Identification and measurement of calcitonin precursors in serum of patients with malignant diseases.

Previous studies have suggested that molecular species larger than the mature calcitonin (CT) are produced by tumors of different origin. In order to study these species, we developed a monoclonal immunoradiometric assay for calcitonin precursors (CT-pr). This assay was based on both monoclonal antibody KC01 directed to the 1-11 region of katacalcin and monoclonal antibody CT08 directed to the 11-17 portion of CT. The sensitivity of this monoclonal immunoradiometric assay for CT-pr was less than 100 pg/ml. Only one of 131 healthy subjects had CT-pr serum levels greater than 100 pg/ml; this value was therefore selected as the standard serum value in healthy individuals. CT-pr was present in the serum of seven of ten patients with advanced renal failure and in that of 21 of 52 patients (40%) with benign liver disease but was undetectable in sera of patients with other benign diseases. The serum CT-pr level was correlated with that of mature CT in patients with medullary carcinoma of the thyroid. In contrast, the serum CT-pr level was frequently elevated in the absence of a detectable CT level in patients with various malignant tumors and, particularly, in those with either tumors of the neuroendocrine system (60%) or hepatocellular carcinomas (62%). CT-pr was detected in tumor extract from a patient with a hepatocellular carcinoma. Moreover, hybridization experiments with total RNA extracted from this tumor demonstrated the presence of RNAs hybridizing with complementary DNA encoding for common region, calcitonin, and katacalcin sequences. These results show that CT precursors are excreted by numerous cancers and might well be useful biological markers for the follow-up of productive tumors.

Positive anticalcitonin immunoscintigraphy in patients with medullary thyroid carcinoma.

A cocktail of three monoclonal F(ab')2 fragments against three distinct epitopes of calcitonin or PDN 21 was labelled with either 111In or 131I. These F(ab')2 fragments, a control 125I-F(ab')2 fragment and 99mTc-pertechnetate were injected into four patients suffering from medullary thyroid carcinoma. Scintigraphy data were processed by energy factor analysis for an optimal separation of images corresponding to each isotope. The best tumor detection was obtained 1-3 days after injection of the 111In-F(ab')2 cocktail which clearly labeled the thyroid tumors in the four patients (smallest tumor detected, 0.6 cm) as well as lymph node and bone metastases. In the liver, positive detection was only successful with the 131I-labeled cocktail. These results were confirmed by counting rates of resected specimens which provided average specificity indices ranging from 3.3 to 13.1. Anticalcitonin antibodies could be particularly useful for immunoscintigraphy detection of residual or recurrent medullary thyroid carcinoma in patients with elevated calcitonin serum level.

Relationship between thyrotropin stimulation and radioiodine uptake in lung metastases of differentiated thyroid carcinoma.

To examine whether the injection of bovine TSH (bTSH) produces maximal radioactive iodine uptake (RAIU) in lung metastases in patients with differentiated thyroid cancer, 10 patients were studied 12 times. In 10 of these studies, an initial RAIU measurement was performed immediately after 3 injections of 10 IU bTSH given immediately after T3 withdrawal. Another RAIU measurement was performed 7-19 days after T3 withdrawal. Uptake increased in all patients even when it was clearly detectable immediately after bTSH stimulation. Thus, 3 days of bTSH stimulation in these patients did not lead to maximal 131I uptake, and it could only be reached after prolonged endogenous TSH stimulation. bTSH was not injected in the 2 other patients, in whom 6 RAIU measurements were carried out. Radioiodine uptake increased with time in both patients. It appears that both the level of endogenous TSH and the length of stimulation play a determining role in RAIU. This might explain why 3 days of bTSH stimulation are insufficient to elicit maximal 131I uptake.

Long-term results of treatment of 283 patients with lung and bone metastases from differentiated thyroid carcinoma.

We assessed the results of treatment in 283 patients with lung or bone metastases from differentiated thyroid carcinoma who were followed for up to 40 yr (median, 44 months) after the discovery of the metastases. The survival rates from the time of discovery of the metastases were 53% at 5 yr, 38% at 10 yr, and 30% at 15 yr; 156 patients died. Multivariate analysis revealed that only 4 variables had an independent prognostic significance for survival. They were extensive metastases, older age at discovery of the metastases, absence of radioiodine uptake by the metastases, and moderately differentiated follicular cell type. The site of metastases (lung or bone) was not a prognostic factor for survival after treatment of metastatic disease. Remission was achieved in 79 patients after metastases were found. The only predictive factor for 5-yr disease-free survival after treatment of metastases was the initial extent of disease. Our results suggest that the aim of management should be to detect and treat metastases in patients with thyroid cancer as early as possible.

