Changes of serum calcium level after glucose load.
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Biomedical subjects
Publications and source records attributed to J Nĕmec.
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In a group fo 860 patients with thyroid cancers (TC), 66 were found having had thyroid surgery for benign disorder more than 5 years before the diagnosis of TC. More than 70% of these patients were operated upon 10 or more years ago. The incidence of cancers developing in thyroid postsurgical remnants could thus be estimated to 5.5-7.7% of all thyroid cancers. These patients had predominantly follicular cancers and usually were older than 40 years at the age of diagnosis of TC. Unusually high incidence of distant metastases (pulmonary or osseous) was proved compared to other patients with TC, while the increase of patients having both pulmonary and osseous metastases was not found. It seems that the risk of developing TC late after thyroid surgery is somehow connected with endemic goitre areas, as all such reports arise from the central European area. Whichever the pathogenic mechanism may be, all patients following surgery for benign eumetabolic goitres should be checked up in regular intervals with regard to the possible benign or malignant recurrence. Patients operated upon because of hyperthyroidism do not seem to carry any similar risk.
A case of different thyroid cancer is reported in detail, showing unusual behaviour both clinically and bioptically. The patient suffered from severe hyperthyroidism, with a scintigraphic finding of independent thyroid adenoma and simultaneous function in pelvic mass proved to be a metastasis of follicular thyroid cancer. Bioptical finding confirmed the aspiration biopsy conclusion that the independently functioning thyroid nodule had been in fact a follicular thyroid cancer. Microscopically, a transition of the usual type of follicular thyroid cancer to solid cancer consisting of water-clear cells was found. Thyroidectomy led to enhancement of uptake in pelvic metastasis but the general condition deteriorated rapidly leading to death by pulmonary embolism. The problem is discussed with regard to the development of hyperthyroidism in thyroid cancer.
The authors present a further description of the classical picture of Cushing's syndrome in a female patient with medullary carcinoma of the thyroid gland (MCT). Analysis of data reported in the literature and the author's own experience indicate the necessity of radical treatment of MCT before the development of the clinical paraneoplastic syndrome and of efforts to detect it in the preclinical stage. Developed Cushing's syndrome or hypokalaemic alkalosis are in the great majority late symptoms associated as a rule with advanced dissemination of the tumour. Metastases in the liver are particularly frequent. As regards therapy, bilateral adrenalectomy is recommended when it is obvious that attempts to eradicate MCT are hopeless, even where the affection of the adrenals seems to be unilateral. Radical surgery of the tumour and of regional metastases, if there is no remote dissemination, is the optimal solution, which can be used, however, only in exceptional cases.
Metastatic dissemination of differentiated cancer was studied in a personal group with the following results. Invasion of cancer to adjacent structures can be encountered even in children with typical increase with age. The lymphatic spread to regional lymph nodes is typical of papillary cancers and in young patients. The same type of spread without the age-dependent decrease can also be proved, with lower incidence, in follicular cancers. Pulmonary metastases are frequently the only type of distant metastases and may originate from previous spread to lymph nodes. The isolated bone metastases a;e probably brought about through the vertebral venous system. Patients having multiple bone metastases or both bone and lung lesions are probably the only typical examples of metastasizing through the systemic blood flow. As the above types of distant metastases carry different prognosis they should also be recognized by the TNM system.
In metastases of the lung which must be considered as typical in cancer of the thyroid, it is possible to differentiate roentgenologically between fine and coarse nodules, the limit being approximately 10 mm. Metastases consisting of fine nodules are by no means to be considered as representing a fatal generalisation, whereas metastases with coarse nodules are frequently accompanied by other metastases distant from the primary tumour.
The levels of total organically bound 131I, per cent of labelled iodoproteins, total labelled iodinated amino acids and a percentage of individual iodinated amino acids (thin-layer chromatography) were measured in serum of 84 patients with thyroid cancer and of 16 patients with thyrotoxicosis at 48 h after the administration of therapeutic dose of 131I. In thyrotoxic patients treated with therapeutic doses of 131I (2 to 39.6mCi; 74 to 1500 MBq) the findings were similar to normal subjects. In patients with thyroid cancer a significant increase of iodotyrosines was found after thyroid radioiodide ablation (100 to 200 mCi; 3.7 to 7.4 GBq). No remarkable differences were found between two groups of patients with thyroid cancer, the first one being treated with thyroid eliminating dose in attempt to activate the metastases of functionally differentiated tumour, while the second one was treated with similar doses (i. e. 100 to 200 mCi) to suppressor destroy a functionally active tumour or its metastases. Even though the hormonogenesis in tumours was hardly distinguishable from the products of its radiation damage, it was suggested that the hormonogenesis in neoplastic tissue differs from that in normal thyroid only quantitatively, being less in patients with thyroid cancer than in these with thyrotoxicosis.
