Routine measurement of serum calcitonin in nodular thyroid diseases allows the preoperative diagnosis of unsuspected sporadic medullary thyroid carcinoma

To assess whether routine measurement of serum calcitonin (CT) could improve the preoperative diagnosis of sporadic medullary thyroid carcinoma (MTC), 1385 consecutive patients presenting for nodular thyroid disease during the year 1991 were submitted to serum CT determination and fine needle aspiration cytology (FNAC). The clinical diagnosis was nontoxic nodular goiter in 1197 (86.4%) patients, toxic multinodular goiter in 65 (4.7%), autonomously functioning thyroid nodule (AFTN) in 64 (4.6%), and autoimmune thyroid disease (Graves' disease or Hashimoto's thyroiditis) with nodule(s) in 59 (4.3%). As controls, 177 patients with nonnodular thyroid disease and 32 normal subjects were also studied. Patients with FNAC suspicious of any kind of thyroid carcinoma and patients with elevated basal and pentagastrin-stimulated serum CT, regardless of the results of FNAC, were submitted to surgery. Eight (0.57%) patients (7 with nontoxic nodular goiter and 1 with AFTN) had elevated basal serum CT levels, ranging between 55-10,000 pg/mL. The pentagastrin test was abnormal in all of them. FNAC was suggestive of MTC in 2, thyroid carcinoma in 1, benign nodule in 3, and inadequate in 2. By histology, immunohistochemistry, and Northern blot analysis of total tumor RNAs, MTC was confirmed in all patients, including the 1 with AFTN, who had the association of microfollicular adenoma and a small MTC in the same lobe. After surgery, serum CT decreased to undetectable levels in 7 patients and remained undetectable in 6 of them during a mean follow-up of 22 months, although 1 of them had a positive response to pentagastrin. Forty-four patients in the group with normal serum CT levels had FNAC suspicious for differentiated thyroid carcinoma and were treated by surgery. Differentiated thyroid carcinoma, mostly papillary, was confirmed at histology in 43 subjects (3.1% of all thyroid nodules). In conclusion, the results of our study indicate that serum CT measurement is useful for the screening of sporadic MTC in patients with thyroid nodule(s). The prevalence of MTC, diagnosed by serum CT measurement in a 12-month period, among an unselected series of 1385 patients with nodular thyroid disease was surprisingly high: 0.57% of all thyroid nodules and 15.7% of all thyroid carcinomas. Serum CT measurement was superior to FNAC in suggesting the diagnosis of MTC and was devoid of falsely positive results. Increasing the diagnostic accuracy helped the surgeon to perform more radical treatment of MTC, thus achieving frequent normalization of postoperative serum CT levels. Whether this result indicates definitive cure remains to be established on the basis of longer follow-up.(ABSTRACT TRUNCATED AT 400 WORDS)

Identification of the Cys634-->Tyr mutation of the RET proto-oncogene in a pedigree with multiple endocrine neoplasia type 2A and localized cutaneous lichen amyloidosis

Following the recent identification of specific germline mutations of the RET proto-oncogene in Multiple Endocrine Neoplasia type 2A (MEN2A) patients, we looked for mutations of this gene in a pedigree showing recurrence of MEN2A and localized Cutaneous Lichen Amyloidosis (CLA). Basal calcitonin and/or pentagastrin test performed in all the 10 available members of this pedigree confirmed the clinical diagnosis and allowed the presymptomatic identification of an additional carrier. A cys634-->tyr missense mutation, already reported as causative in MEN2A patients, was identified after SSCP analysis and direct sequencing of exon 11 of the RET protooncogene in one individual affected with both MEN2A and CLA, thus suggesting a common etiology for the two disorders. Taking advantage of the observation of an RsaI restriction site in the sequence surrounding the mutated codon, we could demonstrate that the same mutation is present in three other affected members, in the presymptomatic carrier and in one additional 25 years old healthy member who shows a mildly positive pentagastrin test.

Expression of p21 ras protein as a prognostic factor in papillary thyroid cancer

We studied the expression of p21, the ras encoded protein, in primary tumour of 45 patients with papillary thyroid cancer (PTC). Patients were grouped according to outcome so that one group (31 patients) had a good outcome and the other (14 patients) a fatal outcome, after a follow-up of at least 5 years. The presence of p21 ras protein was assessed by immunohistochemistry with a specific monoclonal antibody (MAb Y-13259). The results were correlated with the outcome, with the expression of proliferating cell nuclear antigen (PCNA)/cyclin (as a marker of cell proliferation) and with other well established prognostic factors for PTC (age, grading, extension and tumour size; Endocrinol Metab Clin North Am 1990, 19, 545-576). p21 staining in tumours of living patients was negative in 15, weakly positive (1+) in 10 and strongly positive (2+ or more) in 6 patients. In tumours from deceased patients, p21 staining was negative in 1, weakly positive in 2 and strongly positive in the remaining 11 patients (P < 0.001, chi 2). PCNA immunostaining was increased in 63.6% (7/11) of the tumours from deceased patients compared to 17.8% (5/28) of the tumours of living patients, but no direct correlation was found between p21 and PCNA expression. Among the other prognostic factors studied, only age > or = 40 years was a significant predictor of poor outcome. The survival curve of patients with strongly positive p21 staining was similar to that of patients aged > or = 40 years at the time of diagnosis. The combination of p21 > or = 2+ and age > or = 40 was superior to age alone (P < 0.05) as a prognostic indicator of poor outcome. In conclusion, our results indicate that the p21 product of the ras (proto)oncogene is differently expressed in PTC, in relation to the degree of aggressiveness. Regardless of the pathogenetic role of the ras oncogene in thyroid tumorigenesis, our data indicate that the expression of the p21 ras protein may be regarded as a prognostic indicator in PTC. Furthermore, overexpression of p21 ras protein is associated with patients in the older age groups, and might contribute to the poor prognosis of elderly patients.

