Severe endometriosis: low value of AMH did not affect oocyte quality and pregnancy outcome in IVF patients

OBJECTIVE

The aim of this pilot study was to determine whether the low anti-müllerian hormone (AMH) serum level, due to severe endometriosis, was associated with diminished oocyte yield, poor oocyte/embryo quality and reduced in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI) clinical outcomes in young patients (<37 years old).

PATIENTS AND METHODS

A total of 50 IVF cycles of patients younger than 37 with severe endometriosis were retrospectively analyzed in a single center between November 2016 and July 2018. The clinical outcome was then compared to a control group of 84 patients with no story of endometriosis and normal AMH value. AMH value was evaluated within three months before the stimulation. In these two groups, number and maturation of retrieved oocytes, embryo quality, and pregnancy outcomes were evaluated and compared using Student's t-test and Fisher's test.

RESULTS

The number of oocytes retrieved per cycle and the percentage of mature oocytes (MII) were significantly lower (p < 0.001) in IVF patients with severe endometriosis and AMH value ≤ 1.1 ng/ml (Group A; 3.8±2.6 retrieved oocytes, 70% MII) compared to patients without endometriosis and AMH levels > 1.1 ng/ml (Group B; 6.9±4.6 retrieved oocytes, 83% MII). On the other hand, embryo morphology, implantation rate (31% vs. 33%; p = 0.833) and pregnancy rate (50% vs. 49%; p = 1) were comparable in the two groups.

CONCLUSIONS

This study shows that younger patients with an impairment of the ovarian reserve due to severe endometriosis, displayed a diminished oocyte yield but not a reduction in embryo quality and pregnancy outcomes. These results suggest that serum AMH levels should not be adopted as a criterion for discouraging these patients from undergoing IVF/ICSI treatments.

Biosimilar formulations of gonadotropins in a central Italian region: use patterns and time trends

Background

Gonadotropins (Gonas) are hormones that play a central role in the follicular growth of women but also useful in male infertility. Gonas used for infertility treatment in women are available as urinary extracts or recombinants. In 2015, the first biosimilar of follitropin alfa was authorised.

Objectives

We aimed to evaluate use patterns, temporal and spatial variations of Gonas biosimilar formulations in an central Italian region.

Methods

From administrative healthcare databases of Lazio region, we extracted prescriptions that have occurred over the years 2015-2019. Gona's use was grouped as treatment with urinary (u) and recombinant (r). Special focus was made on biosimilar r-Gona. Use patterns were investigated with respect to characteristics of the patients treated, time trends, differences among local health units and type of prescribing physician.

Results

For the study period, we retrieved 136,333 Gona dispensations for 22,325 patients. The 10,927 r-Gona biosimilar dispensations (8.01% of all claims, of which 99.43% Bemfola®, and 0.57% Ovaleap®), were mostly referred to women, aged 18-45 years, (87.11% of all patients). Median age was 37 years for women, 38 for men. Since its authorisation, biosimilar r-Gona steadily gained market from 2015 (0,4% of claims) to 2017 (22,7%) followed by a decrease in 2019 (4,3%). Biosimilars claims are more frequent in treating men (10,8%) than women (6,1%). Most biosimilar prescriptions were issued by general practitioners (86.4%), followed by specialists (10.2%) and others. Biosimilar use patterns varied between different local health units (IQR 3.2%-8,5%).

Conclusions

In clinical pratice, r-Gona biosimilar dispensation, 8,8% of Gonas. are mostly prescribed from general practitioners and are proportionately more targeted at men than women. Further investigation is needed.

Key messages

More and more men and women are using artificial insemination techniques; it is important to monitor fertility drug use patterns. In times of savings for the economic system,the use of the biosimilar drugs is of increasing interest.

Determinants of use of gonadotropin formulations to treat female infertility in an Italian region

Background

Gonadotropins (Gona) are commonly used for infertility treatment in women. They are available as urinary purified extracts (u-Gona) and recombinants (r-Gona). Objectives:We investigated if socio-demographic characteristics of treated women, year of dispensation and type of prescriber may play a role in the choice of a treatment with respect to the other.

Methods

From administrative healthcare databases, we collected claims of Gona for women, aged 18-45, enrolled in the health care system in the year preceding the first prescription (years 2009-2018). Treatment cycles were defined as a 21-day mobile time window. We identified three groups: u-Gona, r-Gona and treatment with both formulations (m-Gona). To identify determinants, we linked women with the socio-economic position (SEP), a composite deprivation index, based on the 2011 Italian Census data,categorized in 4 levels (high, medium-high, medium-low, low). We associated prescriptions with the type of prescriber, distinguishing between specialists and general practitioners.

Results

We retrieved 38,598 Gona treatment cycles prescribed to 23,412 women and distributed between formulations as follows: r-Gona 47.4%, u-Gona 26.3% and m-Gona 26.3%. The median age was 38 years for r-Gona and u-Gona, 39 for m-Gona. Comparing the type of prescriber, specialists were more likely to prescribe u-Gona instead of r-Gona (OR: 2.14; 95%CI: 2.02-2.27) than general practitioners. No relation was found between SEP and Gona formulations, except for patients with the highest level who were more likely to be prescribed with r-Gona instead of u-Gona (OR: 1.12; 95%CI: 1.03-1.21). Time trends showed that treatment choices changed over time.

Conclusions

In the Lazio region, the choice of gonadotropin formulations varied over time and was found to be related to the prescriber and partly to socio-economic position. An analysis of outcomes related to different treatments is under way.

Key messages

More and more women are using artificial insemination techniques; it is important to monitor fertility drug use patterns and determinants of the choice of a treatment. The use of fertility drugs is a multifactorial phenomenon and a matter of public health interest.

Relapsing Bilateral Uveitis and Papilledema in Sinus Histiocytosis with Massive Lymphadenopathy (Rosai-Dorfman Disease)

Sinus histiocytosis with massive lymphadenopathy (Rosai-Dorfman disease) is a non-hereditary histiocytic proliferative disorder affecting young people, with extranodal manifestations in 28-43% of cases. Eye involvement is infrequent. Lymphoproliferation in the soft tissues of the orbit and in the lids has been reported in 12% of cases but intraocular involvement is rare. We describe the case of a 12-year-old boy affected by Rosai-Dorfman disease with bilateral relapsing uveitis and papilledema that appeared four years before the onset of lymphadenopathy.

Work related stress and blood glucose levels

AIM

The aim of the study is to evaluate work-related subjective stress in a group of workers on a major Italian company in the field of healthcare through the administration of a valid "questionnaire-tool indicator" (HSE Indicator Tool), and to analyze any correlation between stress levels taken from questionnaire scores and blood glucose values.

