Surgical reintervention for differentiated thyroid cancer

Reoperation was performed in 110 of 185 patients with a differentiated thyroid carcinoma. In 25 patients (23 per cent) the indication for reintervention was a large thyroid remnant and in the other 85 (77 per cent) persistent or recurrent cancer was suspected. In 32 (29 per cent) of the 110 patients undergoing reoperation no evidence of cancer tissue was found. Tumour tissue in 33 patients (30 per cent) was resectable. Of 45 patients (41 per cent) with residual tumour after operation 24 showed only occult thyroid carcinoma with a raised serum thyroglobulin level. Eight of 21 patients with macroscopically persistent tumour died from the disease during a mean follow-up of 2.3 years. In 13 of 38 patients the investigated recurrent tumours were histologically less differentiated than the primary lesions, stressing the importance of total tumour clearance. The treatment of choice for persistent and recurrent differentiated thyroid carcinoma is surgical reintervention, if feasible, before radioiodine and radiation therapy are considered.

[Surgical therapy of secondary hyperparathyroidism after kidney transplantation]

Between April 1986 and January 1992, a total of 22 patients with chronic renal failure were operated on for secondary hyperparathyroidism after kidney transplantation, and 21 of these patients were normocalcemic postoperatively. In 1 patient three reductions of autotransplanted parathyroid tissue were performed and this patient was still hypercalcemic postoperatively, with a serum calcium of 2.65 mmol/l. The renal function was not impaired by parathyroidectomy. In 9 of the 22 patients subtotal parathyroidectomy was indicated within 4 months after renal transplantation because of serum calcium levels over 3.0 mmol/l or severe clinical symptoms. Subtotal parathyroidectomy is indicated in patients with secondary hyperparathyroidism after renal transplantation with a serum calcium over 3.0 mmol/l and severe clinical symptoms and also in patients with slightly elevated serum calcium levels after an observation period of up to 12 months.

[Experience with presymptomatic screening of patients with C cell carcinoma of the thyroid gland]

Presymptomatic screening of medullary thyroid carcinoma in MEN 2A families enables the early diagnosis of this tumor burdened by significant morbidity. Biochemical screening consists of basal and stimulated serum calcitonin evaluation. Genetic screening is based on DNA analysis using linked DNA markers. Thyroidectomy at an occult tumor stage may provide curative treatment. Calcitonin measurement was carried out in 58 apparently unaffected family members at risk of 11 MEN 2A patients. In 9 individuals calcitonin elevation was detected. All 9 underwent thyroidectomy. Histological examination confirmed medullary thyroid carcinoma in 8 patients and in 1 case C-cell-hyperplasia. Postoperatively 8 patients (89%) are clinically and biochemically tumor-free (mean follow-up 30 months). DNA screening results in one affected family are presented. DNA analysis allowed the recognition of one apparently unaffected individual at risk as MEN 2A gene carrier. One family member at risk was scored as not carrying the gene and may be excluded from further screening.

[Surgical treatment of carcinoid tumors of the intestine]

Carcinoid tumours arise from the neuroendocrine system and present a characteristic morphological picture. They occur in almost every organ, predilected sites are the appendix and the small intestine. Prognosis depends on the primary localization and tumour size. Carcinoids of the appendix and rectum are mostly small and thus have a good prognosis. Growth of bronchial, stomach and small intestinal carcinoids is aggressive and implicates a high percentage of metastatic disease. First choice therapy is the surgical removal of the tumour. Depending on tumour size surgical treatment includes fulguration, local excision and oncologic radical resection up to extended organ extirpation. Reoperation and repeated surgery have good chances to be successful concerning tumour remission and improvement of the carcinoid syndrome. Additive treatment comprises in particular somatostatin therapy and, in some cases, chemotherapy.