Disappearance rate of serum calcitonin after total thyroidectomy for medullary thyroid carcinoma

We studied the half-life of serum calcitonin (CT) in patients subjected to total thyroidectomy for medullary thyroid carcinoma (MTC). One patient showed a rapid serum CT component with a half-life of 3 hours and a slow component with a half-life of 30 hours; in another case only the 30-hour component was found. By chromatography of tumor extracts, we found that all the immunoreactive CT had a molecular weight of 3,600. After surgery, normalization of serum CT was achieved within 15 days in 4 patients, at 3 months and at 6 months in 2 other patients, while 1 patient never normalized. Normalization of serum CT after surgery is not an index of definitive cure in MTC, as demonstrated by one patient who relapsed 3 months after normalization of serum CT. However, as a general rule, patients who reach undetectable serum CT levels soon after surgery, are those having the best prognosis.

Markers of cell-proliferation as prognostic factors in differentiated thyroid-cancer

Age is the most accepted prognostic factor in differentiated thyroid cancer. Other parameters, such as tumor size, grading, extrathyroidal extension, have also been associated with the prognosis of these tumors. Since the identification of reliable prognostic factors is essential to avoid unnecessary aggressive treatment for a disease, such as thyroid carcinoma, which only rarely is fatal, we studied two indices of cell proliferation in patients with differentiated thyroid cancer, in relation to their outcome. We studied two groups of patients with differentiated thyroid cancer, selected in a way to have one group (33 patients) with a good outcome and one (16 patients) with a fatal outcome, after a follow-up of at least 5 years. By immunohistochemistry the primary tumors of all patients were analyzed for the expression of the proliferating cell nuclear antigen (PCNA)/cyclin. In 38 (77.5%) of them also the nuclear DNA content and the percentages of S-phases were analyzed by flow cytometric analysis. At diagnosis the two groups of patients differed significantly with regard to age and extrathyroidal extension, but not for tumor size and grading. A significant difference (p=0.02) was found in the positivity of PCNA/cyclin expression between the fatal outcome group (66.6%) and the surviving patients (27%), and in the percentage of cells in the S-phase, 16.4+/-7.7% in the fatal outcome group patients and 6.0+/-2.6% in the surviving patients (p=0.0001). No difference was found in the nuclear DNA content of the two groups. A positive correlation was found between PCNA expression and S-phase (r(s)=0.55; p<0.001). A positive correlation was found between age and both the percentage of S-phase cells (r(s)=0.48; p<0.002) and PCNA expression (r(s)=0.36; p<0.009). In a multivariate analysis (Cox model) age and S-phase had independent prognostic significance (regression coefficient: 3.85 and 1.70, respectively), while PCNA was not an independent variable (0.98). Our results indicate that differentiated thyroid tumors with fatal outcome are characterized by two parameters of active cell proliferation (S-phase cell fraction and PCNA expression), which can be used as useful prognostic factors.

Salmonella brandenburg: a novel cause of acute suppurative thyroiditis

A patient with suppurative thyroiditis due to infection with Salmonella brandenburg is reported. Localization of the infection occurred to a pre-existing thyroid nodule after Salmonella bacteremia. S. brandenburg was isolated in pure culture from the fluid obtained by needle aspiration of the suppurated thyroid nodule. Surgical drainage followed by subtotal thyroidectomy was required to cure the disease. No evidence of pyriform sinus fistula was found. Suppurative thyroiditis due to Salmonella ubiquitous serotypes is an extremely rare condition, and infection to the thyroid produced by S. brandenburg is reported now for the first time. Indeed, the isolation rate of S. brandenburg from all human sources is low, and this microorganism is an uncommon agent of bacteremia.

Multiple endocrine neoplasia type 2A and cutaneous lichen amyloidosis: description of a new family

Multiple endocrine neoplasia (MEN) 2A associated to cutaneous lichen amyloidosis is a variant of MEN 2A recently reported in few families. We describe an additional family with this syndrome. The skin lesion is a pruritic one, located over the upper back showing, at biopsy, cutaneous amyloid. The propositus of our family was a 35-year-old woman already treated with total thyroidectomy for medullary thyroid cancer and with bilateral adrenalectomy for pheochromocytoma. The patient referred that the skin lesion was present since childhood and increased with time. Skin biopsy showed negative staining for amyloid, for calcitonin and neuron-specific enolase. The paraspinal muscles corresponding to the area of affected skin showed slight neurogenic abnormalities. Ten other members of her family were affected by MEN 2A, three of whom (all females) had the same cutaneous alteration.

Acute intragastric application of capsaicin inhibits 2-deoxy-D-glucose--but not histamine-induced gastric acid secretion in the dog

In this study the influence of acute exposure of gastric mucosa to the sensory neurotoxin capsaicin on basal gastric acid secretion and on secretion induced by 2-deoxy-D-glucose or histamine in conscious dogs with gastric fistulae has been investigated. Under basal conditions intragastric capsaicin (160 microM, 50 ml of volume) did not induce any significant change in acid secretion and in plasma levels of gastrin. Total acid output induced by 2-deoxy-D-glucose (75 mg/kg i.v.) was significantly decreased by intragastric application of capsaicin, while plasma gastrin concentrations were unaffected. A direct stimulant of the parietal cells, such as histamine (64 micrograms/kg s.c.) increased gastric acid secretion which was not sensitive to capsaicin pretreatment. These findings indicate the involvement of capsaicin-sensitive fibers in the control of vagally-induced gastric acid secretion in the dog.

Percutaneous intranodular ethanol injection for treatment of autonomously functioning thyroid nodules

BACKGROUND

The aim of the study is the assessment of percutaneous intranodular ethanol injection (PNEI) as an alternative therapeutic procedure to classic surgery and radioiodine administration in autonomously functioning thyroid nodule treatment.

METHODS

Thirty-seven patients with hot nodules (18 pretoxic and 19 toxic) have been treated by means of PNEI under ultrasonographic guide. Ninety-five percent ethanol in a mean dose of 25 ml has been used.

RESULTS

Nearly 80% of the patients showed normalization of thyroid-stimulating hormone levels and a complete recovery of extranodular tissue at scintiscan. All nodules decreased strikingly in size, many becoming undetectable. Mild and transient side effects were seen in 9% of the patients.

CONCLUSIONS

PNEI seems to be a feasible procedure on outpatients. It is safe when performed by a well-trained staff using ultrasonographic control. It may be carried out at any age and in patients at risk for surgery. PNEI can be considered a useful alternative to surgery and radioiodine administration in all autonomously functioning thyroid nodules and particularly in pretoxic nodules.