MATERIAL AND METHODS

We studied a final sample consisting of 241 subjects with different tasks. The HSE questionnaire - made up of 35 items (divided into 7 organizational dimensions) with 5 possible answers - has been distributed to all the subjects in occasion of the health surveillance examinations provided by law. The questionnaire was then analyzed using its specific software to process the results related to the 7 dimensions. These results were compared using the Pearson correlation and multiple linear regression with the blood glucose values obtained from each subject.

RESULTS

From the analysis of the data the following areas resulted critical, in other words linked to an intermediate (yellow area) or high (red area) condition of stress: sustain from managers, sustain from colleagues, quality of relationships and professional changes. A significant positive correlation (p <0.05) between the mean values of all critical areas and the concentrations of glucose values have been highlighted with the correlation index of Pearson. Multiple linear regression confirmed these findings, showing that the critical dimensions resulting from the questionnaire were the significant variables that can increase the levels of blood glucose.

CONCLUSION

The preliminary results indicate that perceived work stress can be statistically associated with increased levels of blood glucose.

Effect of transferring a morphologically impaired embryo with a good quality embryo on the pregnancy and implantation rates

OBJECTIVE

This study aimed to investigate the effect of transferring embryos with different qualities on pregnancy and implantation rates.

PATIENTS AND METHODS

In a retrospective multi-center study we analyzed 761 patients aged ≤ 35 years who had an elective transfer of one or two embryos. Embryos were scored morphologically by their developmental stage into good "A" and impaired "B" embryos. Pregnancy and implantation rates were compared between patients who had a transfer of: one grade "A" embryo; two grade "A" embryos, two embryos one grade "A" plus one grade "B" embryos; one grade "B" embryo and two grade "B" embryos.

RESULTS

Higher pregnancy and implantation rates were observed in patients who had received one embryo of grade "A" (34.6%) and two grade "A" embryos (45.2%, 25.85% respectively), compared to patients who received two embryos, one of grade "A" plus one of grade "B" (25%, 13.77% respectively).

CONCLUSIONS

Transferring a morphologically and developmentally impaired embryo, significantly lower the implantation chance of the good quality embryo.

Correlation between cadmium and blood counts in workers exposed to urban stressor

The objective of this study was to assess the exposures to cadmium (Cd) in urban workers and the association between Cd exposure and values of blood counts. Urinary Cd, blood Cd, and blood counts were obtained from 355 outdoor workers; a subgroup of 99 subjects were monitored to evaluate personal exposure to airborne Cd. The mean value of personal exposure to Cd was 1.5 ng/m3 for traffic assistants and 1.2 ng/m3 for drivers. Urinary and blood Cd were correlated to the airborne Cd (respectively r=3 and r=4). The multiple linear regression models showed the associations among white blood cell, the percentage of neutrophils (NEU%), the percentage of lymphocytes (LYM%), and the concentrations of blood Cd (respectively R2=27, R2=37, R2=581). The subjects with blood Cd values higher than 1.2 μg/L showed an increase of LYM% mean values and a decrease of NEU% mean values with respect to the group with blood Cd values lower than 1.1 μg/L.

First case of transformation for breast fibroadenoma to high-grade malignant phyllodes tumor in an in vitro fertilization patient: misdiagnosis of recurrence, treatment and review of the literature

INTRODUCTION

Cystosarcoma phyllodes are very rare tumors and may be difficult to diagnose clinically.

BACKGROUND

Fibroadenomas have long been considered benign hyperplastic lesions rather than true neoplastic processes. However, previous clonality studies have shown differing results.

AIM

to assess diagnostic and treatment options for phyllodes tumor.

MATERIALS AND METHODS

A 41-year-old female patient undergoing assisted fertilization treatment. The patient underwent fine needle aspiration biopsy that confirmed fibroadenoma before the IVF attempt. At 17 weeks of gestation, due to an increase in volume of the fibroadenoma, an excisional biopsy was performer that showed a malignant phyllodes tumor. Then she underwent quadrantectomy and chemiotherapy After 1 year there was a recurrence of phyllodes tumors and she underwent mastectomy and chemotherapy.

RESULTS

Fibroadenoma that was transformed into high-grade malignant cystosarcoma after ovarian stimulation, relapsed after one year and it was not immediately diagnosed. The patient underwent mastectomy and chemotherapy.

DISCUSSION

it is difficult to diagnose recurrence and to determine tele frequency and the right treatment for such a rare cancer, so it is important to report any case in the literature.

CONCLUSIONS

We recommend to remove a fibroadenoma before attempting IVF for the risk of malignant transformation.

Simultaneous administration of human acidic and recombinant less acidic follicle-stimulating hormone for ovarian stimulation improves oocyte and embryo quality, and clinical outcome in patients with repeated IVF failures

BACKGROUND

Ovarian stimulation is an integral procedure in assisted reproduction treatment. It is achieved by the administration of exogenous gonadotropins to increase follicular recruitment and oocyte yield. Optimization of ovarian stimulation is an essential prerequisite for the success of IVF treatment.

AIM

This study aimed to evaluate the effect of a combined stimulation protocol of human FSH and recombinant FSH, simultaneously administered, on oocyte and embryo quality and clinical outcome.

PATIENTS AND METHODS

In a prospective randomized study 197 infertile patients with a history of previous IVF failures for at least 3-5 attempts, were enrolled for an in vitro fertilization treatment. All patients had a standard down-regulation with GnRH analog and were then stimulated with FSH. The patients were matched into three groups: group A (no = 66) received human FSH combined with recombinant FSH in equal doses, simultaneously administered; group B (no = 67) received human FSH alone and group C (no = 64) received recombinant FSH alone.

RESULTS

There were significantly higher pregnancy (p < 0.04) and implantation rates (p < 0.03) in favor of group A (hFSH/rFSH) compared to groups B (hFSH) and C (rFSH). A significant increase in the proportion of mature metaphase II oocytes (p < 0.002) and grade 1 embryos (p < 0.03) was observed in group A with respect to group B and C. Significantly higher delivery rate (p < 0.01) was achieved in group A compared to groups B and C. No significant differences were observed between groups regarding miscarriage rate and risk of ovarian hyperstimulation syndrome.

CONCLUSIONS

The results show that the combination of human and recombinant FSH for ovarian stimulation may produce a positive effect on follicular development as it improve oocyte quality, embryo development, and ultimately clinical outcome.

Abstract P1-01-25: Sentinel lymph node biopsy in breast cancer: The approach in day surgery under local anaesthesia for quality-of-life and significant cost reduction

Background: Sentinel lymph node biospy (SLNB) is widely used in the management of breast cancer patients without axillary metastases or inflammatory breast cancer (IBC).