Mutational activation of RAS and GSP oncogenes in differentiated thyroid cancer and their biological implications

Activating mutations of ras-genes (Kirsten-ras, Harvey-ras, N-ras) and genes encoding for the alpha subunit of G-proteins (Gs, Gi2, Gi3, Go, Gz) were assessed in 32 differentiated thyroid cancer (DTC) tissues from German (n = 22) and American (n = 10) patients. Gs-protein (GSP) and/or ras mutations were found in 69% of all tissues with a heterogeneous distribution pattern. An increased prevalence could be demonstrated in metastatic (8 of 9 mutation positive) when compared to localized disease (13 of 23 mutation positive) (p less than 0.001) and in patients greater than 50 years of age (16 of 18 mutation positive), when compared to younger patients (6 of 14 mutation positive) (p less than 0.001). No activating mutations were found on H-ras and K-ras genes nor on genes encoding for the alpha subunits of Gi2, Gi3, Go, and Gz. Differentiated thyroid cancer tissue from German patients revealed a higher prevalence for GSP mutations (73%) than did DTC from American patients (20%) (p less than 0.001). We demonstrated a high frequency of ras and GSP mutations in DTC and suggest that these mutations may contribute to our basic understanding of this disease and might initiate a new search for more rational and individualized therapeutic approaches in patients with DTC.

Invasion by cultured human follicular thyroid cancer correlates with increased beta 1 integrins and production of proteases

A recognized model of tumor invasion requires cells to adhere to epithelial basement membrane and extracellular matrix components triggering release of proteases thus allowing cancer cells to invade the substrate. This adhesion is mediated by beta 1 integrins, a family of receptors to substrates such as collagen, laminin, and fibronectin. In order to study tumor invasion in follicular thyroid cancer (FTC), we used cell lines derived from a single patient's FTC primary tumor (FTC-133), neck lymph node metastases (FTC-236), and lung metastases (FTC-238). In vitro invasion as determined by the ability of the tumor cells to penetrate Matrigel was assessed by scanning electron microscopy. FTC-133 did not invade, FTC-236 was moderately invasive, and FTC-238 was highly invasive. Immunoprecipation with a monoclonal antibody to beta 1 integrin subunits and SDS-PAGE showed increased synthesis and flow cytometry showed increased expression of this subunit in FTC-236 and FTC-238 compared to FTC-133. Proteolytic activity was assessed by gelatin zymography. FTC-238 cell extract and conditioned media exhibited a more complex array of proteases consistent with activated type I collagenase and stromelysin compared to the less invasive clones, however 72 and 92 kd gelatinases consistent with type IV collagenases were present in the conditioned media from all three lines. In conclusion, in vitro invasion parallels in vivo metastasis by the source cells in the FTC-133/236/238 cell-lines. The ability to invade basement membrane preparation correlates with increased synthesis and expression of beta 1 integrins and activation of tumor proteases.

Management of primary hyperparathyroidism caused by multiple gland disease

Multiple gland parathyroid disease is the pathological finding in primary hyperparathyroidism (HPT) in about 10% to 20% of all patients and in approximately a third of all patients with persistent or recurrent disease. The variability of multiple gland disease spans from 2 adenomas to diffuse hyperplasia in patients with multiple endocrine neoplasia type 1. This variability calls into question the proposed common pathophysiologic background in all of these cases. As primary treatment of multiple gland primary HPT, subtotal parathyroidectomy and thymectomy or total parathyroidectomy and heterotopic autotransplantation including thymectomy can be equally advocated. Recurrent hyperparathyroidism frequently occurs in cases of diffuse parathyroid hyperplasia. This must be considered especially in patient follow up and before each surgical procedure. Thus, a defined but adaptable therapeutic regimen might prevent permanent hypoparathyroidism and persistent hyperparathyroidism.

Mutation of the p53 gene in a differentiated human thyroid carcinoma cell line, but not in primary thyroid tumours

The p53 gene has been implicated as a tumour suppressor, with mutations occurring in many carcinomas, such as colon, breast and lung. We have sequenced exons 5, 7 and 8 containing conserved gene regions in the only available differentiated thyroid follicular carcinoma cell line and found a mutation at position 273, Arg----His, with no normal allele present. The same mutation was also present in DNA from the tumour of origin. However immunohistochemical analysis of 129 human thyroid tumours using a panel of p53 antibodies was unequivocally negative. Southern blotting in 20 cases failed to demonstrate any deletion or rearrangement, and direct genomic sequencing of 20 carcinomas showed normal DNA sequence for exons 5, 7 and 8. Thus p53 abnormalities may not be important in human thyroid carcinogenesis, in contrast to colon, breast and lung. However, the FTC 133 cell line was only established after 132 unsuccessful attempts with other differentiated thyroid follicular tumours. Since this line and the corresponding tumour of origin have a p53 mutation, we propose that p53 mutation may confer on thyroid follicular tumour cells the ability to grow in culture. This has potential applications for the future development of thyroid carcinoma cell lines.