Expression of calcitonin gene-related peptide in medullary thyroid cancer

We studied the expression of calcitonin (CT) and calcitonin gene-related peptide (CGRP) in 18 patients with medullary thyroid cancer (MTC) in the neoplastic (primary or metastatic) tissue by immunohistochemistry and in the plasma by radioimmunoassay. CT immunoreactivity was found in 100% of the primary and metastatic MTC, CGRP was expressed in 66% of the primary tumors and in 73% of the metastases. Both the number of positive cells and the degree of staining were always higher for CT than for CGRP staining. While plasma CT concentrations were always increased in patients with metastases, 3 patients with metastases had undetectable plasma CGRP levels. A positive correlation was found between plasma CT and CGRP levels. These data indicate that CGRP is frequently expressed in MTC sections and that plasma CGRP measurement is an additional marker for MTC, although has no advantage with respect to CT measurements in monitoring the progression of the disease.

Detection of thyroglobulin in fine needle aspirates of nonthyroidal neck masses: a clue to the diagnosis of metastatic differentiated thyroid cancer

We studied the feasibility of employing the measurement of thyroglobulin (Tg) in the washout of the needle used to perform the fine needle aspiration cytology (FNA-Tg) for the differential diagnosis of nonthyroidal neck masses of unknown etiology. We studied 35 patients presenting for 1 or more neck lumps outside the thyroid gland. A previous history of treated differentiated thyroid cancer (DTC) was given by 23 patients and of nonthyroidal malignancy by 3 patients. FNA-Tg was measured in the Tg-free serum used to wash out the needle employed for the cytology. Finally, all patients were treated by surgery. FNA-Tg was always detectable in 14 patients with thyroid cancer metastases demonstrated by histology, with a mean (+/- SD) of 27,087 +/- 37,622 ng/FNA (P less than 0.002) compared to patients without thyroid cancer metastases (mean +/- SD, 12.1 +/- 4.8 ng/FNA in 7 cases; undetectable in 14 cases). Assuming 21.7 ng/FNA (the mean +/- 2 SD of the negative patients) as the cut-off value, all patients with metastases from DTC were detected by FNA-Tg. FNA-Tg had better negative predictive value than cytology, since this last technique gave 10 inconclusive results, comprising 2 false negative results in patients with metastases from DTC. Our results indicate that elevated concentrations of FNA-Tg in nonthyroidal neck nodes strongly suggest the diagnosis of metastases from DTC.

Medullary thyroid cancer. An immunohistochemical and humoral study using six separate antigens

The authors investigated the humoral and tissue expression of six antigens associated with medullary thyroid cancer (MTC): calcitonin (CT), calcitonin gene-related peptide (CGRP), carcinoembryonic antigen (CEA), neuron-specific enolase (NSE), somatostatin (SRIF), and thyroglobulin (TG). The antigens were studied in the neoplastic C cells using immunohistochemistry with specific antisera and in the plasma using specific radioimmunoassay. Eighteen patients (8 male and 10 female patients, aged 12-72 years) were studied. Mean follow-up was 70.7 months (range, 2-179 months). Nine patients (50%) died of their disease after a mean follow-up of 47.2 months (range, 2-116 months). By immunostaining, primary tumors expressed CT and CEA in all cases and NSE was positive in 90%, CGRP in 66%, SRIF in 63%, and TG in 58%. Metastatic tissues were positive in all cases of CT staining, 92.8% of CEA, 71.4% of NSE, 73.3% of CGRP, 38.5% of SRIF, and only 13.3% of TG staining. In positive cases the percentage of positive cells and the degree of staining were variable among the different antigens. The expression of an antigen in the neoplastic cells was associated with the hypersecretion of the corresponding antigen in the circulation in the case of CT and CEA. The levels of these antigens were elevated in all patients with metastases and could accurately predict the appearance of new metastases or indicate the effective treatment of previous metastases by surgery. In the case of NSE, CGRP, and SRIF, few patients had increased plasma concentrations of the antigens and these usually occurred during very advanced phases of the disease. Detectable levels of serum TG were never observed. When the outcome of the disease was compared with the expression of CT, CEA, NSE, CGRP, and TG, no correlation could be found. On the contrary, SRIF expression in the primary tumor could differentiate two groups of patients with different survival rates. SRIF-positive patients had survival rates of 100% and 50% at five and seven years, respectively, whereas SRIF-negative patients had survival rates of 40% at five years and 25% at seven years.

Clinical and biologic behavior of bone metastases from differentiated thyroid carcinoma

Thirty (3.8%) of 780 patients with differentiated thyroid cancer seen between 1970 and 1987 had bone metastases. The primary tumor was follicular in 26 patients and papillary in four. Mean age at diagnosis was 61 years. The manifestation of bone metastases was the presenting symptom in 18 patients (60%). Treatment included total thyroidectomy, levothyroxine sodium therapy, and radioactive iodine treatments. Twenty-seven patients had bone metastases from the initial observation, with 44 sites involved. Of the sites, 27 (61%) were shown both on iodine 131 whole-body scan (WBS) and on x-ray film, 11 (25%) only on WBS, and six (14%) only on x-ray film. Multiple involvement was observed in 11 patients. The radiologic appearance was invariably osteolytic. Serum thyroglobulin was elevated in all patients. After radioactive iodine, no WBS+/X-ray+ metastases showed a complete response, although a sclerotic border was noted in several cases, whereas six WBS+/X-ray- lesions were no longer detectable by WBS. Treatment with radioactive iodine and bone surgery resulted in a complete cure in three patients and in a reduction of tumor mass in three. Twenty-one (70%) of the patients died of thyroid cancer after a mean survival of 86 months. Of the nine patients still alive, two are free of disease, three have a good quality of life, and four have severe disability.

