years). One patient relapsed locally requiring further surgery. One patient developed bone metastases dying 7 years after presentation; her planned treatment had been delayed because of an intervening pregnancy. Eight of the original cohort of patients are currently disease free. CONCLUSIONS: Differentiated thyroid cancer presenting in pregnancy generally has an excellent prognosis. When the disease is discovered early in pregnancy, surgery should be considered in the second trimester but radioiodine scans and treatment can be safely delayed until after delivery. In all cases, treatment should not be delayed for more than a year.     

Effects of the association of diabetes and pulmonary emphysema on cardiac structure and function in rats

Chronic obstructive pulmonary disease is often associated with chronic comorbid conditions of cardiovascular disease, diabetes mellitus and hypertension. This study aimed to investigate the effects of the association of diabetes and pulmonary emphysema on cardiac structure and function in rats. Wistar rats were divided into control non‐diabetic instilled with saline (CS) or elastase (CE), diabetic instilled with saline (DS) or elastase (DE), DE treated with insulin (DEI) groups and echocardiographic measurements, morphometric analyses of the heart and lungs, and survival analysis conducted 50 days after instillation. Diabetes mellitus was induced [alloxan, 42 mg/kg, intravenously (iv)] 10 days before the induction of emphysema (elastase, 0.25 IU/100 g). Rats were treated with NPH insulin (4 IU before elastase plus 2 IU/day, 50 days). Both CE and DE exhibited similar increases in mean alveolar diameter, which are positively correlated with increases in right ventricular (RV) wall thickness (P = 0.0022), cavity area (P = 0.0001) and cardiomyocyte thickness (P = 0.0001). Diabetic saline group demonstrated a reduction in left ventricular (LV) wall, interventricular (IV) septum, cardiomyocyte thickness and an increase in cavity area, associated with a reduction in LV fractional shortening (P < 0.05), and an increase in LViv relaxation time (P < 0.05). Survival rate decreased from 80% in DS group to 40% in DE group. In conclusion, alloxan diabetes did not affect RV hypertrophy secondary to chronic emphysema, even in the presence of insulin. Diabetes per se induced left ventricular dysfunction, which was less evident in the presence of RV hypertrophy. Survival rate was substantially reduced as a consequence, at least in part, of the coexistence of RV hypertrophy and diabetic cardiomyopathy.     

Diversity and Adaptation of Human Respiratory Syncytial Virus Genotypes Circulating in Two Distinct Communities: Public Hospital and Day Care Center

HRSV is one of the most important pathogens causing acute respiratory tract diseases as bronchiolitis and pneumonia among infants. HRSV was isolated from two distinct communities, a public day care center and a public hospital in São José do Rio Preto – SP, Brazil. We obtained partial sequences from G gene that were used on phylogenetic and selection pressure analysis. HRSV accounted for 29% of respiratory infections in hospitalized children and 7.7% in day care center children. On phylogenetic analysis of 60 HRSV strains, 48 (80%) clustered within or adjacent to the GA1 genotype; GA5, NA1, NA2, BA-IV and SAB1 were also observed. SJRP GA1 strains presented variations among deduced amino acids composition and lost the potential O-glycosilation site at amino acid position 295, nevertheless this resulted in an insertion of two potential O-glycosilation sites at positions 296 and 297. Furthermore, a potential O-glycosilation site insertion, at position 293, was only observed for hospital strains. Using SLAC and MEME methods, only amino acid 274 was identified to be under positive selection. This is the first report on HRSV circulation and genotypes classification derived from a day care center community in Brazil.     

Evolutionary history or function? Which preponderates in the expression of the muscle mass of the thoracic limb in wild carnivorans?

Thoracic limbs are extremely versatile and exhibit informative characteristics about habits of the Carnivora order in the wild. Despite this relevance, comparative studies with quantitative variables on thoracic limb muscles are still scarce in carnivorans. The aims of this study were to measure the mass of the intrinsic muscles of the thoracic limb of neotropical species of the Carnivora order and to establish comparative conjectures. For this purpose, 39 thoracic limbs of 10 neotropical carnivorans species were dissected. The mass of each muscle was measured on a digital scale, muscles were grouped by function, and the mass average percentage that each functional group of muscles occupied in the thoracic limb was calculated. The data of the present study was added to that available in the literature for 22 other carnivoran species. Three groups of species were considered: Canidae, Musteloidea, and Feliformia. Comparatively, the eight canid species included in this analyses concentrate muscle mass proximally in the thoracic limb to prioritize essential cursoriality. The nine musteloids had more muscle mass in the distal muscles due to the demand for versatility and manual strength, and the 14 Feliformia species exhibited an intermediate trend. The analysis of clusters revealed a great overlap of the percentage distribution of muscle mass with the phylogeny previously established for carnivorans. It could be verified that the distribution of muscle masses meets the demand of the locomotor habits of the species up to a certain level, from which phylogeny begins to limit morphological adaptations.     

Medullary thyroid cancer: multivariate analysis of prognostic factors influencing survival.

AIMS: The aims of this study were to assess the long-term results of treatment of medullary thyroid carcinoma (MTC) and to define prognostic factors. METHODS: Retrospective analysis of all patients diagnosed with MTC between 1949 and 1998 and treated in our unit was carried out. RESULTS: One hundred and sixty-two patients (87 females, 75 males) were identified; 52 patients (32%) had familial disease. Median follow-up was 9 years (2-20 years). The majority of patients (90%) presented with a thyroid mass or enlarged neck nodes. Total/subtotal thyroidectomy was performed in 129/18 patients respectively; 45 patients also underwent neck dissection while 52 had simple nodal excision. External beam radiotherapy (RT) was given to 76 patients with advanced disease at presentation. Overall survival was 72% at 5 years and 56% at 10 years; case-specific survival was very similar. In multivariate analysis the factors which were significant predictors of survival were age at diagnosis, extent of nodal disease, extent of surgery and metastases at presentation. RT significantly reduced local relapse in patients with ipsilateral nodal disease. CONCLUSIONS: MTC may be associated with prolonged survival; the best prognosis occurs in young patients undergoing total thyroidectomy and neck dissection. External beam RT significantly reduces local relapse in patients with limited nodal disease.     

Inherited epidermolysis bullosa: clinical and therapeutic aspects

Inherited epidermolysis bullosa (EB) is a heterogeneous group of genetic disorders that present with skin and, in some cases, mucosal fragility, predisposing patients to the development of blisters and/or erosions after minimal trauma or friction. Children with a recurrent history of these kinds of lesions or neonates that present them in the absence of another reasonable explanation should be investigated. Diagnosis must be based on clinical and histopathological findings. To date, management of inherited EB basically consists in avoiding traumas that trigger lesions, as well as preventing infection and facilitating healing of the wounds with the systematic use of bandages.