Striking Size Reduction of Rapidly Growing Pancreatic Neuroendocrine Carcinoma Metastatic Nodal Conglomerate After Only 2 Cycles of 177 Lu-DOTATATE.

ABSTRACT: Peptide receptor radionuclide therapy (PRRT) with 177 Lu-DOTATATE has shown great treatment efficacy in patients with well-differentiated metastatic neuroendocrine tumors and a metastatic size reduction of ~20% for metastatic lesions <3 cm in size. We present a 66-year-old man with pancreatic neuroendocrine carcinoma, who had a rapidly growing metastatic nodal conglomerate, which measured close to 10 cm in size. After only 2 cycles of PRRT with 177 Lu-DOTATATE, the nodal conglomerate had a striking size reduction greater than 75%. This case highlights the potential efficacy of PRRT with 177 Lu-DOTATATE for treatment of aggressive neuroendocrine neoplasms.

Timing and magnitude of increases in levothyroxine requirements during pregnancy in women with hypothyroidism.

BACKGROUND: Hypothyroidism during pregnancy has been associated with impaired cognitive development and increased fetal mortality. During pregnancy, maternal thyroid hormone requirements increase. Although it is known that women with hypothyroidism should increase their levothyroxine dose during pregnancy, biochemical hypothyroidism occurs in many. In this prospective study we attempted to identify precisely the timing and amount of levothyroxine adjustment required during pregnancy. METHODS: Women with hypothyroidism who were planning pregnancy were observed prospectively before and throughout their pregnancies. Thyroid function, human chorionic gonadotropin, and estradiol were measured before conception, approximately every two weeks during the first trimester, and monthly thereafter. The dose of levothyroxine was increased to maintain the thyrotropin concentration at preconception values throughout pregnancy. RESULTS: Twenty pregnancies occurred in 19 women and resulted in 17 full-term births. An increase in the levothyroxine dose was necessary during 17 pregnancies. The mean levothyroxine requirement increased 47 percent during the first half of pregnancy (median onset of increase, eight weeks of gestation) and plateaued by week 16. This increased dose was required until delivery. CONCLUSIONS: Levothyroxine requirements increase as early as the fifth week of gestation. Given the importance of maternal euthyroidism for normal fetal cognitive development, we propose that women with hypothyroidism increase their levothyroxine dose by approximately 30 percent as soon as pregnancy is confirmed. Thereafter, serum thyrotropin levels should be monitored and the levothyroxine dose adjusted accordingly.

Biochemical changes in the efferent lymph plasma after oxazolone stimulation.

The lymph node is a specialized microenvironment for the regulation of immune responses. The reticular network of the lymph node provides a structure that facilitates not only intercellular interactions, but the intranodal flow of lymph fluid. To assess biochemical changes in the nodal lymph plasma after antigen stimulation, prescapular lymph nodes in sheep were stimulated with the epicutaneous antigen oxazolone. The efferent lymph from both antigen-stimulated and contralateral control prescapular lymph nodes was continuously monitored for more than 120 h. The oxazolone-stimulated lymph plasma was associated with a selective increase in cholesterol content during the 'recruitment' phase of lymph node enlargement. The peak in cholesterol was followed closely by a significant increase in lymph plasma LDH concentration. In contrast, there was no significant difference between oxazolone-stimulated and control lymph plasma in the concentration of triglycerides, albumin, alkaline phosphatase, and alanine transferase. These selective biochemical changes in the efferent lymph appeared to reflect the dynamics of lymphocyte activation within the lymph node as well as provide a practical measure of the lymph node response to antigen stimulation.

Confirmation of the Department of Transportation criteria for a substituted urine specimen.

The purpose of this study was to determine whether people could naturally produce urine sufficiently dilute to meet the federal criteria for a "substituted" specimen. The United States Department of Transportation Regulations (49 Code of Federal Regulations Part 40) defines a urine specimen as substituted if it has a creatinine concentration of < or = 5 mg/dL and a specific gravity of < or = 1.001 or > or = 1.020. These criteria have been criticized based on the contention that an insufficient number of specimens had been tested from the same urine sample for both creatinine and specific gravity measurements. We reviewed the results of 803,130 random urine specimens measured for creatinine and/or specific gravity in a hospital-based laboratory. In this database, 13,467 urine specimens had both creatinine and specific gravity measurements. None of these 13,467 paired urine specimens met the lower limit of specific gravity (< or = 1.001) and creatinine (< or = 5 mg/dL) criteria for a Department of Transportation substituted specimen. We also examined the medical records of those patients meeting even one of the two criteria; creatinine concentration < or = 5 mg/dL or specific gravity < or = 1.001. These patients were neonatal, moribund, or so severely ill that essentially none could have been among the working population. These data in patients with various pathologic states support our belief that normal individuals do not produce urine dilute enough to meet the lower limit of the specific gravity (< or = 1.001) and creatinine (< or = 5 mg/dL) required for meeting substituted specimen criteria. Eleven patients met the criteria for a substituted specimen, with elevated specific gravity of > or = 1.020 and creatinine concentration of < or = 5 mg/dL; however, these patients were seriously ill or terminally ill.