Malignant struma ovarii with a robust response to radioactive iodine.

SUMMARY: Struma ovarii is a rare, usually benign ovarian tumour with malignancy occurring in <5% of cases. Metastases, particularly seeding to bone, are extremely rare. Presentation is variable but often features local pain and/or ascites and hyperthyroidism may occur. It is not established how to best treat and follow patients with extensive disease. Case reports of radioiodine (I131) ablative therapy following thyroidectomy have shown reduced recurrence. We describe the case of a 33-year-old woman who presented with bone pain and was diagnosed with skeletal metastases with features of follicular thyroid carcinoma. However, thyroid pathology was benign. She recalled that 5 years prior, an ovarian teratoma was excised, classified at that time as a dermoid cyst. Retrospective review of this pathology confirmed struma ovarii without obvious malignant features. The patient was found to have widespread metastases to bone and viscera and her thyroglobulin was >3000 µg/L following recombinant TSH administration prior to her first dose of I131. At 25 months following radioiodine treatment, she is in remission with an undetectable thyroglobulin and clear I131 surveillance scans. This case demonstrates an unusual presentation of malignant struma ovarii together with challenges of predicting metastatic disease, and demonstrates a successful radioiodine regimen inducing remission. LEARNING POINTS: Malignant transformation of struma ovarii (MSO) is extremely rare and even rarer are metastatic deposits in bone and viscera. MSO can be difficult to predict by initial ovarian pathology, analogous to the difficulty in some cases of differentiating between follicular thyroid adenoma and carcinoma. No consensus exists on the management for post operative treatment of MSO; however, in this case, three doses of 6Gbq radioiodine therapy over a short time period eliminated metastases to viscera and bone. Patients should continue to have TSH suppression for ~5 years. Monitoring thyroglobulin levels can predict recurrence.

Screening for cytotoxic activity of ovotransferrin and its enzyme hydrolysates.

The aim of this study was to investigate the cytotoxic activities of ovotransferrin (OTF) from egg white and its enzyme hydrolysates (OTH). The OTF was hydrolyzed at 45°C for 3 h using neutrase, alcalase, acid (0.03 N HCl, pH 2.5), protamex, protex 6L, flavorzyme, α-chymotrypsin, trypsin, and collupulin MG. The enzyme to substrate ratio was 1:25 (wt/wt) in all experiments. Using the 3-(4,5-dimethylthizol-2-yl)-2,5-diphenylatetetrazolium bromide (MTT) assay, the cytotoxicity of OTF and OTH was evaluated in human cancer cell lines of various tissue origins, including the lung (A549 and SK-MES-1), stomach (AGS), breast (MCF-7), larynx (Hep-2), cervix (HeLa), and liver (HepG2). The growth of all cancer cell lines was inhibited by both OTF and OTH in a dose-dependent manner. In particular, OTF displayed relatively high cytotoxicity (≤60% inhibition effects) at 40 mg/mL. At lower concentrations (≤5 mg/mL), however, OTF- and OTH-mediated cytotoxic effects were not significant in all cancer cell lines tested. The MCF-7 cells were the least sensitive to all treatments among all cancer cell lines tested. The OTH-trypsin and OTH-neutrase showed a potent cytotoxicity (over 90% cytotoxicity) to HeLa cells at the 10 mg/mL level. The OTH-trypsin, OTH-protamex, OTH-protex 6L, and OTH-collupulin MG caused 95, 96, 86, and 87% growth inhibition, respectively, in AGS cells. These results indicated there are possibilities that OTF and OTH can be used as natural growth inhibitors of human cancer cell lines.

Myositis due to the microsporidian Anncaliia (Brachiola) algerae in a lung transplant recipient.