Actin architecture of cultured human thyroid cancer cells: predictor of differentiation?

The actin cytoskeleton is important for cell structure and motility. A disordered actin architecture has been correlated with a high metastatic potential in melanoma, fibrosarcoma, and colon cancer models. Thyrotropin is known to induce growth and differentiation in cultured thyroid cells, whereas the carcinogenic phorbol ester 12-O-tetradecanoylphorbol 13-acetate (TPA) causes dedifferentiation and malignant transformation in many cell lines. We therefore assessed the effect of thyrotropin and TPA on the actin architecture of FTC-133 human follicular thyroid cancer cells in continuous culture. Staining of filamentous actin with rhodamine phalloidin showed that 1 mU/ml or 30 mU/ml thyrotropin-induced actin polymerization was detectable at 1 hour but more notable at 24 hours. Similarly TPA (0.008 to 10 mumol/L) caused rapid actin fiber disruption and redistribution to the cell periphery. Secondary antibody staining for alpha-actinin, a protein that binds and crosslinks actin, was more prominent after treatment with thyrotropin but decreased after TPA. These findings indicate that the actin cytoskeleton has a dynamic response to trophic factors. Thyrotropin promoted actin polymerization, but TPA caused depolymerization. These effects may correlate with cellular alpha-actinin levels. Actin architecture may therefore reflect the state of differentiation of thyroid tumor cells.

[Progress in the diagnosis and therapy of C cell carcinoma of the thyroid gland]

Between 1986 and 1989 172 patients were operated on thyroid cancer. Twenty-nine (17%) of them had a medullary carcinoma. In 20 of these patients (69%) the carcinoma occurred in a sporadic and in 9 (31%) patients in a familial form. Eighteen patients (62%) had to be operated because of tumor recurrence and in 4 of them additional surgery was necessary because of distant metastases. Due to tumor recurrence 7 patients underwent multiple operations during the above period. Adequate first operation was performed only in 6 patients (33%). Based on family screening a carcinoma was diagnosed in 4 patients in its occult stage. Diagnostic methods include biochemical and imaging methods. Calcitonin is the most sensitive tumor marker. Basal and stimulated serum calcitonin analysis provides a very efficient method to detect medullary carcinoma in early tumor stage and to treat the disease curatively. DNA-analysis improves early diagnosis of persons at risk.

West Germany: still an underdeveloped country in the diagnosis and early treatment of primary hyperparathyroidism?

Early diagnosis of asymptomatic patients with primary hyperparathyroidism (primary HPT) has been achieved in Scandinavia, the United States of America, and the United Kingdom during the last 20 years. Comparable results have been reported from some medical centers from West Germany; however, clinical manifestations were pronounced and patient symptoms were high in our population with primary HPT (N = 128) operated on at the University of Düsseldorf from April, 1986 to July, 1989. Only 19 patients (14.8%) were asymptomatic while the others suffered from nephrolithiasis (39%), osteopathy (32%), gastrointestinal disturbances (28.9%), and depression (11.7%). In 46 (35.9%) of our patients, the duration of these clinical symptoms exceeded 10 years, in 27 patients (21%) 15 years, and in 12 patients (9.3%) even 25 years. We, therefore, conclude that primary HPT is still a grossly underdiagnosed illness in parts of West Germany, presently, with patients suffering from severe clinical symptoms for more than 1-2 decades before definitive treatment.

[Subtotal thyroid gland resection as therapy for thyrotoxic crises]

Thyrotoxic crises occurred in six patients (four women aged 51, 63, 72 and 76 years; two men aged 52 and 63 years). In four patients the crisis was triggered by a contrast medium containing iodine, and in one by amiodarone. The cause of the crisis in the 51-year-old woman remained uncertain. After a latent period of up to two months, T3 and T4 concentrations rose in all the patients, and abnormal findings such as tachycardia, increased blood pressure, dehydration, tremor, restlessness, hallucinations and coma ensued. Because of ineffective conservative treatment, five patients underwent subtotal thyroidectomy. In all five the symptoms and signs of hyperthyroidism were promptly relieved, and the postoperative course was uneventful. The 76-year-old woman was considered unfit for surgery because of her cardiac condition, and she died of left ventricular failure resistant to therapy.