Methods: From Jan. 1st 2006 through Dic. 31st 2011 we performed 302 SLNB at St. M. Goretti Hospital. Mammary carcinoma was diagnosed as malignant by aspiration citology and/or biospy. In all cases with positive citology or biospy, we performed quadrantectomy and SLNB at the same time. All patients underwent pre-operative lymphoscintigraphy with intradermal pericicatritial and/or periareola injection of 12–15 MBq 99Tc colloidal albumin particles 50–80 nm size range, in 0,2 ml saline solution. We never used vital blue dye. All patients underwent surgical treatment 3–12 h. later. We performed SLNB and quadrantectomy in day surgery (DS) and local anaesthesia (LA) with 2% of Carbocaine. Axillary incision was 3–4 cm. This study was approved by an ethics committee, was discussed with all patients and informed consent was obtained.

Purpose of the study is to investigate the approach in DS under LA for quality of life and significant cost reduction.

Results: Six patients underwent pre-operative lymphoscintigraphy the radiotracer did not show any sentinel lymph node (SLN), in five cases we performed axillary dissection (AD). In one case of young patient who had previously been treated with chemotherapy for non-Hodgkin's lymphoma, negative positron emission tomography (PET), we performed quadrantectomy without AD. In three cases the axilla was positive. In four cases of multifocal (MF) and two of multicentric (MC) invasive breast cancer, the SLN was identified in axilla and SLNB was perfomed. SLNB in MF and MC tumors was similar to unifocal cancers. Only one case of MC cancer the SLN was positive. Six patients classified T4b according to AJCC, were treated with neoadjuvant chemotherapy (NC). The axilla was negative to ultrasound (US), PET and citology. After completion of NC, lymphatic mapping was able to identify SLN and we performed SLNB. In these patients SLN was negative. In two cases of male cancer the axilla was negative to clinical examination, in both cases SLN was positive for macrometastases. Six cases showed axillary isolated tumor cells (ITC). Eighteen micrometastases. Thirty-two macrometastases. In two case of negative SLN there was a positive second palpable lymph node. One case showed a double SLN in the axilla and internal mammary chain, only the internal mammary lymph node was positive.

The SLN identification rate was 99%. After surgery we distributed a questionnaire to the patients about the acceptability of this approach.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P1-01-25.

Correlation between squamous intraepithelial lesions (SILs) and bacterial vaginosis

Bacterial vaginosis (BV) is a condition that seldom occurs in prepuberal girls or postmenopausal women, suggesting a hormonal component in its aetiology. The precise mechanisms by which BV arises are not fully understood. One proposed mechanism suggests that carcinogenic nitrosamines act either independently or via human papilloma virus (HPV). Human papillomavirus is known to be associated with the development of squamous intraepithelial lesion (SIL). Still today the relationship between BV and SIL is debated. Many confounding factors regarding the relationship between BV and SIL include the presence of HPV and/or other sexually transmitted diseases. In a case-controlled study the correlation between BV, SIL and the presence of HPV was evaluated. BV was diagnosed according to standard criteria: vaginal pH > 4.5; positive amine test or 'whiff' test; presence of clue cells and abnormal discharge. High risk-HPV testing by PCR was performed. X2 Pearson analysis was applied for statistical evaluation of data. The results of the study have shown that BV is not associated with SIL.

Expression of TCL1 and CD27 in primary cutaneous B-cell lymphomas

AIMS

To investigate by immunohistochemical analysis the expression of the TCL1 oncogene product and of CD27 in 25 cases of primary cutaneous B-cell lymphomas (PCBCL) classified according to the World Health Organization-European Organization for Research and Treatment of Cancer classification of cutaneous lymphomas. In B-cell ontogenesis TCL1 is mainly expressed by 'naive' B lymphocytes and by a subset of germinal centre B cells, whereas CD27 is expressed by a subset of germinal centre B cells, 'memory' B lymphocytes and plasma cells, suggesting that their expression in physiological conditions is mutually exclusive.

METHODS AND RESULTS

Overall, TCL1 was expressed in 5/25 cases (20%) and CD27 in 15/25 cases (60%). Furthermore, 7/25 cases (28%) were TCL1- and CD27- and 2/25 cases (8%) were TCL1+ and CD27+. In particular, primary cutaneous follicle-centre lymphomas (10 cases) showed a variable expression of both TCL1 and CD27, whereas primary cutaneous marginal-zone B-cell lymphomas (eight cases) showed, with the exception of a single case, a definite CD27+/TCL1- profile.

CONCLUSIONS

These findings indicate: (i) the TCL1 oncogene product is uncommonly expressed in PCBCL (20% of cases, mainly of the follicle-centre subtype); (ii) in contrast, CD27 is often expressed in PCBCL (60% of cases), mainly of the marginal-zone subtype; (iii) the coexpression of TCL1 and CD27 may be seldom observed in PCBCL (8% of cases); (iv) PCBCL does not seem to show, in terms of either TCL1 or CD27 expression, significant differences compared with its systemic counterparts.

[Sentinel node biopsy for malignant melanoma. Technical details and clinical results on 390 patients]

BACKGROUND

The purpose of this paper is to present personal experience with sentinel node biopsy for the treatment of malignant melanoma. Technical details influencing the efficacy of the procedure are presented and the clinical, therapeutic and prognostic advantages of this technique discussed.

METHODS

A total of 390 consecutive patients with primary skin melanoma (T2-3,N0,M0) underwent sentinel node biopsy between March 1996 and May 2001. All patients underwent previous excisional biopsy of the primary lesion and clinical and radiographic examination to exclude lymphatic or systemic macroscopic spreading of the disease. Preoperative lymphoscintigraphy (99mTc nanocoll) was routinely performed in the last 315 patients. Intraoperative detection of the sentinel nodes was performed by perilesional, intradermical, injection of blue dye associated with a g probe (Neoprobe(R) 2000) in the last 315 patients. Sentinel nodes, serially sectioned, were all Haematoxylin-Eosin and immunohistochemically stained. All patients positive for micro-metastasis underwent radical lymphadenectomy. Comparative analysis between the incidence of metastasis in sentinel and non-sentinel nodes, according to the clinical stage of the disease, was done.

RESULTS

The overall detection rate of sentinel nodes was 97.4%. Relevant differences were found according to the site of dissection and the use of a g probe. The g-probe makes the procedure more effective, less invasive and less expensive. Timing and accuracy of the preoperative lymphoscintigraphy is a basic step of the procedure. The overall incidence of positive sentinel nodes was 14.7% with differences correlated with thickness of primary lesion (0.75-1.5 mm: 5,8%; 1.5-3 mm:18%; 3-4 mm: 24.6%). Metastasis in other non-sentinel nodes was found only with primary tumour thickness exceeding 2 mm.

CONCLUSIONS

Sentinel node biopsy is a procedure requiring a multidisciplinary approach (surgery, nuclear medicine and pathology). A specific learning phase (>30 patients) is recommended to obtain reliable results.

