Giacomo Accardo

Cardiovascular abnormalities in Klinefelter Syndrome

BACKGROUND Several epidemiological studies have demonstrated an increased mortality from cardiovascular causes in patients with Klinefelter Syndrome (KS). Little information is available about the nature of the underlying cardiovascular abnormalities. Aim of the study was to investigate exercise performance, left ventricular architecture and function, vascular reactivity, and carotid intima-media thickness in a group of patients with KS. MATERIALS AND METHODS Sixty-nine patients with KS and 48 age-matched controls participated in our population-controlled study. Forty-eight Klinefelter subjects were on testosterone treatment at the time of the investigation while 21 were naive and underwent a complete Doppler echocardiographic examination, a cardiopulmonary exercise test as well as a vascular study including measures of carotid intima-media thickness and endothelial function with flow-mediated dilation of the brachial artery. Patients with KS on testosterone therapy (n=48) were also matched against a population of men with treated secondary hypogonadism (n=21). RESULTS Patients with KS exhibited a wide array of cardiovascular abnormalities including left ventricular diastolic dysfunction, reduced maximal oxygen consumption (p<0.01), increased intima-media thickness (p<0.05) (-34% and +42% vs. controls, respectively) and a high prevalence of chronotropic incompetence (55% of patients, p<0.01). No significant difference was found between treated and untreated KS in variance with men treated for secondary hypogonadism. CONCLUSION Left ventricular diastolic dysfunction, impaired cardiopulmonary performance, chronotropic incompetence, and increased intima-media thickness suggest that cardiovascular abnormalities are a common finding in KS that is not reversed by testosterone replacement therapy and may represent the pathophysiological underpinnings of the increased risk of dying from heart disease.

Lessons to be learned from the clinical management of a MEN 2A patient bearing a novel 634/640/700 mutation of the RET proto‐oncogene

A cluster of germline gain-of-function mutations of the RET proto-oncogene are responsible for Multiple Endocrine Neoplasia type 2A (MEN 2A), an autosomal dominant, inherited disorder characterized by medullary thyroid carcinoma (MTC), phaeochromocytoma (Phaeo) and hyperparathyroidism. Genetic screening of MEN 2A patients has been available for the past decade and useful genotype–phenotype correlations have been established: specific RET mutations are associated with age at first diagnosis and tumour aggressiveness. Accordingly, MEN 2A patients can be stratified into three risk groups depending on the RET mutation. Management uncertainties remain regarding patients bearing uncommon RET mutations or genetic variations for which mutation-specific risk profiles and treatment recommendations are unavailable. Here we report the thirteen-year clinical and surgical follow-up of a patient with MEN 2A bearing three de novo RET mutations at codons 634, 640 and 700 (p. C634R, p.A640G and p.M700L) in exon 11: a combination of mutations which has not previously been described. In May 1998, a 26-year-old female patient was admitted to our unit because of recurrent episodes of hypertension, tachycardia and headache. She had recently been diagnosed with a MTC which had been removed surgically, with associated cervical central lymphectomy. Elevated urinary catecholamine levels and imaging examinations showing a left adrenal mass were suggestive of a Phaeo. Hyperplasia of the contralateral gland was also detected. The patient underwent left “open” adrenalectomy 3 months later; post-operative catecholamine levels decreased to normal values, while the serum calcitonin remained elevated (Fig. 1). The diagnosis of MEN 2A was confirmed by testing the patient’s DNA for RET mutations. Two heterozygous germline mutations were identified: a transition at position c.1900 replaced a T with a C and a transversion at position c.1919 replaced a C with a G, resulting in the substitution of a cysteine with an arginine and an alanine with a glycine at positions p.634 and p.640, respectively. The patient presented with MTC and Phaeo without parathyroid gland involvement, so we speculated that this clinical picture could be correlated with the two RET mutations identified and the unusual feature of calcitonin production by the adrenal tissue. No clinical symptoms suggestive of MEN 2A and no RET mutations were found in either parent or any of the available relatives tested (three sisters and one brother). In 2003, at

Female sexual dysfunction in women with thyroid disorders.