Somatostatin in medullary thyroid cancer. In vitro and in vivo studies

The authors evaluated the presence of somatostatin (SRIF) in the plasma and in the tumor tissue of a total of 22 patients with medullary thyroid cancer (MTC) and studied the effect of exogenous SRIF administration on basal and pentagastrin (PG)-stimulated plasma calcitonin (CT) and carcinoembryonic antigen (CEA) levels. Mean plasma SRIF concentrations were significantly higher than those found in normal controls, with five of 15 patients having plasma SRIF levels above the mean + 2 SD of normal controls. High immunoreactive SRIF concentrations were found in the extract of three tumor tissues but not in one follicular thyroid cancer or in one toxic diffuse goiter. By immunoperoxidase staining seven of 11 (63.6%) primary MTC and five of 13 (38.5%) metastases expressed SRIF antigen in a low number of cells and with a weak degree of staining. As expected, CT was expressed in almost 100% of the cases with positivity in most of the cells and strong degree of staining. Patients with positive SRIF staining in the primary tumor had longer survival than SRIF negative patients. Infusion of synthetic SRIF (11 micrograms/minute/45 minutes) produced a significant reduction of plasma CT (but not CEA) levels in 12 of the 15 patients submitted to this test. Maximal percent decrease of plasma CT ranged from 10.8% to 72.7% of the basal value and was usually observed between 30 and 45 minutes from the beginning of the infusion. When infused together with the injection of PG, SRIF was able to significantly (P less than 0.05) inhibit the PG-induced CT release in five of six patients tested. These results demonstrate the following: SRIF is present in a few cells of many primary MTC and less frequently in their metastases; tentatively, the expression of SRIF antigen in the tumor seems to be associated with longer survival; increased SRIF concentrations are found in the plasma of some patients with metastatic involvement; and treatment with exogenous SRIF reduces the basal and PG-induced CT (but not CEA) release from the tumor.

Thyroid-thymus interactions during development and aging

A good body of experimental and clinical evidences suggests that bidirectional interactions do exist between the neuroendocrine system and the thymus activity. In particular, thymic endocrine activity seems to be strongly influenced by neuroendocrine signals. In this context, studies performed in hyper- and hypothyroid subjects and in the low triiodothyronine (T3) syndrome, which affects premature infants, have clearly shown that thyroid hormones and in particular T3 physiologically modulate thymic peptide secretion. In vitro experiments, with thymic whole-organ cultures, have demonstrated that thyroid hormones exert their action on the epithelial cells of the thymus deputed to synthesize and secrete thymic peptides and that such an effect does not seem to depend on the known permissive action of thyroid hormones.

Thyroid cancer in children and adolescents

We report on 49 patients younger than 18 years at diagnosis, of 776 patients with thyroid cancer, seen in our institution in the last 17 years. Female/male ratio was 2.2:1. Histologic type was papillary in 44, follicular in 4, and medullary in 1. Initial treatment was near-total thyroidectomy with or without neck dissection. Surgical complications (vocal cord palsy, permanent hypoparathyroidism, or both) were found in 25 patients and were usually associated with more advanced primary tumors. At surgery, node metastases were present in 73% of the patients and lung metastases, detected by chest x ray films, in 6%. Patients were treated with thyroid suppressive therapy and, except the one with medullary cancer, with radioiodine (131I) therapy. After a mean follow-up of 7.7 +/- 4.4 years (range, 1 to 17 years), one patient with lung metastases died of respiratory failure. Of 36 patients who have been followed up more than 4 years, 22 (61.1%) are now cured, and 14 have metastases (to lymph nodes, 2; to nodes and lung, 10; and to lung, 2). Since 1977 serum thyroglobulin (Tg) was used routinely as a tumor marker for differentiated thyroid cancer. After operation, Tg was elevated in all patients both not receiving (mean +/- SE, 902 +/- 380 ng/ml) and receiving (44 +/- 15 ng/ml) suppressive therapy; after 131I treatment, serum Tg dropped to 104 +/- 50 and 7.3 +/- 1.7 ng/ml, without and with suppressive therapy, respectively. Of 11 patients with lung metastases treated with 131I, respiratory function, as assessed by means of spirometry, was normal in three, mildly reduced in six, and severely impaired in two (including the one who died). In conclusion, our study indicates that thyroid cancer in young patients is rather advanced at initial examination and usually associated with node and, less frequently, lung metastases. Total thyroidectomy, radioiodine treatment, and thyroid suppressive therapy represent an effective combination of treatments for this disease and allow a good quality of life. The most serious adverse effect is represented by the high incidence of surgical complications and by pulmonary restrictive disease in relation to lung metastases.

Thyroid autoantibodies in thyroid cancer: incidence and relationship with tumour outcome

In the present investigation we studied serum anti-thyroglobulin and anti-thyroid microsomal autoantibodies, measured by hemagglutination technique, in 600 patients with thyroid cancer seen by us from 1975 to 1985 (mean follow-up 46 months). Positive thyroglobulin antibodies and/or microsomal antibodies were found in 138 (23%) patients (23.9% with papillary, 25% with follicular, 16.1% with anaplastic, and 4.1% with medullary thyroid carcinomas). The incidence of positive tests was similar in each decade of life (ranging between 21.9% and 27.9%), whereas in a normal sex-matched population with no evidence of thyroid disease, the frequency of positive tests was very low in young people and increased to 23% in people older than 60. In 64 patients with no evidence of residual or metastasic thyroid tissue after surgery and radioiodine, initially positive antibody titres became negative in 54.6%, decreased in 32.8%, did not change in 3.1%, and increased in 9.3%. On the contrary, antibody titres of patients with persistent disease became undetectable in 8.3%, decreased in 16.6%, remained unchanged in 25%, and increased in 50%. The clinical course of differentiated thyroid cancer was unaffected by the presence of thyroid antibodies and no difference was found in the death rate between antibody-positive and antibody-negative patients (11.5% and 13.6%, respectively). In conclusion, our data indicate that: 1) autoimmune phenomena are not an infrequent finding in thyroid cancer; 2) as in non-malignant thyroid diseases, positive-antibody tests are more frequently observed in females than in males; 3) at variance with normal controls, no age-dependent increase in serum anti-thyroid antibodies was found in thyroid cancer; 4) the presence of metastatic thyroid tissue seems to be necessary to perpetuate the autoantibody synthesis, and 5) anti-thyroid autoantibodies are not a protective or worsening factor in the tumour outcome.