[Immune tolerance in pregnancy. Maternal-fetal interactions]

The conceptus may be considered as a sort of semi-allogenic graft for the maternal organism, since it shares a half of genomic complement with the father. Nevertheless, its rejection does not take place physiologically during a pregnancy. The mechanisms resulting in the maternal immune tolerance versus the conceptus are not yet completely clarified. Such mechanisms are probably multiple and interacting with each other. In animal and in vitro studies provide evidence suggesting that the following factors are important in producing the maternal immune tolerance: the anatomical position of the fetus; the absence of expression of the class I and II Major Histocompatibility Complex (MHC) molecules in trophoblast tissues; the activity of blocking antibodies; a modification of the immune response; the fetal-placental production of immunosuppressive hormones and substances. Amongst pregnancy-related changes in the immune response, a reduced Natural Killer (NK) cell activity and an increased synthesis of Th2 cytokines (which inhibit the cell-mediated immunity) with an altered Th1/Th2 balance appear to be remarkably important. With regard to fetal-placental hormones, progesterone seems to exert an important immunosuppressive influence mediated by the protein named "Progesterone Induced Blocking Factor" (PIBF). Nevertheless, the real contribution of each of the above mentioned mechanisms still remains to be elucidated in humans.

Pathogenetic and clinical implications of Bcl-6 and Bcl-2 gene configuration in nodal diffuse large B-cell lymphomas

Bcl-6 (LAZ-3) and Bcl-2 gene rearrangements have been respectively reported in 20-35 per cent and 10-25 per cent of diffuse large B-cell lymphomas (DLBCLs). Although these genetic lesions have been associated with different clinical outcomes (i.e., more favourable in Bcl-6 rearranged cases and poorer in Bcl-2 rearranged cases), their prognostic significance is still controversial. In the present study, we have investigated by Southern blot analysis the Bcl-6 and Bcl-2 gene configuration in a series of 80 lymph nodes involved by well-characterized DLBCLs, histologically defined according to the REAL and the updated Kiel classifications. The molecular findings have been correlated with the clinical features at presentation and with response to therapy. The majority of cases (57/80 = 71.2 per cent) had a centroblastic morphology. Bcl-6 rearrangements were detected in 23/80 cases (28.8 per cent), and were similarly associated with centroblastic (18/57 = 31.6 per cent) or immunoblastic (3/11 = 27.3 per cent) histotypes. In contrast, Bcl-2 was found to be rearranged in only three cases of centroblastic lymphoma (3.8 per cent). No significant differences were found between Bcl-6 rearranged and germline cases, as far as the clinical features at presentation are concerned. Forty-one patients, in whom the lymph node biopsy was performed at diagnosis, could be evaluated for response to treatment and clinical outcome. Most of these cases (30/41 = 73.2 per cent) were nodal DLBCL, without extranodal site involvement. Analysis of the clinical outcome showed no statistically significant differences between Bcl-6 rearranged and Bcl-6 germline cases (actuarial overall survival 50 per cent vs. 48 per cent, event-free survival 45 per cent vs. 46 per cent, at 4 years). These findings confirm that Bcl-6 rearrangements are the most frequent genetic lesion in DLBCL. The incidence of Bcl-2 involvement in our series is significantly lower than the figures reported in other studies, mainly from North American countries, probably reflecting heterogeneous patient selection and/or epidemiological variability. Finally, our results suggest that no relevant clinical differences are observed between Bcl-6 rearranged and Bcl-6 germline cases, when nodal DLBCLs are considered.

Simultaneous occurrence of large B-cell non-Hodgkin lymphoma and myelodysplastic syndrome rapidly evolving into acute myeloblastic leukemia

We describe a case of simultaneous occurrence of large B-cell non-Hodgkin lymphoma and myelodysplastic syndrome in the absence of previous chemotherapy or radiotherapy. After initiation of steroid treatment, the myeloid clone showed a rapid increase in both the bone marrow and peripheral blood with transformation into acute myeloid leukemia. The diagnosis were confirmed by immunophenotypic studies performed in the histologic sections of the lymph node, as well as in bone marrow and peripheral blast cells. This case may be indicative of potential down-regulation of a malignant myeloid clone induced by the malignant lymphoid clone.

Analysis of the BCL-6 gene configuration in diffuse B-cell non-Hodgkin's lymphomas and Hodgkin's disease

BCL-6 is a novel proto-oncogene that codes for a zinc-finger protein sharing homologies with many transcription factors. It has recently been shown that BCL-6 is involved in chromosome band 3q27 aberrations in non-Hodgkin's lymphomas (NHLs) and BCL-6 rearrangements have been detected in 34-45 per cent of diffuse large cell lymphomas with B immunophenotype. We have studied the BCL-6 gene configuration by Southern blot analysis in 60 cases of B-cell NHL and in 17 cases of Hodgkin's disease (HD). BCL-6 was rearranged in 15/46 (32.6 per cent) diffuse B-large cell lymphomas, mainly with centroblastic morphology, and in 2/11 (18.2 per cent) follicular (centroblastic-centrocytic) lymphomas. Conversely, all cases of HD, including four cases of lymphocyte predominant, nodular type (nodular paragranuloma), had a germline configuration. These findings confirm that BCL-6 is rearranged in a significant percentage of diffuse B-large cell lymphomas, suggesting that this proto-oncogene might have a pathogenetic role in this subset of NHLs, but our preliminary analysis suggests that BCL-6 lesions are not involved in the pathogenesis of HD. However, further investigations using more sensitive techniques are required to confirm these findings.

Multinucleated giant cells generation induced by interferon-gamma. Changes in the expression and distribution of the intercellular adhesion molecule-1 during macrophages fusion and multinucleated giant cell formation

BACKGROUND

Multinucleated giant cells (MGC), interferon-gamma (IFN-gamma) production, and increased expression of adhesion molecules are features of granulomatous reactions. IFN-gamma induces the fusion of macrophages and the subsequent MGC generation in vitro. Moreover, IFN-gamma increases ICAM-1 expression on lymphoid cells and an important role for adhesion molecules in MGC generation has been proposed.

EXPERIMENTAL DESIGN

The time course of the IFN-gamma-driven MGC generation was investigated in slide-chamber cultures of adherence-purified human monocytes. The fusion index, the monocytes clustering the total number of MGC were determined. The expression of intercellular cell adhesion molecule-1 (ICAM-1), LFA-1 and HLA-DR was investigated by immunohistochemistry. The effect of anti-ICAM-1, anti-LFA-1 and anti-HLA-DR monoclonal antibodies on IFN-gamma-induced MGC generation was also examined.