Background: Few data exist on the prevalence of female sexual dysfunction (FSD) in thyroid disorders. Aim: We evaluated FSD in women with thyroid diseases and in control age-matched healthy women to investigate the relationship between sexual function and thyroid hormones. Methods: One hundred and four women with thyroid diseases and 53 controls participated in the study. Eighteen with hyperthyroidism (Group 1), 22 hypothyroidism (Group 2), 45 Hashimoto’s thyroiditis (Group 3), 19 nodular goiter (Group 4) underwent thyroid function evaluation and sonography. The Female Sexual Function Index (FSFI) assessed sexual function. Results: The prevalence of FSD was 46.1% in thyroid diseases and 20.7% in controls. Only in Group 4, the prevalence (68.4%) was significantly higher than in controls (p<0.005). The mean total FSFI score was 20.1±7.1 in women with thyroid diseases and 25.6±4.7 in the controls (p<0.001). Compared with controls, there was a significant decrease of desire in Group 2; desire, arousal and lubrication in Group 3; desire, arousal, lubrication, orgasm and satisfaction in Group 4. In thyroid diseases the prevalence of FSD was 53% and 42%, while in the controls was 55% and 20%, in menopausal and pre-menopausal groups, respectively. We found a significant inverse correlation between TSH and FSFI (r=−0.7, p=0.01) in Group 4, which showed the lowest FSFI score (17.8±5.7) and the highest body mass index (28.4±7.1 kg/m2). Conclusions: Women with thyroid diseases present a higher prevalence of FSD than controls. Although our findings suggest a higher impairment of sexual function in Group 4 and a role for TSH in FSD, further researches are needed.

CDKN1B V109G polymorphism a new prognostic factor in sporadic medullary thyroid carcinoma

CONTEXT CDKN1B encodes the cyclin-dependent kinase inhibitor p27Kip1 and is mutated in multiple endocrine neoplasia-like syndromes. CDKN1B also harbors single nucleotide polymorphisms; the T/G transversion at nucleotide 326 (the V109G variant) has been reported to be protective in breast, hereditary prostate, and pancreatic tumors. Association of CDNK1B mutations or polymorphisms with sporadic medullary thyroid carcinoma (MTC) has not been investigated yet. OBJECTIVE AND DESIGN We screened germline DNA from 84 patients affected by sporadic MTC and 90 healthy age- and gender-matched controls for CDKN1B mutations or polymorphisms by PCR amplification and sequencing of the amplicons. We also tested all germline and 50 tumor tissue DNA for RET proto-oncogene mutations. Computed tomography, ultrasound scans, and serum calcitonin were carried out before surgery and during the follow-up and associated with CDKN1B polymorphism and disease remission. RESULTS The T/G transversion at nucleotide 326 was the only DNA variation detected. The overall frequency of the T/G and G/G alleles in combination was 46.4%. This variant (V109G) was correlated with post-operative calcitonin levels in the normal range and biochemical remission. Conversely, the wild-type (T/T) allele was associated with post-operative calcitonin levels above normal and a higher risk to develop clinical recurrence and distant metastases. Somatic RET mutations were significantly associated with a more aggressive behavior especially in wild-type allele-bearing patients. CONCLUSIONS Collectively, in sporadic MTC, the CDKN1B V109G polymorphism correlates with a more favorable disease progression than the wild-type allele and might be considered a new promising prognostic marker.