The influence of surgery on endocrine ophthalmopathy

Since the pathogenesis of endocrine ophthalmopathy is unclear, there has been little agreement on the treatment of the disease. The influence of thyroid surgery on endocrine ophthalmopathy is controversial. To evaluate the effect of thyroid surgery on the course of the disease, we developed a special ophthalmopathy index. As a standard procedure, subtotal thyroidectomy with thyroid remnants of 3-5 g was performed. A total of 176 patients with Graves' disease underwent the above treatment between 1986 and 1988. In 78 patients suffering from concomitant endocrine ophthalmopathy, ocular status was examined prior to operation and postoperatively. The history of endocrine ophthalmopathy had been present less than 2 years preoperatively in 74% of the patients. Follow-up ranged from 6 to 36 months. Postoperatively, 54 (69%) patients showed a marked improvement of their eye symptoms. In 18 (23%), there was no change and, in 6 (8%) patients, the severity of the eye symptoms increased after the operation. As a result of these data, a cautious and preliminary conclusion may be justified--that subtotal thyroidectomy may have a positive effect on endocrine ophthalmopathy.

Growth regulation of normal thyroids and thyroid tumors in man

Our studies using thyrocyte membranes from different human thyroid tissues, monolayer cultures of human thyrocytes, and the permanant cell line FTC-133 demonstrate the stimulatory effect of TSH on metabolism, DNA synthesis, and cell growth in human thyrocytes. Up- and down-regulation of cAMP cell content fails to show direct effects on DNA synthesis and cell growth in primary thyrocyte cultures in man. Increased AC responsiveness to TSH in adenomatous human thyroid tissues, when compared to normal thyroids of the same patient (p less than 0.005), is thus of only questionable importance for thyroid tumor growth. The permanant cell line FTC-133 was established from differentiated follicular human thyroid cancer cells. FTC-133 cells proved to be of particular usefulness in assessing growth regulation of human thyroid tissue. These cells could be propagated in serum free medium, showed thyroglobulin immunoreactivity and EGF receptors, lacked any fibroblast contamination, and responded to TSH and local active growth factors such as EGF and IGF with a stimulated [3H]thymidine incorporation. The latter could be shown in primary cell cultures of normal and pathological human thyrocytes as well. Additional to the stimulatory effect of TSH and IGF on [3H]thymidine incorporation, these substances show an additive effect when incubated simultaneously. Locally active growth factors and endocrine growth stimulation by TSH therefore act synergistically on thyrocyte growth in human thyrocyte cultures. Whether the TSH effect on cell growth is related to its stimulation of AC remains as yet questionable.

[Various strategies in the diagnosis and therapy of thyroid gland cancer. Results of a survey]

In a questionnaire we compared generally adviced therapeutical and technical procedures in patients with thyroid carcinomas with the actually favorized strategy of the clinically active surgeons. At present, sonography and cytology are not favored as preoperative diagnostic tools by the questioned surgeons. Hemithyreoidectomy as primary procedure in suspicious nodules is performed only seldomly. In the treatment of thyroid carcinoma total thyroidectomy is the accepted procedure and the possibility of restricted radicality in the treatment of papillary thyroid carcinomas has gained wide acknowledgement. Most surgeons prefer to visualize the recurrent nerve and at least one or two parathyroid glands. Autotransplantation of parathyroid glands with insufficient blood supply is considered only seldomly.

[Indications for and basic principles of the surgical treatment of thyroid diseases]

Surgical treatment is indicated for patients with nodular goiter if malignancy seems possible, if there are mechanical reasons, or on request from the patient. In patients with goiter and hyperthyroidism, surgery and radioiodine are alternatives. In contrast, thyroid autonomy always requires surgery. The treatment of patients suffering from differentiated thyroid cancer includes thyroidectomy and radioiodine, and in those with anaplastic thyroid cancer external radiation and surgery should be performed. Apart from the classic indications and surgical procedures, in recent years selective resection of multinodular goiter, more conservative surgery of small papillary thyroid cancer and surgical treatment of iodine-induced thyrotoxicosis have become established.