RESULTS

IFN-gamma enhanced the generation of MGC in a dose- and time-dependent fashion. In all experiments, MGC formation was preceded by a sequence of changes in the morphology of cultured monocytes. Cell clustering occurred as early as 3 days after IFN-gamma stimulation and was followed by the adhesion of cells that eventually fused. Immunohistochemistry showed that ICAM-1 was increased by IFN-gamma and constantly polarized on a cell uropode. When monocytes clustered, ICAM-1 was localized on the membrane where the cell-to-cell contact occurred. In newly formed MGC, ICAM-1 stained in the center of the giant cell. The cellular distribution of LFA-1 on cultured monocytes was not modified by IFN-gamma. HLA-DR expectedly enhanced by IFN-gamma was mostly cytoplasmic and tended to disappear when MGC formed. Finally, anti-LFA-1 and anti-ICAM-1 monoclonal antibodies variably inhibited IFN-gamma-induced MGC generation.

CONCLUSIONS

Taken together, these data add support to the concept that IFN-gamma is essential for MGC generation by promoting cell clustering and cell-to-cell adhesion. The present data also indicate that among the mechanisms by which IFN-gamma exert such a promoting effect, changes in the ICAM-1 expression and cellular distribution are included. The observation that ICAM-1 appears to be trapped in the cytoplasm of IFN-gamma-driven MGC and that HLA-DR tend to disappear from macrophages undergoing MGC formation, also suggest changes in the functional properties of these cells.

Peripheral neuroectodermal tumor of the chest (Askin tumor) as secondary neoplasm after Hodgkin's disease: a case report

The authors present the case of a 20-year-old woman who developed a peripheral neuroectodermal neoplasm of the thoracopulmonary region (Askin tumor) 7 years after achieving complete remission of stage-IV Hodgkin's disease. The previous treatment had consisted of eight courses of alternating MOPP/ABVD combined with involved-field 20-Gy radiotherapy. The second neoplasm appeared in a nonirradiated area of the chest wall, with erosion of the ribs as shown by sonography and computed tomography. The histological pattern was in accordance with a generic diagnosis of a malignant small cell tumor; the immunostaining positivity of the neoplastic cells for the neuron-specific enolase allowed us to make the diagnosis of a tumor with a neuroectodermal origin. Partial resection of the neoplasm and four courses of chemotherapy including adriamycin, cisplatin, and ifosfamide induced a complete remission, confirmed by surgical restaging. She is alive and well 10 months after the completion of therapy. The clinical, radiological, and microscopic features of this tumor occurring as a secondary neoplasm after Hodgkin's disease are described.

Nocturnal serum thyrotropin (TSH) surge and the TSH response to TSH-releasing hormone: dissociated behavior in untreated depressives

TSH secretion, with particular regard to the nocturnal surge of the hormone, was evaluated in 15 women (age range, 35-66 yr; mean, 50 yr) with untreated major endogenous depression and 15 healthy women (age range, 32-67 yr; mean, 53 yr) using an ultrasensitive assay. Mean morning (0830 h) TSH values did not differ in the 2 groups (1.3 +/- 02 mU/L in depressives and 1.4 +/- 0.1 mU/L in controls), whereas mean nighttime (2400-0200 h) values were significantly reduced in depressives (1.5 +/- 0.3 vs. 3.1 +/- 0.3 mU/L; P less than 0.0005). At variance with the control group, morning and nighttime TSH values did not differ in the depressives. The nocturnal serum TSH surge was abolished in 14 of 15 depressed patients. The mean peak TSH value after TRH was slightly yet significantly lower in the depressives. Patients with subnormal (less than 0.4 mU/L) TSH values in the morning had a serum TSH increase after TRH less than 2 mU/L in 5 of 6 cases and a lack of the nocturnal TSH surge in 6 of 6. Among the 9 patients with normal TSH values in the morning, the nocturnal serum TSH surge was lost in 8 of 9, whereas the response to TRH was normal in all. The depressives, at variance with other reports, showed significantly lower values of total and free thyroid hormones. Mean serum sex hormone-binding globulin (SHBG) and ferritin were also significantly reduced. In conclusion, major endogenous depression is associated with a major impairment of TSH secretion, which baseline TSH measurements in the morning and the evaluation of the TSH response to TRH may not reveal. In this regard, the loss of the nocturnal serum TSH rise would appear to be a more sensitive indicator of hypothalamus-pituitary-thyroid axis alterations in depressives than the TRH test, which is commonly used in the evaluation of these patients. The lack of the nocturnal TSH surge may be responsible for the reduced thyroid hormone secretion and supports the case for some degree of central hypothyroidism in endogenous depression.

Lack of nocturnal serum thyrotropin (TSH) surge in patients with chronic renal failure undergoing regular maintenance hemofiltration: a case of central hypothyroidism

Thyrotropin (TSH) secretion was evaluated in a group of patients with chronic renal failure (CRF) undergoing regular maintenance hemofiltration and in normal controls. The study group included 68 patients (39 males and 29 females, age range 39-73 years, mean: 53 years). In all patients blood was drawn at 08:30-09:00 h; in 20 patients the nocturnal (24:00-02:00 h) serum TSH peak was also evaluated; 12 patients underwent stimulation test with synthetic TSH-releasing hormone (TRH). TSH was measured by an ultrasensitive immunoradiometric assay. CRF patients showed a significant decrease in serum total and free thyroxine and triiodothyronine concentrations, which in a substantial proportion of subjects were below the lower normal limit. Serum reverse triiodothyronine and thyroxine-binding globulin values did not differ in the two groups. Despite this trend of thyroid hormones to decrease, no patient had supranormal TSH values as in primary hypothyroidism. While the mean morning TSH concentrations of CRF patients did not differ from those of controls, the mean nocturnal values were significantly reduced in CRF (1.0 +/- 0.2 vs 3.2 +/- 0.4 mU/l, p less than 0.0005) and the nocturnal serum TSH surge was not observed in 18 of the 20 patients (90%) in whom it was evaluated. The mean serum TSH peak value after TSH-releasing hormone (TRH) administration was also reduced in CRF patients, and the TSH response to TRH was blunted in 3 out of 12 patients (25%). The results of this study demonstrate a major impairment of TSH secretion in CRF, which baseline TSH measurements in the morning and the evaluation of the TSH response to TRH may not reveal.(ABSTRACT TRUNCATED AT 250 WORDS)

Lack of nocturnal serum thyrotropin surge after surgery

The effects of surgery on TSH secretion, with particular regard to the nocturnal TSH surge, were evaluated in 10 consecutive patients followed for 6 days after surgery. Surgical trauma was associated in all patients with significant decreases in serum total and free T3 and a significant increase in serum rT3 levels, with no variations in serum total and free T4 concentrations. A marked increase in serum cortisol levels was observed, with higher values at night than in the morning. Serum cortisol levels and circadian rhythm normalized on the fifth day. Serum TSH values in the morning significantly decreased on the first day after surgery and returned to normal on the second day. Serum TSH values at night (2400-0200 h) were higher than in the morning preoperatively, but the nocturnal surge was abolished from days 1-5 after surgery and was restored only on the sixth day. Thus, surgery was associated with a prolonged loss of the nocturnal serum TSH surge. This effect on TSH secretion was more marked than predictable on the basis of serum TSH measurements in the morning alone. An inverse relationship was found between serum cortisol and serum TSH values at night, suggesting that the excessive endogenous cortisol secretion might play a role in the derangement of TSH secretion.