An unusual case of a false-positive iodine-131 whole body scan in a patient with papillary thyroid cancer

A false-positive I-131 whole body scan (WBS) for lung uptake in a patient with papillary thyroid cancer, with replacement of his infiltrated esophagus with a left colon graft, is presented. The I-131 image, seen in the upper right lung field, was due to the contaminated colon graft lacking normal peristaltic movements, which was located in the right paramediastinal region. This finding was demonstrated by imaging the upper digestive tract with orally administered Tc-99m DTPA and by a barium x-ray.

Thyroid carcinoma in thyrotoxic patients treated by surgery

We report the incidence of thyroid cancer in a series of 1832 consecutive patients seen for thyrotoxicosis of any etiology during 1970 and 1985 in our department. Surgical treatment for thyrotoxicosis was selected as the treatment of choice in 179 patients (9.8%), 86 with toxic diffuse goiter (TDG), 21 with toxic nodular goiter (TNG) and 40 with toxic adenoma (TA). The presence of thyroid cancer was found in 11 patients for a total incidence of 6.1%. Six patients had TDG (percent incidence in this group 6.9%), 4 patients had TNG (7.5%) and 1 had TA (2.5%). While the presence of thyroid cancer was totally unsuspected in TNG and TA, in TDG 4 out of 6 patients found to have a cancer, had been suspected before surgery. When a thyroid nodule was present in a toxic diffuse goiter the possibility to face with a malignant lesion reached 22.2% of the cases (4 out of 18 cases), while only 2 out of 68 patients (2.9%) with TDG and no nodule had thyroid cancer. These results confirm recent other series reporting the frequent association of hyperthyroidism and thyroid cancer and suggest that in thyrotoxic patients any nodule must be screened carefully to rule out malignancy.

Therapeutic doses of iodine-131 reveal undiagnosed metastases in thyroid cancer patients with detectable serum thyroglobulin levels

Serum thyroglobulin (Tg) measurements in patients with treated differentiated thyroid cancer are usually well correlated with the presence or absence of residual or metastatic thyroid tissue. However, it is not rare to find a patient with detectable serum Tg levels but negative 131I whole-body scan (WBS) and no evidence of disease activity. To clarify the reason for this discrepancy, we decided to perform the WBS after the administration of a therapeutic dose of 131I in 17 consecutive patients in whom serum Tg was detectable while the WBS performed with a 5 mCi tracer dose was negative (12.6% of 135 patients studied with both WBS and serum Tg). The result of this study demonstrated that after this procedure the WBS became positive for significant residual or metastatic areas of radioiodine uptake in all patients but one. Such data indicate that in our patients the presence of circulating Tg is not a false-positive Tg result, but is due to the presence of residual or metastatic tissue that is not detected in the conventional WBS, that can be visualized using therapeutic doses. Preliminary follow-up data indicate that this procedure may also have therapeutic effect, although the relevance of this aspect remains to be established.

McCune-Albright syndrome with gigantism and hyperprolactinemia

We describe the case of a 38-year-old man with typical Mc Cune-Albright syndrome and the unusual combination of both growth-hormone and prolactin hypersecretion. The patient was extremely tall, which is unusual in Mc Cune-Albright syndrome, suggesting that he did not have precocious fusion of the epiphysis, a common finding in this syndrome. Unfortunately the patient refused any treatment for his disease. A similar case has been previously described only in a 14-year-old boy.

Thymulin deficiency and low 3,5,3'-triiodothyronine syndrome in infants with low birth weight syndromes

Experimental and clinical evidence indicates that thymic endocrine function is under neuroendocrine control. Recently, a positive correlation was found between plasma thymulin (a major endocrine product of thymus) and serum thyroid hormone concentrations. Low serum thyroid hormone concentrations are frequently found in premature newborn infants. In this study we measured plasma thymulin by bioassay and serum T3 and T4 in a series of healthy fullterm newborns and in premature infants with various disorders. The study subjects were 26 healthy fullterm infants, 23 fullterm small for gestational age infants, 30 preterm appropriate for gestational age (AGA) infants, 22 preterm small for gestational age infants and 30 infants with respiratory distress syndrome, of whom 15 were fullterm and 15 were preterm AGA. Blood samples were obtained 3, 5, 10, 20, and 40 days after delivery. In the healthy fullterm infants plasma thymulin concentrations were low during the first days of life and subsequently increased, reaching normal values for children aged 1-12 months by the 10th day after birth. Persistently low plasma thymulin and serum T3 levels were found in the majority of infants with pathological conditions; the lowest values for both hormones were found in infants with respiratory distress syndrome. A highly significant positive correlation was present in all groups between mean plasma thymulin and serum T3, but not T4. Short term T3 administration in 6 additional preterm AGA infants caused a significant increase in plasma thymulin titers compared to those in 6 untreated infants. We conclude that plasma thymulin is decreased in premature newborns with the low T3 syndrome and that this abnormality may be reversed by administration of T3. These findings indicate that thymic endocrine activity is modulated by thyroid function in early postnatal life.

Circulating neuron-specific enolase in medullary thyroid cancer

The utility of determining circulating neuron-specific enolase (NSE) in medullary thyroid carcinoma was assessed in 25 patients followed up for a mean period of 45.6 months. In 5 patients tested before any treatment serum NSE concentrations were in the normal range. After total thyroidectomy abnormally high serum NSE concentrations (more than 9.8 ng/ml) were found in 1/3 patients with normal calcitonin (CT) in remission, in 2/10 with elevated CT levels but no evidence of disease and in 9/12 with elevated CT levels and documented metastases. The mean (+/- SD) NSE value in this last group was 12.0 +/- 12.6 ng/ml, significantly higher than in the other groups (p less than 0.005). The time course of serum NSE in patients with long follow-up seems to indicate that serum NSE rises when a large tumor mass is present and usually parallels the pattern of circulating CT. Effective treatment of the metastases is usually followed by reduction of serum NSE. Thus, serum NSE can serve as an additional humoral marker for medullary thyroid carcinoma, its elevation being associated with important metastatic involvement and with a poor prognosis of the tumor.