Genetics of medullary thyroid cancer: An overview

Medullary thyroid carcinoma (MTC) represents 3-5% of thyroid cancers. 75% is sporadic and 25% is the dominant component of the hereditary multiple endocrine neoplasia (MEN) type 2 syndromes. Three different subtypes of MEN2, such as MEN2A, MEN2B, and Familial MTC (FMTC) have been defined, based on presence or absence of hyperparathyroidism, pheocromocytoma and characteristic clinical features. Mutations of the RET proto-oncogene are implicated in the pathogenesis of MTC, but there are many other mutational patterns involved. In MEN2A, Codon 634 in exon 11 (Cys634Arg), corresponding to a cysteine in the extracellular cysteine-rich domain, is the most commonly altered codon. Many other mutations include codons 611, 618, 620. In the genetical testing of RET mutations in MTCs, Next-Generation Sequencing (NGS) is taking an increasingly important role. One of the most important benefit is the comprehensive analysis of molecular alterations in MTC, which allows rapidly to select patients with different risk levels. There is a difference in miRNA expression pathway between sporadic and hereditary MTCs. Among sporadic cases, expression of miR-127 was significantly lower in those who harbor somatic RET mutations than those with wild-type RET. CDKN1B mutations are associated with many clinical pictures of cancers, such as MEN4. V109G polymorphism is associated with sporadic MTCs negative for RET mutations, and might influence the clinical course of the patients affected by MTC. Although surgery (i.e. total thyroidectomy with neck lymph node dissection) is the elective treatment for MTCs, about 80% of patients have distant metastases at diagnosis and in this cases surgery is not enough and an additional treatment is needed. Interesting results come from two large phase III clinical trials with two targeted tyrosine kinase inhibitors (TKIs), vandetanib and cabozantinib. CONCLUSIONS New genetical testings and therapeutical approaches open new perspectives in MTC management.

Testicular parenchymal abnormalities in Klinefelter syndrome: a question of cancer? Examination of 40 consecutive patients

Klinefelter syndrome (KS) is a hypergonadotropic hypogonadism characterized by a 47, XXY karyotype. The risk of testicular cancer in KS is of interest in relation to theories about testicular cancer etiology generally; nevertheless it seems to be low. We evaluated the need for imaging and serum tumor markers for testicular cancer screening in KS. Participants were 40 consecutive KS patients, enrolled from December 2009 to January 2013. Lactate dehydrogenase (LDH), alpha-fetoprotein (AFP), and beta-human chorionic gonadotrophin subunit (β-HCG) serum levels assays and testicular ultrasound (US) with color Doppler, were carried out at study entry, after 6 months and every year for 3 years. Abdominal magnetic resonance (MR) was performed in KS when testicular US showed micro-calcifications, testicular nodules and cysts. Nearly 62% of the KS had regular testicular echotexture, 37.5% showed an irregular echotexture and 17.5% had micro-calcifications and cysts. Eighty seven percent of KS had a regular vascular pattern, 12.5% varicocele, 12.5% nodules <1 cm, but none had nodules >1 cm. MR ruled out the diagnosis of cancer in all KS with testicular micro calcifications, nodules and cysts. No significant variations in LDH, AFP, and β-HCG levels and in US pattern have been detected during follow-up. We compared serum tumor markers and US pattern between KS with and without cryptorchidism and no statistical differences were found. We did not find testicular cancer in KS, and testicular US, tumor markers and MR were, in selected cases, useful tools for correctly discriminating benign from malignant lesions.

Maternal hypothyroidism and subsequent neuropsychological outcome of the progeny: a family portrait

IntroductionNormal neuropsychological development depends uponadequate function of both maternal and foetal thyroid gland[1]. Previous studies suggested that even mild hypothy-roidism can interfere with normal brain development [2, 3].Maternal hypothyroidism is not a rarely diagnosedcondition during pregnancy [4]. The diagnosis and thetreatment of such condition are not troublesome [5–7], butthe possibility to predict what will be going on in thenewborn, once maternal hypothyroidism is discovered,remains difficult. As a result it is not rare that somepregnant women with severe hypothyroidism during ges-tation could consider early termination of pregnancy fear-ing that their infant might have significant mentalretardation [8, 9].We are here reporting the early and long-term neu-ropsychological development of the progeny of a thy-roidectomized woman displaying different degrees ofhypothyroidism in three subsequent pregnancies.Even if limited to three patients, analysis of this familyis of potential clinical relevance in that the three sisters,besides the parents, shared the same social and culturalenvironment, which would prevent the confounder effectsof the environment thus, allowing a more bias-free com-parison of the effects of maternal hypothyroidism on theirneurodevelopment outcome. Furthermore, the comparisonsof the early versus long-term neuropsychological outcome,provides some clinically useful informations.Patients and methodsThe case history of three sisters (F.F., A.F. and C.F.) bornto a thyroidectomized mother under levothyroxine substi-tutive treatment are reported. Briefly, the mother had beenthyroidectomized for Graves’ disease at the age of 12 yearsand was under replacement therapy with levothyroxine(200 mcg/day). The case history of the first pregnancy waspreviously reported [10]. Throughout the three pregnanciesLT4 doses were adjusted up to 300 lg/day. The LT4 doseadjustments were performed at variable timing at eachpregnancy because the patient did not attend regular fol-low-up and displayed a poor compliance to the treatment.In particular, the patient was found to be severely hy-pothyroid at 29 weeks gestation in the first pregnancy (TSHlevel of 79 lU/ml, FT4 6.0 pg/ml). A mild hypothyroidismwas found at 24 weeks gestation in the the second preg-nancy (TSH 15 lU/ml), while euthyroidism resulted at 6weeks gestation in the third pregnancy (TSH 3.5 lU/ml).(1) F.F. The case history of the first daughter waspreviously reported [10]. Briefly, she had been foundto be growth-retarded at her 29 week of intrauterinelife, when the mother was severely hypothyroid