Effects of the antileukemic drug L-asparaginase on sex hormone-binding globulin: studies in vivo and in vitro

L-asparaginase, an antineoplastic drug used in the treatment of acute lymphoblastic leukemia (ALL), has been previously shown to inhibit the hepatic synthesis of thyroxine-binding globulin (TBG). In two children treated by this drug for ALL, a dramatic decrease in serum sex hormone-binding globulin (SHBG) concentrations was also observed. Serum SHBG levels were still below normal 10 days after L-asparaginase withdrawal. To ascertain whether this reduction was due to the inhibition of SHBG synthesis, SHBG was measured by an immunoradiometric assay (IRMA) in the medium from human hepatoblastoma-derived cells, Hep G2 cells, grown in the absence or presence of graded amounts of the drug from 0.1 nM to 0.1 mM. The results showed a dose-dependent inhibition of SHBG synthesis, with a 50% reduction of SHBG in the medium, assayed by IRMA, using 250 nM L-asparaginase. Furthermore, a time-dependent inhibition was observed using a fixed concentration of the drug (50 nM) added for variable time intervals (1-4 days). These data suggest that the changes observed in vivo are likely due to the inhibitory effect exerted by the drug on SHBG synthesis. This action is not specific, but is part of a general effect at the hepatic level.

Thyroxine uptake by human hepatoma cells from serum of patients submitted to long-term thyroxine suppressive therapy

The significance of thyroxine (T4) uptake from serum in the assessment of thyroid status was evaluated, using human hepatoma (Hep G2) cells, in 30 euthyroid subjects, 6 hypothyroid and 19 hyperthyroid patients, and in 23 athyreotic cancer patients under T4 suppressive therapy. Cellular thyroxine (CT4) was determined according to Sarne and Refetoff, J. Clin. Endocrinol. Metab. 61: 1046, 1985. CT4 averaged 9.9 +/- 2.8 pg/well (mean +/- SD, range 5.7-15.3) in euthyroid subjects, 1.5 +/- 1.0 pg/well (range 0.05-4.2) in hypothyroid patients, 40.5 +/- 18.8 pg/well (range 18.3 +/- 104.7) in hyperthyroid patients, and 23.7 +/- 7.2 pg/well (range 14.2-40.2) in T4-treated patients. In eu-, hypo- and hyperthyroid patients, a significant correlation was observed between CT4 and free T4 index (FT4I), free T4 (FT4) or Sex Hormone Binding Globulin (SHBG) values. In T4-treated patients, CT4 values were correlated with FT4I values, but not with FT4 or SHBG levels. All T4-treated patients with elevated SHBG levels had elevated FT4, FT4I and CT4 values. In contrast, of the 16 T4-treated subjects with normal serum SHBG concentrations, all but one had normal FT3, 3 (19%) had elevated FT4, 10 (62%) elevated FT4I and 13 (81%) elevated CT4, but all (100%) had undetectable TSH levels. Thus, considering serum SHBG concentrations as a parameter of hepatic tissue response to thyroid hormone, CT4 values, at least in T4-treated patients, do not accurately reflect the liver responsiveness to thyroid hormone action.

Free thyroxine values in dried blood spots on filter paper in newborns are related to both gestational age and birth body weight

The results of free thyroxine (FT4) measurements in dried blood spots on filter paper in 744 euthyroid newborns (616 at term, 128 preterm), 10 newborns with congenital hypothyroidism and 4 euthyroid newborns with congenital TBG deficiency are reported. FT4 was measured by column adsorption chromatography of free hormone followed by radioimmunoassay in the eluate. FT4 values averaged 24 +/- 0.2 pmol/L (mean +/- SE) in euthyroid newborns, 23.0 +/- 0.9 pmol/L in euthyroid newborns with TBG deficiency (p = NS), and 5.7 +/- 0.4 pmol/L in hypothyroid newborns (p less than 0.001 vs both groups). Total T4 (TT4) values in newborns with TBG deficiency were not different from those in hypothyroid newborns, but were significantly lower than those in euthyroid newborns without TBG abnormalities. FT4 values were higher in full-term newborns than in preterm newborns (25.2 +/- 0.3 vs 21.2 +/- 0.5 pmol/L, p less than 0.001). In both full-term and preterm newborns FT4 values in dried blood spots increased with birth body weight (bbw), virtually plateauing when bbw was greater than 2,500 g. The cut-off values established on the basis of the bbw (8.0 and 13.1 pmol/L for a bbw of less than or equal to 2,500 g and greater than 2,500 g, respectively) showed higher specificity and predictive value of positive results than the cut-off values based on the gestational age. In any case, the sensitivity, specificity and predictive values of FT4 determinations proved to be higher than those of TT4 and TSH measurements.(ABSTRACT TRUNCATED AT 250 WORDS)

Free thyroxine and free triiodothyronine measurement in dried blood spots on filter paper by column adsorption chromatography followed by radioimmunoassay

Free thyroxine (FT4) and free triiodothyronine (FT3) were measured by column adsorption chromatography followed by radioimmunoassay in dried blood spots on filter paper in euthyroid subjects, hyperthyroid and hypothyroid patients, and in subjects with TBG excess. The sensitivity (B/T% = 95%) was 1.5 pg/ml (working range 1.5-46.4 pg/ml) for FT4 and 1.5 pg/ml (working range 1.5-32.0 pg/ml) for FT3. Intraassay coefficient of variations (CVs) ranged 4.4-8.8% for FT4, 8.7-10.1% for FT3; interassay CVs varied from 8.9-9.0% for FT4, 9.3-10.4% for FT3. FT4 and FT3 values found in dried blood spots were highly correlated with the corresponding values in serum (r = 0.97, P less than 0.001 for FT4; r = 0.96, P less than 0.001 for FT3). FT4 concentrations in dried blood spots ranged 8.1-20 pg/ml in euthyroid subjects, 19.4-60.0 pg/ml in hyperthyroid patients, less than 1.5-7.1 pg/ml in hypothyroid patients, 7.8-18.8 pg/ml in euthyroid subjects with TBG excess. FT3 values in dried blood spots ranged 2.5-5.8 pg/ml in euthyroid subjects, 7.1-30.0 pg/ml in hyperthyroid patients, less than 1.5-2.8 pg/ml in hypothyroid patients, 2.5-5.2 in euthyroid subjects with TBG excess. The results of the present study, while confirming previous data on FT4 determination in dried blood spots, represent the first report on FT3 measurement in the same system, thus allowing a more complete assessment of thyroid status made by mail at the expense of few drops of blood.