Comparison of octreotide scintigraphy and conventional imaging in medullary thyroid carcinoma.

UNLABELLED: We evaluated the clinical utility of positive somatostatin receptor scintigraphy in patients with medullary thyroid cancer (MTC). METHODS: Twenty-four MTC patients with increased calcitonin levels underwent somatostatin receptor scintigraphy using 111In-pentetreotide (120-200 MBq) with early (4 hr after injection) and delayed (24 hr) whole-body scans and liver SPECT imaging. In Group 1 (12 patients), conventional imaging modalities demonstrated the presence of tumor sites prior to somatostatin receptor scintigraphy; in Group 2 (12 patients), conventional imaging modalities were negative or inconclusive. RESULTS: Somatostatin receptor scintigraphy had positive results in 9 of 24 patients (37%): of Group 1 patients, 7 of 12 had positive somatostatin receptor scintigraphy results. Of these patients cases, somatostatin receptor scintigraphy demonstrated several involved organs and tumor sites either identical (two patients) or smaller (five patients) in size than conventional imaging modalities. Only two patients in Group 2 had positive somatostatin receptor scintigraphy results which demonstrated significant mediastinal uptake previously classified as indeterminate on conventional imaging modalities. No new tumor site was identified nor were therapeutic options modified by the somatostatin receptor scintigraphy results. CONCLUSION: Somatostatin receptor scintigraphy only demonstrates part of tumor sites and cannot visualize small tumor sites (< or = 1 cm). We believe that somatostatin receptor scintigraphy has a limited role in the management of MTC patients.

Radioactive iodine treatment and external radiotherapy for lung and bone metastases from thyroid carcinoma.

UNLABELLED: We assessed the therapeutic benefits of 131I treatment in patients with distant metastases of differentiated thyroid carcinoma. METHODS: Of 2200 patients treated for differentiated thyroid carcinoma at our institution, 394 had lung and/or bone metastases. RESULTS: Two-thirds of the patients had 131I uptake in their metastases, but only 46% achieved a complete response. Prognostic factors for complete response were: younger age, presence of 131I uptake in the metastases and small extent of disease. The survival rate was 33% at 15 yr. As shown by multivariate analysis, favorable prognostic factors for survival were: younger age and time of metastases detection, well-differentiated histologic type of the thyroid tumor, presence of 131I type uptake in the metastases, small extent of the disease and year of discovery of metastases. CONCLUSION: In terms of survival, the benefits of 131I therapy cannot be demonstrated by prospective controlled studies. The present study clearly demonstrates, however, that treatment with 131I is one of the factors which accounts for survival; patients whose metastases concentrated 131I and who could be treated with radioiodine had higher survival rates. Patients who achieved complete response following treatment of distant metastases had a 15-yr survival rate of 89%, while those who did not achieve complete response had a survival rate of only 8%. The survival rate improved with the year of discovery of distant metastases, after 131I total-body imaging and serum thyroglobulin measurements were routinely used.

Cytogenetic studies on patients with medullary carcinoma of the thyroid.

Cytogenetic studies were carried out on stimulated lymphocyte cultures of patients with medullary carcinoma of the thyroid. Of 32 patients studied, seven had a hereditary carcinoma, and five had multiple endocrine neoplasia type 2A and two had type 2B. Neither a constitutional chromosome abnormality nor an increase in chromosomal breakage were detected in these patients.

Construction and clinical validation of a sensitive and specific assay for serum mature calcitonin using monoclonal anti-peptide antibodies.

Using calcitonin (CT) as an hapten, we have generated a library of monoclonal antibodies. Six monoclonal antibodies were developed and analyzed with respect to affinity and specificity for epitopes on CT by enzyme linked immunosorbent assay and radioimmunoassay. These antibodies were used in the construction and the optimization of a two-site monoclonal immunoradiometric assay (m-IRMA) for CT. We used a combination of two monoclonal antibodies to develop an assay which is rapid (overnight incubation), sensitive (10 pg/ml) and strictly specific for the mature form of calcitonin, ie the 32 amino acid-long polypeptide bearing a prolineamide as the C-terminal residue. This assay was utilized to demonstrate that mature calcitonin circulates as heterogeneous molecular species resulting from polymerization of calcitonin by disulphide linkage and/or by aggregation on irrelevant proteins. The clinical relevance of this assay was studied on a series of patients with medullary carcinoma of the thyroid (MCT) and the characteristics of the assay was compared with those of a conventional polyclonal radioimmunoassay. The m-IRMA for CT proved to be useful for both the diagnosis and the follow-up of MCT.