Thyroid function modulates thymic endocrine activity

The thymus produces humoral factors that induce proliferation and differentiation of T-cells, which are responsible for cell-mediated immunity. Recent data in animals suggest that such thymic hormone activity is modulated by the neuroendocrine network and, in particular, by thyroid hormones, but no information is presently available in humans. To study this question, we measured the circulating thymic factor called thymulin (Zn-FTS) in hyperthyroid and hypothyroid patients. Thymulin levels were higher in hyperthyroid patients than in normal subjects, whereas hypothyroid patients had lower thymulin levels than normal subjects. A significant correlation was found between circulating thymulin and serum T4 and T3 levels. Thymulin changes could be reversed by appropriate treatment in both groups of patients. Recent data indicate that zinc is required to confer biological activity on thymic hormone molecules. This raised the question of whether the influence of thyroid status on thymulin activity could be mediated by changes in serum zinc concentrations. No support for such an explanation was obtained by thymulin measurements by a modified bioassay using an optimal zinc concentration in the assay system. In conclusion, thyroid status modulates thymic endocrine function in humans. Whether and to what extent such modulation is relevant to the function of the immune system remain to be established.

Impaired ventilatory drive in short-term primary hypothyroidism and its reversal by L-triiodothyronine

Alveolar hypoventilation is known to occur in myxedema. Reduction of hypercapnic ventilatory drive has not been reported, up to now, in patients with short-term hypothyroidism. Eleven patients with short-term hypothyroidism, before and after L-triiodothyronine (L-T3) replacement therapy, and 10 normal controls were studied. Hypercapnic ventilatory drive was assessed by the evaluation of the relation between the response of ventilation and mean expiratory flow to CO2 rebreathing and by the evaluation of ventilation and mean expiratory flow at a fixed level of carbon dioxide. In patients with short-term hypothyroidism these parameters were reduced as compared with normal controls and returned to normal after L-T3 replacement. We conclude that hypercapnic ventilatory drive is blunted by short-term hypothyroidism and normalizes following replacement therapy.

Diagnostic value of a single serum thyroglobulin determination on and off thyroid suppressive therapy in the follow-up of patients with differentiated thyroid cancer

To assess the significance of a single serum thyroglobulin (Tg) determination on and off thyroid suppressive therapy, serum Tg measurements have been performed in 349 serum samples from 82 patients with differentiated thyroid cancer. All samples were collected after total thyroidectomy with or without subsequent ablation of residual thyroid tissue by radioiodine. One hundred and fifty-three samples were obtained while the patients were on thyroid suppressive therapy and 196 after withdrawal of medication. The results of serum Tg assays were analysed in relation to the presence or absence of residual or metastatic thyroid tissue, as assessed by clinical and laboratory evaluation, including 131I whole body scan. In patients with thyroid residue but no metastases, undetectable serum Tg (false negative results) occurred in 45% of cases off therapy and in 92.9% of cases during therapy. In the presence of metastases no undetectable serum Tg result was found in patients off therapy, while four (6.9%) out of 58 samples from patients with bone and/or lung metastases and seven (31.8%) out of 22 samples from patients with lymph node metastases alone were undetectable (falsely negative) during suppressive therapy. Serum Tg was undetectable in sera from patients with no evidence of thyroid residue or metastatic disease in all but one (1.7%) of 59 samples on and three (5.4%) of 56 samples off suppressive therapy. These Tg results were confirmed to be truly rather than falsely positive, since evidence of metastatic disease was obtained by whole body scan after the administration of therapeutic doses of 131I.(ABSTRACT TRUNCATED AT 250 WORDS)

Humoral markers for thyroid carcinoma

We investigated the usefulness and limits of serum thyroglobulin, serum calcitonin, and serum tissue polypeptide antigen as humoral markers for thyroid carcinoma in 364 patients with papillary, follicular, medullary, and undifferentiated types of thyroid cancer. In agreement with other studies we found that serum thyroglobulin was a specific and sensitive marker for well-differentiated thyroid cancer after total thyroidectomy. Lymph node, lung, and bone metastases were associated with high serum thyroglobulin concentrations, both during and after thyroid-suppressive therapy with L-thyroxine. Serum thyroglobulin determination was superior to whole body scanning in predicting the presence of differentiated metastases, because patients with nonfunctioning metastases and negative whole body scan also had high levels of serum thyroglobulin. Serum calcitonin levels were increased in all patients with active medullary thyroid cancer, confirming the specificity of this marker in detecting tumors arising from parafollicular C-cells. Furthermore, in medullary thyroid cancer serum tissue polypeptide antigen levels were also increased in most patients. This last substance was found to be increased also in undifferentiated thyroid cancer. Of particular interest was the finding of increased serum tissue polypeptide antigen levels in 15 cases of differentiated thyroid cancer, whose metastases underwent a progressive process of "dedifferentiation."

Metastatic medullary and undifferentiated thyroid cancers are not associated with elevated levels of serum thyroglobulin

It is now well accepted that serum thyroglobulin (Tg) determination is a specific marker of disease activity in well-differentiated thyroid cancer after total thyroidectomy. In this study we examined 15 thyroidectomized patients with metastases from medullary thyroid cancer and 10 patients with metastases from undifferentiated thyroid cancer, to determine whether serum Tg measurement could be useful also in these types of thyroid tumors. In contrast with differentiated thyroid cancer, which had high levels of circulating serum Tg, patients with medullary and undifferentiated thyroid cancer had undetectable or low levels of serum Tg. Thus, serum Tg measurements are not useful in the diagnosis of metastatic disease in these patients.