High circulating levels of CCL2 in patients with Klinefelter's syndrome

We would like to thank Dhindsa and colleagues for their interest and comments on our recent review article published in Clinical Endocrinology entitled ‘The Role of Obesity and Type 2 Diabetes Mellitus in the development of Male Obesity-associated Secondary Hypogonadism’. We would also like to thank the Editor for the opportunity to respond. We would like to confirm that we agree with the useful comments raised and provide further comment below. In our published review, we commented that the mechanisms implicated in the pathogenesis of secondary hypogonadism in men and its association with obesity and type 2 diabetes mellitus are multiple, complex and incompletely understood. We also stated that one of the pathogenic mechanisms implicated in the development of male obesity-associated secondary hypogonadism is increased aromatase activity within adipocytes. This results in increased peripheral conversion of testosterone into oestradiol and subsequent negative feedback on secretion of luteinizing hormone secretion from the pituitary. The suppressive effect of such a mechanism on the male hypothalamo–pituitary–gonadal axis results in a reduction in plasma testosterone levels and secondary hypogonadism. Consistent with this hypothesis, it has been reported in the literature that obese men show increased levels of oestrogens and decreased levels of bioavailable androgens within the serum. It has also been noted that use of aromatase inhibitors in men with obesity-related hypogonadism may normalize serum testosterone, again consistent with an important pathogenic role for aromatization in this condition. However, we acknowledge that there is controversy in the literature regarding the role of aromatization in the pathogenesis of male obesity-associated secondary hypogonadism. There is some inconsistency in the literature regarding relationships between serum levels of testosterone and oestradiol and the severity of obesity in this condition. We acknowledge that in some studies on obese men, serum levels of free oestradiol directly correlate with free testosterone. One explanation for this direct correlation is that with increasing obesity in men, as serum levels of testosterone fall (following suppression of the male gonadal axis), serum oestradiol levels would also be expected to fall eventually due to lack of substrate (testosterone) for the aromatase enzyme. This hypothesis has been supported by the European Male Ageing Study. We feel that it is important to emphasize that there are many potential mechanisms that underlie the complex pathogenesis of male obesity-associated secondary hypogonadism other than enhanced aromatase activity, as outlined in our published review article. These include the increasingly important roles of leptin, inflammatory mediators (TNF-a, IL-1b, CRP), the role of sleep disruption and the serotoninergic system and endogenous kisspeptin. We also outline the effects of insulin resistance at various levels including lipases, suppression of hepatic SHBG synthesis and the suppression of the hypothalamo–pituitary unit as potentially important pathogenic mechanisms. There may also be other, as yet unknown mechanisms at play. Clearly, there is a need for further focused studies in this field to develop a clear understanding of pathogenesis and to inform future novel treatment strategies.

Increased platelet reactivity in Klinefelter men: something new to consider.