Microsporidia are obligate intracellular parasites, more closely related to fungi than protozoa on molecular phylogenetic analysis, and are known to be a rare cause of opportunistic infection in immune compromised patients including human immunodeficiency virus-positive patients and solid organ transplant recipients. We report the first case to our knowledge of microsporidial myositis in a lung transplant recipient. He was 49 years old and had received a lung transplant in 2000 for cystic fibrosis. He presented in 2009 with fevers, chronic diarrhea, myalgia, and pancytopenia, and developed progressive weakness and neurological symptoms before his death 35 days after hospital admission. Multiple investigations, including stool culture, rectal biopsy, colonoscopy, cerebrospinal fluid examination, bone marrow biopsy, lung biopsy, and bronchoalveolar lavage, failed to reveal a definite cause for the patient's deterioration. The diagnosis of microsporidial infection was made on post-mortem light microscopic examination of tissue sections of the tongue and deltoid muscle. Light microscopy diagnosed a microsporidial myositis, confirmed by transmission electron microscopy, which suggested that the organism was Brachiola species. The identity of the organism was confirmed by polymerase chain reaction as Brachiola algerae (recently renamed Anncaliia algerae). The case highlights the need to consider protozoal organisms in the differential diagnosis of myalgia and multisystemic infections in immune compromised patients.

Cell uptake and tissue distribution of radioiodine labelled D-luciferin: implications for luciferase based gene imaging.

Optical luciferase gene imaging is emerging as a method to monitor gene expression in small animals. However, there is concern over how regional availability of exogenously administered substrate may affect photon emission. We thus synthesized [125I]iodo-D-luciferin, which demonstrated substrate characteristics for firefly luciferase, and investigated its cell uptake kinetics and in vivo biodistribution. Luminescence assays of luc gene transduced cells confirmed a linear decline in emitted light units with decreasing luciferin concentration. Both luc gene transduced and control cells demonstrated a low level of cellular uptake and rapid washout of [125I]iodo-D-luciferin, although early uptake was slightly higher for transduced cells (P < 0.005). Biodistribution in ICR mice demonstrated that early uptakes in liver, lung, myocardium and muscle were lower with intraperitoneal compared to intravenous administration. In view of the poor cell uptake, uptake levels (< 3%ID/g) suggest that substrate concentration may limit light emission rates in organs such as bone, muscle, myocardium, and particularly the brain. Thus, substrate availability should be considered as a potential limiting factor for photon emission efficiency in certain organs when attempting quantitative interpretation of optical luc gene imaging.

Use of insulin to improve [18 F]fluorodeoxyglucose labelling and retention for in vivo positron emission tomography imaging of monocyte trafficking.

While 18F-FDG labelling of monocytes would allow in vivo trafficking with positron emission tomography (PET), present methods suffer from poor retention of radioactivity. We investigated the feasibility of utilizing insulin for improved [18F]fluorodeoxyglucose (18F-FDG) labelling. Separated human monocytes and lymphocytes were labelled with 18F-FDG with or without 3 h insulin pre-incubation. Insulin had no effect on lymphocyte labelling (21.4+/-0.8% vs 20.8+/-1.1% efficiency, P=NS). However, for monocytes, insulin pre-incubation led to a 169+/-9% increase in labelling efficiency (19.3+/-4.1 vs 32.5+/-1.8, P<0.05), without significant effects on cell activation or viability. Moreover, while only 57.7+/-4.8% and 40.4+/-5.6% of the 18F-FDG was retained at 1 and 3 h for controls, the retention rate increased to 91.6+/-2.1% (P=0.01) and 86.5+/-1.9% (P<0.01) after insulin pre-incubation. Improved 18F-FDG retention was accompanied by a 70.3+/-7.4% decrease in glucose-6-phosphatase activity (P=0.02). PET imaging of rats showing hepatic ischaemia-reperfusion injury demonstrated higher liver uptake for monocytes labelled after insulin treatment. Thus, insulin improves monocytic 18F-FDG uptake and retention, and may provide a feasible labelling method for PET imaging.

Employer-sponsored Medicare HMO strategies: common selection criteria.

Retiree health care costs have increased at an astronomical rate for employers. In order to gain control over these costs and reduce Financial Accounting Standards FAS 106 expense and liability, many employers have turned to Medicare HMOs as a solution. The Medicare HMO arena has exploded over the last few years. With the wide diversity of Medicare HMOs in the marketplace, the prospect of selecting Medicare HMOs can be daunting. However, as more and more employers offer Medicare HMOs to retirees, some common criteria to assist in the selection process have evolved. These criteria are in the categories of sufficient access, high quality care, generous benefit levels, at affordable cost. These are by no means the only criteria employers should consider; however, they should serve as a solid foundation from which a Medicare HMO strategy can be developed.