[Persistent postoperative hyperthyroidism--a surgical problem]

The rate of persistent or recurrent hyperthyroidism after surgical treatment of Graves' disease correlates with the size of a thyroid remnant. Reoperation should be viewed as a last resort because of a high complication rate. A subtotal thyroidectomy with a thyroid remnant of 5 to 8 g is recommended.

[Reinterventions for hyperparathyroidism in multiple endocrine adenopathy]

Six out of a series of 10 patients with hyperparathyroidism associated with an MEA type I syndrome were treated by subtotal parathyroidectomy with resulting normocalcaemia over a follow-up time of one to 7 years. Three patients with repeated previously unsuccessful operations underwent total parathyroidectomy with simultaneous autotransplantation. The first type of operation remains our first choice, while the radical approach with forearm transplantation is reserved only for recurrent surgery for various reasons.

[Subtotal thyroidectomy as a superior therapeutic principle in the treatment of endocrine ophthalmopathy: a comparison with retrobulbar irradiation and thyrostatic therapy alone]

In order to investigate the influence of near total thyroidectomy on the course of endocrine ophthalmopathy (E.O.) in patients with Graves' disease, 29 patients with goitre and E.O. were classified before and after (up to 18 months) operation by use of a special ophthalmopathy index. 14 patients without goitre served as controls; they get only antithyroid drug treatment (ADT) (E.O. I and II, n = 7) or additional retoorbital irradiation (E.O. III and IV, n = 7, linear accelerator, 20 Gray). 20 out of 29 operated patients showed an improvement in the E.O., 4 a deterioration, 5 were unchanged. 3 out of 7 not operated patients with mild E.O. showed an amelioration during ADT, 4 no change. Additional radiotherapy in 7 patients with severe E.O. caused an improvement in the clinical condition of 3 patients, 3 patients deteriorated and 1 patient showed no change. It is concluded that adequate near total thyroidectomy has a positive effect on the clinical course of E.O. in patients with Graves' disease and E.O.

[Reintervention in C-cell carcinoma]

Cervical re-exploration in persistent medullary thyroid cancer usually fails to normalize serum calcitonin levels, which is the most sensitive criterion of tumour-free status (2 out of 21 patients in our re-exploration series). Positive lymph nodes - even at an early tumour stage - seem much more important (postoperative normal serum calcitonin: 86% in the occult tumour group, 71% in patients with palpable primary tumour and negative lymph nodes, as opposed to only 18% with a palpable cervical mass and positive lymph nodes). However, local re-exploration in case of persistent medullary thyroid cancer seems to offer a possible curative chance for the control of recurrence, especially after inadequate primary surgery. In cases without visible distant metastases a marked reduction in serum calcitonin level may be expected (21% of the preoperative level for stages N1 and N2 and 16% for stage N3 on average). In patients with elevated calcitonin levels after stimulation as sole indicator of persistent tumour the indication for reoperation should be handled cautiously. Thus, in 3 out of 5 patients with occult medullary thyroid cancer diagnosed only on the basis of venous sampling who were subjected to multiple cervical re-explorations, distant metastases were subsequently found during follow-up.

[Acute abdomen in unrecognized hyperparathyroidism]

The incidence of acute abdomen in patients with unrecognised hyperparathyroidism (HPT) was investigated in 61 patients with primary and 15 patients with secondary HPT, operated on at the Surgical University Department in Düsseldorf between 4/86 and 10/87. In seven patients (9%) an acute abdomen occurred preoperatively (bleeding ulcer n = 3, ulcer perforation n = 1, acute pancreatitis n = 3). Recurrent gastrointestinal disease was observed in 20 of the 76 Patients (28%). The fast and surprising clinical recovery of patients with pancreatitis and HPT after operation of the HPT support the assumption of a causal relation between hyperparathyroidism and pancreatitis. The importance of hypercalcaemia and HPT as causative factors in gastrointestinal ulcers, remains uncertain, however. Possible acute abdominal emergencies in the clinical course of primary hyperparathyroidism support the indication for early operation.