Study of calcitonin and thyroglobulin gene expression in human mixed follicular and medullary thyroid carcinoma.

mRNAs were isolated from 2 patients suffering from a familial form of a rare variant of medullary carcinoma of the thyroid (MTC), called mixed follicular and medullary carcinoma. The presence of calcitonin (CT) and thyroglobulin (Tg) mRNAs was checked by northern and in situ hybridization and compared with immunohistochemical results. In each case, mRNAs hybridizing to probes specific for CT and Tg were detected. Both proteins were quantified by radioimmunoassay determination in tissue extracts. Patient 1 had 20 ng Tg and 68 ng CT per micrograms total protein, and patient 2 had 0.4 ng Tg and 1.7 ng CT per micrograms total protein. Northern analysis showed that mixed carcinoma expressed several species of both CT mRNAs and Tg mRNAs. The main Tg transcripts present in neoplastic cells (8.5 and 4.8 kb for patient 1 and patient 2) were identical to or smaller than those of normal thyroid tissue (8.5 kb). The tumor CT mRNA (1 kb) was identical to that of normal tissue. In situ hybridization confirmed the presence of CT and Tg mRNA in the great majority of tumor cells. Furthermore, the presence of small amounts of organified iodine was evidenced by analytical ion microscopy in 35% of these cells. This raises an important question regarding the histogenesis of this tumor.

Chemotherapy in metastatic nonanaplastic thyroid cancer: experience at the Institut Gustave-Roussy.

Forty-nine patients with metastatic nonanaplastic thyroid carcinoma were treated over a 10-year period. Five successive chemotherapeutic protocols were used: a combination of doxorubicin, etoposide, 5-fluorouracil and cyclophosphamide; elliptinium acetate; doxorubicin; cisplatin; and the combination of doxorubicin and cisplatin. Results obtained with the different protocols were very disappointing, with only two objective responses (3%). Phase II trials with new chemotherapeutic agents are warranted in selected cases of nonanaplastic metastatic thyroid carcinoma.

[Clinical signs in medullary cancers of the thyroid]. / Les signes cliniques des cancers médullaires de la thyroïde.

Medullary thyroid carcinoma is diagnosed with difficulty and at an advanced stage as a consequence of its rarity and its relatively recent knowledge. Therefore, the extent of the disease is already important at the therapeutic stage and the chance of cure is poor. One hundred and thirty four cases treated in the Gustave Roussy Institut (Villejuif) and the Jean Godinot Institut (Reims) between 1942 and 1983 have been studied retrospectively. One hundred and seventeen of them diagnosed after 1960 have been analyzed. We have pointed out the clinical features which should lead to diagnosis and with present means should assure it with the minimum of delay. We have outlined the multiple endocrine neoplasia syndromes IIa and IIb and repeated the necessity of clinical and biological familial screening, 11 per cent of cases are inherited.

[Chemotherapy for medullary cancer of the thyroid. Phase II trials with adriamycin and cis-platinum administered as monochemotherapy]. / Chimiothérapie des cancers médullaires de la thyroïde. Essais phase II avec adriamycine et cis-platinum administrés en monochimiothérapie.

Medullary thyroid carcinoma (MTC) is a rare tumor, and patients with distant metastases have a poor prognosis. Chemotherapy efficacity is not well established and we have conducted a phase II trial of monochemotherapy with Adriamycin (ADR) and Cis-platinum (CDDP) in 18 patients. Fourteen MTC have been treated by ADR, the dose was 60 mg/m2 every 4 weeks. The mean number of administration has been 5.3. The results have been: 1 complete response (6 months), 1 partial response (36 months), 1 minor response, 4 stabilisations and 6 failures. The overall responses rate has been 15 per cent and the toxicity has been low. Fourteen MTC have been treated by CDDP. Ten patients had been treated before with ADR. The dose of CDDP was 90 mg/m2 in two hours perfusion with hyperhydration administered every 4 weeks. The mean number of treatment has been 5. The results have been: 1 complete response (9 months), 2 partial responses (16 and 48 months), 4 stabilisations and 7 failures. The overall responses rate has been 21 per cent. In conclusion, ADR and CDDP have some, but limited, efficiency in treatment of metastatic MTC. The effect of their association must be evaluated.

[Role of radiotherapy in the treatment of medullary cancer of the thyroid]. / Place de la radiothérapie dans le traitement des cancers médullaires de la thyroïde.