Evaluation of the nocturnal serum thyrotropin (TSH) surge, as assessed by TSH ultrasensitive assay, in patients receiving long term L-thyroxine suppression therapy and in patients with various thyroid disorders

Circadian variations of serum TSH concentrations have been reported, with higher values occurring in the late evening or early morning. In patients receiving long term L-T4 suppression therapy, it may be important to achieve suppression of TSH secretion throughout the day. To investigate whether undetectable serum TSH values in the morning are associated with undetectable serum TSH levels at night, serum TSH concentrations were measured by an ultrasensitive immunoradiometric assay in 16 normal subjects, 20 hyperthyroid patients, 10 patients with primary hypothyroidism (either untreated or inadequately treated with L-T4), 1 patient with central hypothyroidism, 10 patients with nontoxic nodular goiter, 5 patients with functioning thyroid adenoma, 20 patients receiving L-T4 replacement therapy, and 30 patients receiving L-T4 suppression. In 6 subjects blood was drawn at hourly intervals for 24 h; in 2 normal subjects a major TSH surge occurred between 2300-0100 h, with other minor peaks, and the same pattern was found in two patients receiving L-T4 replacement, whereas in 2 patients receiving L-T4 suppression, serum TSH was constantly below the limit of detection of the assay (i.e. less than 0.07 mU/L). In the remaining patients blood was drawn at hourly intervals between 2300-0200 h and on the next morning before (0830-0900 h) and 30 min after iv TRH administration. In normal subjects, in patients receiving L-T4 replacement therapy, and in hypothyroid patients, serum TSH values at night were higher than in the morning, with normal responses to TRH in the first 2 groups and exaggerated responses in the latter. The patient with central hypothyroidism had no nocturnal TSH surge and no TSH response to TRH. In all hyperthyroid patients, serum TSH was undetectable both at night and during the day, and none had a serum TSH response to TRH. Among patients with nontoxic goiter, 7 had detectable serum TSH in the morning, with higher values at night, and a normal response to TRH; the remainder had undetectable serum TSH both at night and in the morning, and subnormal or absent TSH responses to TRH. All 5 patients with a functioning thyroid adenoma had undetectable serum TSH levels in the morning and during the night, and subnormal or absent TSH responses to TRH. Of the 30 patients receiving long term (greater than 6 months) L-T4 suppression therapy, 28 had undetectable serum TSH both during the night and in the morning and unresponsiveness to TRH.(ABSTRACT TRUNCATED AT 400 WORDS)

Further studies on the role of glycosylation in thyroxine-binding globulin secretion by human hepatoma (HEP G2) cells

To investigate the role of glycosylation of T4-binding globulin (TBG) in the secretion of the protein, human hepatoma (Hep G2) cells were continuously labeled with [35S] methionine or [3H]mannose or pulse-chase labeled with [35S] methionine in the absence or presence of 1 microgram/ml swainsonine, an inhibitor of Golgi alpha-mannosidase II and lysosomal alpha-mannosidase. In the presence of this alkaloid, TBG was released into the medium at a faster rate than in control cells (50% being secreted after 35 min and 47 min, respectively), owing to accelerated intracellular transport of the newly synthesized protein. TBG secreted from swainsonine-treated cultures moved faster in sodium dodecyl sulfate-polyacrylamide gel electrophoresis, probably because of the reduced sialylation of TBG consequent to the perturbed processing of the oligosaccharide units. Furthermore, secreted TBG was sensitive to endo-beta-N-acetylglucosaminidase H digestion as shown by the shift in the apparent molecular size in sodium dodecyl sulfate-polyacrylamide gel electro-phoresis from 50,000 to 45,000 daltons. Sensitivity to endo H indicated the presence of hybrid-type oligosaccharide chains with high mannose structures. This was also suggested by the higher incorporation of [3H]mannose in swainsonine-treated cultures. In conclusion, the results of the present study demonstrate that swainsonine accelerates the release of TBG from Hep G2 cells and that complete processing of oligosaccharide moieties is not required for TBG secretion.

Factors affecting suppression of endogenous thyrotropin secretion by thyroxine treatment: retrospective analysis in athyreotic and goitrous patients

Factors affecting TSH suppression by L-T4 administration were retrospectively evaluated in 452 patients: 180 who were athyreotic after total thyroidectomy and remnant radioiodine ablation for differentiated thyroid carcinoma and 272 with nontoxic diffuse or nodular goiter. All patients were considered clinically euthyroid. TSH secretion was assessed by iv TRH stimulation testing. The T4 dose associated with an undetectable basal serum TSH level and no increase in serum TSH after TRH administration (suppressive dose) averaged 2.7 +/- 0.4 (SD) micrograms/kg body weight (BW)/day in athyreotic patients and 2.1 +/- 0.3 micrograms/kg BW/day in goitrous patients (P less than 0.001). The 25th-75th percentile intervals were 2.5-2.9 micrograms/kg BW/day for athyreotic patients and 1.9-2.3 micrograms/kg BW/day for goitrous patients. The suppressive dose of T4 was dependent in both groups on patient age, younger patients needing higher doses than older patients. The duration of treatment also proved to be an important parameter, since in both groups the percentage of patients with suppressed TSH secretion increased if TRH testing was carried out after at least 6 months after the initiation of therapy. Serum total T4, total T3, free T3 (FT3), free T4 (FT4) index, and FT3 index values did not differ in the two groups and were significantly higher (P less than 0.001) than in normal subjects. Mean serum FT4 was significantly higher in athyreotic patients than in goitrous patients with suppressed TSH secretion. Among athyreotic patients with suppressed TSH secretion, 24% had elevated serum FT4 and FT3, and 47% had elevated serum FT4 alone. Of goitrous patients with suppressed TSH secretion, 20% had elevated serum FT4 and FT3, and 27% had elevated serum FT4 alone. On the other hand, 35% of athyreotic patients and 14% of goitrous patients whose TSH secretion was not suppressed had elevated serum FT4. Serum sex hormone-binding globulin concentrations were measured in 3 groups of goitrous women. Values above normal limits were found in 13/26 patients (50%) with high serum FT4 and FT3, in 4/30 patients (13%) with elevated serum FT4 alone, and in 1/25 patients (4%) with normal FT4 and FT3.