Nerve growth factor (NGF) sensitizes human medullary thyroid carcinoma (hMTC) cells for cytostatic therapy in vitro

Medullary thyroid carcinoma (hMTC) cells were established from nine patients with MTC disease to initiate a new approach of adjuvant medical therapy in these patients. We measured calcitonin (CT) secretion, DNA synthesis, and cell proliferation in vitro and their response to various substances. Nerve growth factor (NGF) (0.01 to 10 micrograms/ml), glucagon (0.01 to 100 micrograms/ml), and isoproterenol (4 to 500 micrograms/ml) stimulated CT secretion and DNA synthesis in hMTC cells. Other substances, calcium (1.0 to 15 mmol), pentagastrin (1.0 to 50 mumol), dibutyryl-cyclic-adenosine-monophosphate (1.0 to 100 mumol), and phorbol ester TPA (1.0 to 100 nmol), stimulated CT secretion but not DNA synthesis. In addition, NGF enhanced cell proliferation of hMTC cells 2- to 3- fold and caused an increased sensitivity of these cells for chemotherapy in vitro. Thus 0.5 microgram/ml doxorubicin (half-maximal effective dose) induced a cell death rate of up to 32.8%, which was enhanced by preincubation with NGF to 68.1% (1.0 microgram/ml, NGF) and to 100% (10.0 micrograms/ml, NGF), respectively. Pulsative stimulation of APUD cell carcinomas with NGF may therefore improve the response rate of these tumors to chemotherapy, which would be of significant clinical importance for patients with residual postoperative MTC tissue.

Thyrotropin (TSH) stimulates cell growth and DNA synthesis in monolayer cultures of human thyrocytes independent of the adenylate-cyclase system

Monolayer cultures of human thyrocytes from normal thyroids (n = 13), thyroid adenomas (n = 8), differentiated (n = 7), poorly and undifferentiated (n = 5) thyroid cancers as well as thyroid cancer metastases (n = 2) were established to assess the significance of TSH and cAMP on cell growth and DNA synthesis. Cell growth was stimulated by 0.1 IU bTSH/ml and inhibited by 1.0 IU bTSH/ml (P less than 0.01), while dibutyryl-cAMP (dbcAMP) failed to show any effect on cell growth at the concentrations (10-5; 10-3 mol/l), tested. Neither did the adenylate-cyclase inhibitor dideoxy-adenosine (ddA) (2 X 10-5 mol/l) stimulate thyrocyte growth. DNA synthesis, however, measured indirectly by [3H]thymidine incorporation, was stimulated not only by TSH 2-12-fold, but also by ddA 1.3-7-fold (P less than 0.01), and was not affected by dbcAMP. TSH had no effect on [3H]thymidine incorporation in fibroblasts and c-cells from c-cell carcinomas. The stimulatory effect of TSH on thyrocyte growth and DNA synthesis was unpredictable in thyrocytes from cancerous tissues (n = 14) with no obvious correlation to tumour differentiation or stage. Thus, we showed that TSH is a promotor for cell growth and DNA synthesis in monolayer cultures of human thyrocytes from normal and adenomatous human thyroid tissues with no obvious correlation to the AC system. This TSH effect is unpredictable, however, in thyrocytes from human thyroid cancer.

Pathophysiological and clinical implications of thyroid growth-stimulating immunoglobulins: evidence for their intrathyroidal production

Thyroid growth-stimulating immunoglobulins are responsible for goitre formation not only in Graves' and Hashimoto's disease but also (partly) in simple goitre, especially in recurrent cases. TGI are antibodies, the TSH receptor, however, appears not to be the antigenic site in simple goitre. In our own studies two TGI assay systems ([3H]thymidine incorporation into isolated porcine thyroid follicles and into FRTL-5 cells) gave comparable results. TGI was found in 20 out of 72 patients with simple goitre (27%) coming from an endemic goitre area (biased by selection, i.e. certainly including sporadic forms) and in 10 out of 26 patients (38%) with recurrent goitre. TGI levels were higher in thyroidal venous blood compared to cubital blood (simultaneously drawn during surgery) indicating an intrathyroidal production of TGI. Thyroid growth-blocking antibodies as estimated in the FRTL-5 cell assay in one of our patients might be of significance not only in primary myxoedema but also for congenital hypothyroidism.