Serum thyroglobulin in newborns' cord blood, in childhood and adolescence: a physiological indicator of thyroidal status

Serum thyroglobulin (Tg) was measured in the cord blood of 635 newborns and serum thyroxine (T4) reverse triiodothyronine (rT3), TSH and T3 were measured in about 200 of them. Cord Tg was detectable in all newborns with a mean +/- SE value (50 +/- 1.3 ng/ml) higher than that found in the serum of adult subjects (n = 144; Tg = 13 +/- 1.1; p less than 0.0001). Cord Tg had a log-normal distribution. A low, but positive correlation was found between cord Tg and cord TSH (n = 242; r = 0.17; p less than 0.05) but not with cord T4 or cord rT3. Gestational age was negatively correlated with cord Tg or cord rT3 (rS = 0.97; p less than 0.01; rS = -0.89; p less than 0.02, respectively) while was positively correlated with cord T4 or cord TSH (rS = 0.85; p less than 0.05; rS = 0.86; p less than 0.01, respectively). Birth weight, maternal diabetes, induction of labor with oxitocin, cesarian section and newborns' illness showed no influence on cord Tg levels when considered alone, but decreased cord Tg levels were found in ill newborns delivered by cesarian section. On the contrary, increased cord Tg levels were present in cord blood of newborns who developed hypoglycemia soon after birth and in small for gestational age newborns. In 24 newborns studied daily for the first 6 days of life, serum Tg was always detectable with mean values not different from those found in the cord blood.(ABSTRACT TRUNCATED AT 250 WORDS)

Serum tissue polypeptide antigen (TPA) in thyroid cancer

Serum tissue polypeptide antigen, (TPA), carcinoembryonic antigen (CEA), calcitonin (CT) and thyroglobulin (Tg) have been measured by specific radioimmunoassays in 174 patients with various types of thyroid cancer previously submitted to thyroidectomy. Elevated serum TPA concentrations were found in 12 of 13 patients with local invasion or distant metastases from undifferentiated thyroid cancer or thyroid lymphosarcoma, while serum Tg and CEA values were normal or undetectable. In 123 patients with well differentiated thyroid cancer serum TPA was usually normal regardless of the presence or absence of functioning metastases. On the contrary, 14 of 15 patients with "dedifferentiated" metastases from previously differentiated thyroid cancer had elevated serum TPA values, while serum CEA was normal and serum Tg variable. Serum CT was confirmed as the most sensitive marker of metastatic medullary thyroid carcinoma, but elevated serum TPA values were also found in most of these cases. The present data indicate that serum TPA provides a new humoral marker in the follow-up of undifferentiated and "dedifferentiated" thyroid carcinoma and may also be usefully employed as an additional marker for medullary thyroid carcinoma.

Serum thyroglobulin determinations in the differential diagnosis of congenital hypothyroidism

The value of serum thyroglobulin (Tg) determination in the differential diagnosis of congenital hypothyroidism was assessed by serum Tg measurements in 14 patients with proven congenital hypothyroidism, in 3 subjects with transient perinatal hypothyroidism, in 3 newborns with congenital thyroxine binding globulin (TBG) deficiency and in 34 normal controls. Serum Tg was undetectable in all 6 cases with thyroid agenesis, normal or moderately elevated in the 4 cases with ectopic thyroid, markedly increased in the 4 cases with dyshormonogenic goiter and normal in the 3 cases with transient hypothyroidism and in the 3 with TBG deficiency. The present data indicate that serum Tg measurements may be useful in the differentiation of athyreotic hypothyroidism from other conditions of congenital hypothyroidism.

Effect of hypo- and hyperthyroidism on the balance between helper and suppressor T cells in rats

The proportion of total, helper and suppressor T lymphocytes among mononuclear cell preparations from blood and spleen of rats made hypo- and hyperthyroid was measured using three monoclonal antibodies specifically directed against total, helper and suppressor T cells. Compared to normal rats, hypothyroid (thyroidectomized or treated with 6-propyl-2-thiouracil (PTU) rats had a decreased proportion of suppressor T cells in the spleen, which produced an increase in the helper/suppressor T cells ratio. The opposite alterations (increased suppressor T cells and decreased ratio) was found in the blood of the same animals. Triiodothyronine (T3) added to PTU in the drinking water prevented these alterations. Animals treated with high doses of T3 for 17 days did not develop any alteration either in the proportions or in the ratio of helper/suppressor T cells. Our results suggest that hypothyroidism but not hyperthyroidism alters the normal balance between helper and suppressor T cells in rats.

Binding of immunoglobulin-G from patients with thyroid autoimmune disease to normal T lymphocytes

Sera from patients with Graves' disease and Hashimoto's thyroiditis were reacted with normal T lymphocyte preparations in an attempt to detect binding of immunoglobulin G (IgG) to T cells. Sera from normal subjects and patients with toxic adenomas served as controls. Each serum was reacted with at least three different preparations of normal T cells. Bound IgG was identified using a fluoresceinated second antibody, antihuman IgG. Positive cells were enumerated by means of epifluorescent microscopy. IgG from 57.8% of toxic Graves' patients, 30.7% of Graves' patients who were euthyroid after treatment, and 41.6% of Hashimoto's patients bound to normal T cells more than did IgG from normal controls. Reactivity of toxic adenoma sera was similar to that of normal sera. When the positive sera were reacted with helper or suppressor/cytotoxic T cell preparations (separated by negative selection technique), the binding was shown to be directed against suppressor/cytotoxic T cells but not against helper cells. These data indicate that a significant proportion of patients with autoimmune thyroid disease have IgG in their serum which react with a subset of normal T suppressor/cytotoxic cells. This phenomenon could be the expression of anti-lymphocyte antibodies, which may relate to previously recognized reductions in number and function of suppressor T cells in autoimmune thyroid disease.

Multiple complications of propylthiouracil treatment: granulocytopenia, eosinophilia, skin reaction and hepatitis with lymphocyte sensitization

An association of granulocytopenia, eosinophilia, skin reaction and hepatitis during propylthiouracil (PTU) therapy for thyrotoxicosis in a 47 year old black female is reported. Clinical and biochemical abnormalities disappeared soon after discontinuation of PTU. That the drug was directly responsible for the observed complications is suggested by the clinical course and by in vitro lymphocyte transformation studies. The latter revealed sensitization to PTU during the acute phase of the disease, which was greatly reduced 5 weeks after discontinuation of the drug and was completely absent after 5 months.