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In 206 patients with differentiated thyroid cancer, the distribution of iodine-131 were compared after diagnostic (200-500 microCi) and thyroblative (approximately 100 mCi) doses. In the diagnostic scans, only normal thyroid tissue could be seen, whereas in one-fourth of the patients the therapeutic scans showed tumor tissue as well, usually in lymphnode metastases. In 16% of patients, the therapeutic scan was the only way to demonstrate the presence of tumor tissue, since no further uptake was achievable. In patients in whom all tumor was believed to have been removed by surgery alone, a "preventive" I-131 ablation was used, and in 16 of these 97 patients tumor was revealed in the therapeutic scan. In ten more, tumor was found in subsequent followup scans, its functioning having been induced by destruction of postsurgical remnants of normal thyroid. Some possible explanations for the differences in scans are proposed, and the importance of therapeutic scans for correct staging of thyroid cancer is stressed.
Pulmonary metastases were found in 123 out of 840 patients with thyroid cancer between 1955-1977, 87 patients with pulmonary metastases of differentiated cancer were studied in detail, including an evaluation of prognostically important factors. In 66 of them, the induction of 131I uptake in metastases was attempted, in half of them successfully. Uptake was achieved more frequently in younger subjects, in papillary cancers and in patients with fine pulmonary metastases on chest films. Survival (not corrected for age) was evaluated 10 and 15 years following the diagnosis of thyroid cancer and was found to be 29,1% and 12,2%, respectively. Significantly higher survival rates were seen in younger patients, in patients with the fine type of pulmonary metastases, in the absence of bone metastases and, particularly, in patients with induced 131I uptake in metastases. Papillary cancers were found to have higher survival rates in males and in young subjects only, in the whole group the survival rates were independent of either microscopic type or sex. It is believed that biologic behaviour of distant (pulmonary) metastases may be influenced by radiodide therapy.
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The evaluation of the nuclear morphology for the diagnostic cytology of the various types of goiters with special regard to thyroid malignancy was studied. The material for the light microscopy was obtained from the goiters by means of aspiration biopsy with thin needle and that for electrone microscopy from the excision at the operation. Both the patterns of the nucleoli were compared. The nucleolus of the thyroid cell, like in other cells, is a marker of the RNA synthetic activity. Secondary it signals the intensity of the proteosynthetic activity, that means of secretory or proliferative processes. In thyroid cells, the increased activity has a different nucleolar pattern. For that reason the study of the nucleoli is very useful in differential diagnosis of thyroid malignancy. The cytochemical examination of the nucleoli by means of toluidine blue staining is in accord with the electron microscopic pattern, where the mutual relation of the fibrillar and granular components of RNA can be evaluated.
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In experiments performed in mice, Adriamycin (15 mg/kg i. p.) produced serious damage of the heart muscle. Damvar (2 x 200 mg/kg orally) a new cytostatic drug combined with Adriamycin decreased conspicuously its cardiotoxicity.
In a group of 840 patients with thyroid carcinoma the authors found pulmonary metastases in 123 patients, i. e. in 14.6%. In 78 pulmonary metastases were the only remote ones, in the remainder they were combined also with other remote metastates, almost always bone metastases. Cases of "pure" pulmonary metastases were found in the whole group without a proved relationship to age and histology, with a slight prdominance of men, while in patients with a combination of pulmonary and bone metastases follicular carcinoma predominates and it is found mainly in patients of more advanced age. The biological behaviour of these two groups differs completely, and this should be taken into account in the international TNM classification. When investigating the biological properties of thyroid carcinoma, we evaluated in detail in a recent publication (15) bone metastases. As all remote metastases of thyroid carcinoma are included according to the classification of WHO under the common sign M1 (9), we wanted to compare some factors in the incidence of pulmonary and bone metastases.
In thyroid cancer patients with pulmonary metastasis lymph nodes involvement was found in 62.6%. The incidence of lymph nodes metastases is discussed in relation to the age of patients and to the stage of the disease.