Adenylate cyclase stimulation and [3H]thymidine incorporation in human thyroid tissues and thyrocyte cultures: the effect of IgG preparation from patients with different thyroid disorders

Primary cell cultures of normal and adenomatous human thyroid tissues were incubated with TSH or ammonium sulphate precipited IGG fractions (1 mg/ml) of sera from patients with different thyroid diseases (Graves' disease: active n = 7 in remission n = 12; thyroid autonomy n = 39; simple euthyroid goitre n = 15) and were compared to controls (n = 26). [3H]thymidine incorporation in primary thyrocyte cultures demonstrated a typical bell shape curve after incubation with EGF and TSH with a maximal effect at 10-100 microIU/ml. This effect, however, was inconsistent and positive only in 2 of 7 primary cultures. Only TSH positive cultures were used for IgG studies. 16-28% of IGG fractions from sera of thyroid patients caused high (more than X + 5 SD of controls) stimulation of [3H]thymidine incorporation. Dose response curves of IgG fractions of 19 additional patients (Graves' disease in remission n = 15; thyroid autonomy n = 4) showed an increase in [3H]thymidine incorporation at 0.1 mg protein/ml for 10 patients and at low concentrations of 10-5 mg/ml for 5 patients. There was a good correlation (r = 0.72) (P less than 0.0001) between positive findings in TSH-binding inhibition (TBII) and AC-stimulation (TSI) IGG fractions but none between stimulation of [3H]thymidine incorporation and any other thyroid specific immunoglobulin nor thyroid function nor any other available data. Immunoglobulins stimulating [3H]thymidine incorporation differ therefore from TBII and TSI. The growth effect of these immunoglobulins, however, has yet to be determined.

[Surgery of metastases of differentiated thyroid cancers]

84 (19.5%) of 431 patients with differentiated thyroid cancer developed distant metastases in bone and parenchymal organs. 78% of primary bone metastases and only 21% of primary lung metastases were treated operatively. High survival rates of 33-60% at 5 years supported the necessity of surgical interventions primarily in bone metastases to prevent early morbidity due to pathological fractures. Even in case of questionable increase in survival rate surgery of metastases from differentiated thyroid carcinomas doubtlessly improves the quality of life in these patients.

Management of goiter and thyroid nodules in an area of endemic goiter

This article discusses the diagnostic and therapeutic measures we have used during the past five years to treat 861 patients from an edemic goiter area with various thyroid disorders. The similarities and differences between these patients, with nontoxic goiter, toxic goiter, and thyroid cancer, were compared with those seen in patients with thyroid problems who live in iodine-rich areas.

The effect of thyrotropin and cAMP on DNA synthesis and cell growth of human thyrocytes in monolayer culture

Monolayer cultures of human thyrocytes from normal tissue (n = 10), and adenomas (n = 7), differentiated (n = 4), poorly differentiated (n = 2), and undifferentiated (n = 3) thyroid cancers were established to assess the significance of thyrotropin (TSH) and cAMP (adenosine 3',5'-cyclic monophosphate) on cell growth and DNA (deoxyribonucleic acid) synthesis. Cell growth of thyrocytes from normal and adenomatous tissues increased more rapidly (p less than 0.01) after TSH (0.1 IU/ml) was added but was unaffected by cAMP (10(-4) mol/L). In these cells, TSH also enhanced DNA synthesis twofold to twelvefold (p less than 0.01). The adenylate cyclase (AC) inhibitor, 2',3' dideoxyadenosine (ddA), increased DNA synthesis 1.3 to 6 times at a concentration of 2 X 10(-4) mol, whereas the membrane/passable cAMP analogue, dibutyryl-cAMP, and the AC stimulator, forskolin, failed to show any effect on DNA synthesis up to a concentration of 10(-5) mol/L (p less than NS). When administered simultaneously, TSH (1/2 maximum) and ddA (20 mumol) had no cumulative effect on DNA synthesis (p = NS). TSH stimulation in cancerous thyroid tissue (n = 11) demonstrated a lack of TSH response in seven of 11 monolayer cultures with no apparent correlation to cancer differentiation, patient age, or sex. Thus TSH was demonstrated to stimulate DNA synthesis and cell growth of human thyrocytes in monolayer cultures independent of the AC system. However, the TSH effect on cell growth and DNA synthesis was unpredictable in thyrocytes from cancerous tissues.