IN CONCLUSION

TSH suppression requires daily doses of T4 between 2.5 and 2.9 micrograms/kg BW in athyreotic patients and between 1.9 and 2.3 micrograms/kg BW in goitrous patients, with appropriate adjustments in relation to the age of the patient; Assessment of the adequacy of treatment should not be carried out before 6 months after the institution of therapy.

Effect of the antileukemic agent L-asparaginase on thyroxine-binding globulin and albumin synthesis in cultured human hepatoma (HEP G2) cells

L-Asparaginase (ASNase), a drug widely used in the treatment of acute lymphoblastic leukemia, has been reported to decrease serum T4-binding globulin (TBG) levels, while results of serum albumin determinations were conflicting. This effect in vivo has been attributed to depressed liver protein synthesis, but this hypothesis has not been proved. To investigate this problem, human hepatoma (Hep G2) cells were continuously labeled for 4 h with 100 microCi/ml [35S]methionine in the absence or presence of graded amounts of ASNase (from 0.1 nM to 0.1 mM). Media and cell lysates were collected, immunoprecipitated with antialbumin or anti-TBG serum and protein A, and submitted to sodium dodecyl sulfate-polyacrylamide gel electrophoresis. Gels were sliced, and the radioactivity was counted in a beta-counter. A dose-dependent inhibition of TBG and albumin biosynthesis (as well as of total protein synthesis) was demonstrable, but TBG appeared to be more sensitive to the action of the drug. In fact, TBG biosynthesis was reduced by 8% with 0.1 nM ASNase, while an effect on albumin was observed only at 1 nM ASNase; 50% inhibition was obtained with 30 nM ASNase in the case of TBG and with 800 nM in the case of albumin. At the highest concentration (0.1 mM), TBG biosynthesis was reduced by 94%, and albumin biosynthesis by 75%. ASNase also proved to have a time-dependent effect, as assessed by the measurement of radioimmunoassayable TBG in the media from Hep G2 cells grown in the presence of 10 nM ASNase for 1-4 days. The TBG concentration was progressively reduced, by 40% after 1 day to 85% after 4 days. In pulse-chase experiments, a reduction of total (intracellular plus secreted) immunoprecipitable TBG and, to a lesser extent, albumin was observed, suggesting that the drug also affected the catabolism of newly synthesized proteins. These results provide the first in vitro evidence that ASNase actually inhibits TBG biosynthesis. This effect is not specific for TBG, but this protein appears to be more susceptible than albumin to ASNase action. This can explain why in patients treated with ASNase for leukemia, a decrease in serum TBG concentrations has not always been associated with a reduction in serum albumin levels.

Serum free thyroid hormones in subclinical hypothyroidism

Serum free thyroxine (FT4) and free triiodothyronine (FT3) concentrations were measured in a group of 52 patients with subclinical hypothyroidism (SH) and in an equal group of age and sex-matched normal controls. SH was defined by normal total T4 (TT4) and total T3 (TT3) concentrations, normal FT4 and FT3 indices, raised TSH levels, in the absence of signs and symptoms of hypothyroidism. Serum FT4 levels averaged 6.1 +/- 1.6 pg/ml (mean +/- SD, p less than 0.001 vs controls), with values below lower normal limits in 33/52 patients; mean FT3 concentrations averaged 3.1 +/- 0.7 pg/ml (p less than 0.001 vs controls), with values below lower normal limits in 8/52 patients. The analysis of results by the Galen and Gambino predictive value model demonstrated a higher sensitivity, but a lower specificity of FT4 as compared to FT3 in the diagnosis of SH. These results indicate that FT4 should be measured in addition to TSH for the diagnosis of impending thyroid failure, thus showing that in many cases patients with so-called subclinical hypothyroidism are actually already mild hypothyroid.

Serum thyrotropin by ultrasensitive immunoradiometric assay and serum free thyroid hormones in pregnancy

Variations of serum TSH, measured by an ultrasensitive immunoradiometric assay, of serum total and free thyroid hormones and of thyroxine-binding globulin (TBG) and sex hormone-binding globulin (SHBG) were investigated in a group of 18 normal women before and during pregnancy. A gradual increase of total thyroid hormones, TBG and SHBG was observed, while mean serum free thyroxine and free triiodothyronine progressively decreased. Serum TSH concentrations were comprised within the normal range throughout pregnancy, although a small but significant increase was found in the 2nd and 3rd trimester. These changes may represent a compensatory mechanism to meet the increased demand for thyroid hormones in pregnancy and must be taken into account for a correct evaluation of thyroid function during gestation.

Serum free thyroxine in patients with T3-toxicosis

The serum free thyroxine concentration was measured by direct radioimmunoassay in 38 untreated T3-thyrotoxic patients with elevated serum total and free triiodothyronine, normal serum thyroxine and free thyroxine index, no TSH response to TRH, and with clinical evidence of hyperthyroidism. An elevation of circulating free thyroxine values was observed in 58% of the patients, whereas total serum thyroxine concentration was within the normal range. It is suggested, therefore, that T3-thyrotoxicosis should be reserved for patients with elevated serum total T3 and free T3 concentrations and normal serum total T4 and free T4 concentrations. Serum thyroxine-binding globulin concentrations were significantly lower (P less than 0.025) in patients with an elevated serum free thyroxine (18.7 +/- 3.6 micrograms/ml: mean +/- SD) as compared with those in patients with a normal free thyroxine concentration (23.4 +/- 2.6 micrograms/ml). In addition, no daily fluctuations in total and free thyroxine concentration were observed in 6 patients over a 4-8 day period.

Environmental iodine intake and thyroid dysfunction during chronic amiodarone therapy

Amiodarone, an iodine-containing drug used frequently in the treatment of cardiac arrhythmias and angina pectoris, has many effects on thyroid hormone metabolism, including decreasing the production of triiodothyronine (T3) and decreasing the clearance of thyroxine and reverse T3. These effects result in elevated serum thyroxine and reverse T3 concentrations and decreased serum T3 concentrations. In addition, iodine-induced hyperthyroidism or hypothyroidism may occur in patients chronically treated with amiodarone. This study is a retrospective analysis of the incidence of thyroid dysfunction in Lucca and Pisa, West Tuscany, Italy, and in Worcester, Massachusetts. Hyperthyroidism was a more frequent (9.6%) complication of amiodarone therapy in West Tuscany, where iodine intake is moderately low; hypothyroidism was more frequent (22%) in Worcester, where iodine intake is sufficient. In patients receiving chronic amiodarone therapy, clinically suspected hyperthyroidism is best confirmed by showing elevations in serum T3 or free T3 concentrations; hypothyroidism is best diagnosed by showing an elevated serum thyrotrophin concentration. Thyroid function should be carefully monitored in patients receiving amiodarone chronically, especially if they have goiter or Hashimoto's thyroiditis.