Patients with Klinefelter syndrome (KS) exhibit an increased cardiovascular risk, but underlying mechanisms are largely unknown. The present cross‐sectional study has been conducted to evaluate platelet reactivity and the expression of platelet activation markers (8‐iso‐prostaglandin F2α[8‐iso‐PGF2α] and 11‐dehydro‐thromboxane‐B₂[11‐dehydro‐TXB2]) in KS patients and healthy controls. Twenty‐three consecutive KS patients under testosterone replacement therapy have been included as case group and 46 age‐matched healthy males recruited among hospital staff served as controls. Light transmission aggregometry was performed in both cases and controls and maximal platelet aggregation (max‐A%) was defined as maximal light transmittance reached within 5 min after the addition of 0.2 or 0.4 mm arachidonic acid (AA). A ≥ 50% irreversible light transmittance (LT‐50%) following platelet stimulation defined an adequate platelet aggregation and AC‐50% was defined as the minimal agonist concentration needed to achieve LT‐50%. The AC‐50% was 0.26 mm AA for KS and 0.36 mm for controls (p < 0.001). Whereas AA (0.2 mm) induced LT‐50% in 69.6% of KS and in 15.2% of controls (p < 0.001), the stimulation with AA (0.4 mm) determined LT‐50% in all cases and controls. However, max‐A% was higher in KS than in controls both after AA (0.2 mm) (65.61% vs. 46.30%, p = 0.002,) and after AA (0.4 mm) (96.43% vs. 81.04%, p < 0.001). 8‐iso‐PGF2α and 11‐dehydro‐TXB2 were higher in KS than in controls (446.54 pg/mg creatinine vs. 230.00 pg/mg creatinine, p < 0.001 and 1278.36 pg/mg creatinine vs. 595.08 pg/mg creatinine, p = 0.001, respectively) and AC‐50% inversely correlated with 8‐iso‐PGF2α (ρ = −0.548, p < 0.001) and with 11‐dehydro‐TXB2 (ρ = −0.523, p < 0.001). In a linear regression model, KS independently predicted a lower AC‐50% (β = −0.597, p < 0.001) and higher levels of 8‐iso‐PGF2α (β = 0.709, p < 0.001) and 11‐dehydro‐TXB2 (β = 0.605, p < 0.001). In contrast, no correlation has been found between max‐A%, testosterone and estradiol levels in KS. We observed increased platelet reactivity in KS. This might, at least in part, explain the increased thrombotic risk associated with this disease.

Hashimoto's thyroiditis and entero-chromaffin-like cell hyperplasia: Early detection and somatostatin analogue Treatment

Type IIIb polyglandular autoimmune disease comprises autoimmune thyroid disease (HT) and chronic atrophic gastritis (AIG). Hypergastrinemia, secondary to AIG, predisposes to gastric enterochromaffin-like cell (ECL) hyperplasia, a preneoplastic condition. We evaluated the prevalence of AIG, hypergastrinemia and ECL hyperplasia in HT patients. A secondary end-point was to assess the efficacy of treatment with a somatostatin analogue in HT patient with ECL hyperplasia. From 2009 to 2011, 146 HT patients were enrolled in a prospective study. All cases underwent hormonal profile, and parietal cell antibody (PCA), gastrin, and chromogranin A (CgA) serum level assays. Selected patients with elevated gastrin and CgA levels underwent gastro esophageal endoscopy (EGDS). Patients positive for ECL hyperplasia received Octreotide LAR 30 mg/28 days for 12 months. Gastrin and CgA assays were repeated every three months and EGDS after one year. The results show that gastrin and CgA were significantly higher than normal in 17/115 (14.7%) patients. Seven more HT had isolated PCA positivity and in the 17 PCA positive patients histology diagnosed AIG, corpus prevalent, with mild to moderate atrophy. Diffuse ECL hyperplasia of the gastric body was present in three subjects, one of them presenting a type-1 carcinoid. Gastrin and CgA levels were significantly reduced (p<0.01) after 3 months of therapy with a somatostatin analogue and returned to normal after 1 year. ECL hyperplasia regressed in all three patients. We suggest that selected HT patients may need a more accurate surveillance for early signs of gastric EC risk. In the case of altered values of gastrin and in the presence of PCA positivity, EGDS and histology should be performed for an early diagnosis of AIG and treatment of ECL hyperplasia.