[Radicality principles in operations on malignant thyroid tumors]

Different concepts are required by different tumors: anaplastic carcinomas rarely are accessible to curative surgery, but tumor reduction gives sense in combined concepts. In follicular carcinomas general ("near"-) total thyroidectomy + radioiodine + hormonal suppressive therapy is recommended, with respect to the high incidence of distant metastases even in low 1 degree Tu-stages. Papillary carcinomas allow a stage related procedure with exceptions from total thyroidectomy: no reintervention for "occult" carcinomas and-in patients under 40 years of age-hemithyroidectomy for intrathyroid tumors without regional metastases. In C-Cell-carcinomas total thyroidectomy has to be accompanied by lymph-node dissections of various extent, depending on familiary or sporadic type and tumor-stage.

Low T3 syndrome in patients following major surgery

Time sequence and specificity of thyroid hormones and biochemical parameters were investigated in patients following major surgery. Serum concentration of triiodothyronine decreases significantly following operation, with a biphasic regression. There is a reciprocal change in serum reverse triiodothyronine levels, but serum thyroxine levels show no significant change after operation. The significant decrease in serum concentration of alpha-2-macroglobulin and antithrombin III during and after surgery is the result of consumption of these inhibitors because the reciprocal change in serum concentration of elastase-like protease has been recognized. According to the change of curvilinear regression of serum triiodothyronine levels, 14 patients were grouped into 3. The patients for whom the curvilinear regression resembled a polynomial of degree 3 and 2 had a good prognosis, but the remaining 4 with no significant curvilinear regression had major complications and 2 died. It is meaningful that the postoperative change of triiodothyronine levels relates to the clinical outcome, to some degree.

Absence of high-affinity binding sites for beta-adrenergic blockers and lack of adenyl cyclase stimulation to beta-adrenergic stimulators in most normal and adenomatous human thyroid tissues

To determine whether the beta-blocking drug propranolol had any physiologic effect on normal (n = 14) and adenomatous (n = 15) human thyroid tissues, experiments were performed to study the binding of the beta-blockers 125I-iodocyanopindolol (125I-ICYP) and 125I-iodohydroxybenzylpindolol (125I-IHYP) and the stimulation of adenyl cyclase (AC) by isoproterenol. 125I-ICYP and 125I-IHYP failed to show high-affinity binding in 27 of 29 specimens, whereas two (one normal and one adenomatous) thyroid tissues demonstrated high-affinity binding (Kd 5.5 +/- 1 X 10(-9) M) for 125I-ICYP. Thyroid-stimulating hormone (0.3 IU/ml), guanosine triphosphate (10(-4) M), and Gpp (NH)p(10(-4) M) stimulated AC in all thyroid tissues, although in two tissues (normal) Gpp (NH)p failed to cause a significant increase. Isoproterenol (10(-4) M), in contrast, had no effect on basal AC activity or on guanosine triphosphate, and Gpp (NH) p stimulated AC activity in 26 of the 29 thyroid tissues. In one of the two tissues that increased AC in response to isoproterenol, the beta-blocking drugs propranolol hydrochloride, bunitrolol hydrochloride, and tolilprolol hydrochloride decreased AC stimulation to isoproterenol at concentrations of 10(-6) M (p less than 0.05). Higher concentrations of propranolol (10(-4) - 10(-2) M) decreased AC stimulation to thyroid-stimulating hormone (p less than 0.01), not only in this responsive tissue but also in tissues that failed to demonstrate high-affinity binding for 125I-ICYP and AC stimulation to isoproterenol (p less than 0.01). Thus most normal and adenomatous human thyroid tissues lack beta-receptors and a functioning beta-receptor AC system. High concentrations of propranolol in vitro decreased AC response by thyroid-stimulating hormone, but this is probably a nonreceptor-mediated effect.