Medullary thyroid carcinoma (MTC) is a rare tumor for which the main treatment is surgery. However, external radiation therapy (RT) plays an important part in well-defined patients. Out of the 115 patients with MTC treated at the Institute Gustave Roussy: Thirty-five MTC patients with residual cervical disease and without distant metastases had their thyroid region irradiated (60Co, 45 to 50 Gy in 5 weeks). The overall survival of these patients is similar to that of patients with limited cervical extension (n = 57) treated by surgery alone. The results of this study show the effectiveness of cervico-mediastinal irradiation treatment for MTC with extensive local tumor after incomplete surgery. Eight MTCs with inoperable cervical tumor were treated only by external RT. Median survival was 44 months. In six of them, long-term local control was observed: three are alive at 52, 62 and 70 months and 3 died from distant metastases at 36, 36, and 117 months after treatment. Sixteen MTCs with distant metastases were treated with RT on bone metastases (n = 10) or compressive lymph node metastases (n = 6) with good palliative effect. This study shows the efficacy of post-operative external RT in MTCs with extensive cervical tumors, as a curative treatment in non-surgically eradicable cervical tumors and as a palliative treatment for metastatic localisations. The technique of cervico-mediastinal RT is discussed.

[Multiple endocrine neoplasia type 2b. Clinical, diagnostic and therapeutic aspects]. / Néoplasies endocriniennes multiples type 2b. Aspects cliniques, diagnostiques et thérapeutiques.

Multiple Endocrine Neoplasia type 2b (MEN 2b) is a rare syndrome. The principal features are: medullary thyroid carcinoma (MTC), dysmorphism, a ganglioneuromatosis and pheochromocytomas. Eight cases of MEN 2b have been observed at the Institute Gustave Roussy, between 1968 and 1983. Seven involved children under 15 years of age. Eight had a bilateral MTC; six had dysmorphism; six had mucosal tongue neuromas. Six were troubled with visceral ganglioneuromatosis of whom two had intestinal obstruction and one urinary chronic retention. One patient had pheochromocytoma with hypertension. From this experience and other data it appears that: the dysmorphism is frequently poorly interpreted; the visceral ganglioneuromatosis is an early and severe feature; it is important to examine the patient for pheochromocytoma; the MTC must be detected by calcitonin dosage after stimulation, and requires total thyroidectomy; familial screening must be done. To improve the poor prognosis of MEN 2b, early diagnosis and aggressive treatment are necessary.

[Ultrasonographic aspects of hepatic metastases of thyroid medullary cancers]. / Aspects échographiques des métastases hépatiques des cancers médullaires de la thyroïde.

PURPOSE: The aim of this study was to describe the different ultrasonic features of hepatic metastases of medullary thyroid carcinoma and to point out two particular patterns. MATERIAL AND METHOD: A retrospective review of the sonographic examinations of 35 patients with hepatic metastases from medullary thyroid carcinoma was performed. The metastases were classified relatively to their size and sonographic appearance. RESULTS: Four ultrasonic types of metastases were described: Type I: small (< 3 cm) hyperechoic nodules with the same features as typical hepatic hemangioma (54%); Type II: markedly hyperechoic micronodules often associated with acoustic shadowing (40%); Type III: hyperechoic nodules of more than 3 cm in diameter (14%) corresponding to advanced intrahepatic disease; Type IV: hypoechoic or in target form nodules (28%) rarely isolated (8%), mostly associated with additional hyperechoic lesions (20%). Thirty two out of 35 patients had hyperechoic nodules; in 22 patients the HM were of a single type, mainly type I (n = 12) and in 13 patients different types of nodules were present. These sonographic features were correlated with the histologic characteristics of medullary thyroid carcinoma. No precise relationship could be establish between the histologic form of MTC and the US features. CONCLUSION: The authors underline the possible mistake between the metastases of type I and the hemangioma and the characteristic appearance of metastases of type II.

[Causes of death in patients with medullary cancer of the thyroid. GETC. Groupe d'Etude des Tumeurs à Calcitonine]. / Causes de mortalité chez les patients atteints de cancer Médullaire de la thyroïde. GETC. Groupe d'Etude des Tumeurs à Calcitonine.

OBJECTIVE: Medullary thyroid carcinoma (MTC) is characterized by different clinical forms and a possible prolonged survival, despite presence of metastases. In the present study, we have studied the clinical and biological characteristics of 119 decreased MTC patients. METHODS: Our data were retrieved retrospectively from the French medullary thyroid cancer study group (GETC). RESULTS: Our results showed that the cause of death was basically MTC (87%) but not exclusively, depending on the clinical forms and the age. Patients with type IIb multiple endocrine meoplasia (MEN) died earlier from their carcinoma. Patients with type IIa MEN died of causes other than MTC, especially pheochromocytoma. Two-thirds of the patients with sporadic forms of MTC, died with advanced metastases, usually from MTC. CONCLUSION: A significant number of deaths in patients with medullary thyroid carcinoma result from non-cancerous causes. This study established the clinical and biological characteristics of patients at risk of death.