Effect of indomethacin on phytohemagglutinin-stimulated peripheral blood lymphocytes in thyroid autoimmune diseases

Suppressor lymphocyte function was evaluated in control subjects and in patients with autoimmune thyroid disease, utilizing an assay in which indomethacin was added to lymphocyte cultures to inhibit prostaglandin-producing suppressor cells. This assay is based on the observation that the addition of indomethacin, a potent prostaglandin synthesis inhibitor, to phytohemagglutinin-stimulated peripheral blood lymphocytes should cause an increase in the incorporation of iododeoxyuridine in control subjects and a smaller increase in diseases with reduced prostaglandin-producing suppressor cells. The addition of indomethacin, 1 microgram/ml, stimulated iododeoxyuridine incorporation in phytohemagglutinin-stimulated cultures in control subjects to an index value of 1.43 (i.e., the increment in iododeoxyuridine incorporation with both indomethacin and phytohemagglutinin was 43% greater than the incorporation with phytohemagglutinin alone). The stimulation index was significantly lower in patients with Graves' disease who were toxic and untreated (1.18 +/- 0.25, mean +/- SD; P less than 0.003). Patients who were toxic while receiving antithyroid drugs or after radioiodine therapy or patients euthyroid after treatment had a mean stimulation index in the normal range, although the spread of data was very large in these groups. Responses in patients with Hashimoto's thyroiditis were also quite variable. The average response was 1.74 +/- 0.72, with 40% of the patients showing a high stimulation index. This study supports our previous investigations in which we used different assay systems for measuring suppressor-cell function in patients with thyroid autoimmune diseases and indicates that a defect in suppressor lymphocyte function is measureable by another technique. The abnormality persists in some cases after metabolic control has been achieved, but usually returns toward normal over months or years.

Decreased suppressor T-lymphocytes in autoimmune thyroid diseases detected by monoclonal antibodies

Monoclonal antibodies reacting with cell surface antigens of helper (T4), suppressor (T8) T cells and common T-cell antigen (T3) were used by an immunofluorescence technique to enumerate peripheral T-lymphocytes in 42 patients with Graves' disease and 16 patients with Hashimoto's thyroiditis. The percentages of total T cells (cells which react with anti-T3) and helper/inducer cells (cells which react with anti-T4) among peripheral mononuclear cells in Graves' and Hashimoto's patients were not significantly different from those found in normal controls, except for a decrease in cells which react with anti-T3 in toxic Graves' disease without medication. The most important finding was a decrease in the percentage of cytotoxic/suppressor T cells (cells which react with anti-T8) in toxic Graves' disease and Hashimoto's thyroiditis. In patients with Graves' disease who were hyperthyroid or euthyroid on propylthiouracil treatment and euthyroid after radioactive iodide treatment, the percentage of cells which react with anti-T8 was also decreased, but this did not reach statistical significance. These findings support the hypothesis of defects in suppressor T-lymphocytes in autoimmune thyroid diseases.

Serum thyroglobulin in thyroid carcinoma and other thyroid disorders

Measurements of serum thyroglobulin (hTg) were performed using a specific radioimmunoassay. Sera with detectable anti-thyroglobulin (anti-Tg) antibody titers (> or = 1:10) as assessed by passive hemagglutination were discarded. Assays were carried out under conditions in which anti-Tg titers less than 1:10 produced no interference. The assay sensitivity was 1.25 ng/ml and the mean +/- SE concentration of serum hTg in 58 control subjects was 9.5 +/- 0.9 ng/ml (range < 1.25-27 ng/ml). A slight but significant (p < 0.025) increase in the mean hTg level was observed in 12 pregnant women at delivery (25.7 +/- 5.2 ng/ml). Moderate to marked elevations of serum hTg were observed in patients with nontoxic goiter (61.4 +/- 15 ng/ml; n = 23), subacute thyroiditis (138 +/- 67 ng/ml; n = 5), toxic adenoma (129 +/- 47 ng/ml; n = 13), untreated (424 +/- 101 ng/ml; n = 35) or treated (328 +/- 222 ng/ml; n = 14) toxic diffuse goiter. 88 patients with thyroid carcinoma and 10 with nonthyroidal malignancies were studied. The mean level of serum hTg was increased in untreated differentiated thyroid carcinoma (89.5 +/- 19 ng/ml; n = 13) but not in undifferentiated (10 +/- 2.9 ng/ml; n = 6) or medullary (0.8 +/- 0.2 ng/ml; = 3) carcinoma. In treated differentiated thyroid carcinoma the mean hTg levels were normal (8.2 +/- 0.2 ng/ml) in patients (n = 24) with no evidence of either a thyroid residue or metastatic disease, moderately increased (56.6 +/- 16 ng/ml) in patients (n = 27) with residual thyroid tissue, markedly elevated in patients with lymph node metastases (199 +/- 50 ng/ml; n = 5) and extremely elevated in those with bone (4004 +/- 982 ng/ml; n = 8) or lung (2520 +/- 620 ng/ml; n = 5) metastases. There was no significant difference in serum hTg between functioning (n = 23) and nonfunctioning (n = 5) metastases as assessed by 131I whole body scan. A slight but significant (p < 0.0005) increase in the mean concentration of hTg was observed in nonthyroidal malignancies (21.7 +/- 4.5 ng/ml; n = 10). Serial measurements showed a transient increase of serum hTg after 131I therapy of differentiated thyroid carcinoma, toxic diffuse goiter or toxic adenoma, with peak values usually occurring within the first three days. A fall of serum hTg after administration of suppressive doses of thyroid hormone to patients with nontoxic goiter and a rise after discontinuation of thyroid suppressive therapy in patients with metastatic differentiated thyroid carcinoma was observed.(ABSTRACT TRUNCATED AT 400 WORDS)

Serum thyroglobulin concentrations and 131I whole body scans in the diagnosis of metastases from differentiated thyroid carcinoma (after thyroidectomy)

Measurements of circulating thyroglobulin (hTg) and 131I whole body scan were performed in 101 patients with differentiated thyroid carcinoma who had been subjected to surgical thyroidectomy and 131I ablation of remaining thyroid tissue. All 45 patients with positive scans (i.e. functioning metastases) had elevated hTg concentrations. Of fifty-six patients with negative scans forty-two had undetectable or very low hTg levels and were considered to be free of metastatic thyroid tissue, whereas fourteen showed the presence of non-functioning metastases in the clinical and/or radiological examination. In this group of patients, eleven had elevated serum hTg levels while the other three patients had detectable hTg concentrations within the normal range. These results indicate that serum hTg measurements correlate very well with scan findings and have the added advantage of detecting non-functioning metastases which would not be detected by scanning. We concluded that measurement of serum hTg may be used together with scanning, as the first step in the follow-up of thyroidectomized patients with differentiated thyroid carcinoma.