Katia Cioni

The Diagnostic Value of Calcitonin Measurement in Wash-Out Fluid from Fine-Needle Aspiration of Thyroid Nodules in the Diagnosis of Medullary Thyroid Cancer

OBJECTIVES The diagnostic value of calcitonin measurement in fine-needle aspiration biopsy (FNAB) wash-out fluid (Ct-FNAB) for medullary thyroid cancer (MTC) remains to be determined. This prospective study aimed to assess the diagnostic value of Ct-FNAB in thyroid nodules in comparison with basal serum calcitonin (Ct), pentagastrin-stimulated Ct (Pg-sCt), and cytology. METHODS Among patients with goiter addressed with US-FNAB who had an initial clinical suggestion for thyroidectomy, 27 patients with thyroid nodule/s (n = 60) and normal, borderline, or increased Ct fulfilled the criteria for thyroidectomy. All 27 patients (enrolled according to exclusion/inclusion criteria) underwent ultrasonography (US), Ct, Pg-sCt, US-assisted FNAB of each patients nodule for both cytology, and Ct-FNAB before thyroidectomy. RESULTS Ct-FNAB always resulted in >1,000 pg/mL in MTC nodules at histology. For values between 36 and 1,000 pg/mL, MTCs and nodular or micronodular C-cell hyperplasia (CCH) results overlapped. Most of the nodules without MTC and/or CCH had Ct-FNAB ≤ 17 pg/mL. Ct-FNAB diagnostic power was superior to and similar to other diagnostic procedures (Ct, Pg-sCt, and cytology) in identifying both MTC and CCH, and MTC alone, respectively. CONCLUSION The diagnostic power of Ct-FNAB is valuable compared with other routine procedures. Ct-FNAB is highly reliable for the early detection and accurate localization of MTC in thyroid nodules, but it does not differentiate between MTC and CCH. Ct-FNAB is an extremely valuable diagnostic tool, especially considering that other diagnostic procedures do not provide a definitive diagnosis, and it can be included in the clinical work-up of thyroid nodules when MTC is suspected.

Are pre-miR-146a and PTTG1 associated with papillary thyroid cancer?

Papillary thyroid carcinoma (PTC) is the most common endocrine malignancy, with a steadily increasing incidence in the last few decades worldwide. The predisposition to developing this carcinoma by the heterozygous state of rs2910164 within the precursor of the miR-146a has been reported, but recently not confirmed. Interestingly, on the same chromosome, almost 50 kb separate the pre-miR-146a from the pituitary tumor-transforming gene 1 (PTTG1), a proto-oncogene involved in several tumors, including thyroid cancers. In this study, we analyzed, using a case–control design, the genetic association between PTC and the genomic region encompassing pre-miR-146a rs2910164 and PTTG1 rs1862391 and rs2910202. We enrolled 307 affected patients and 206 healthy controls. The possible presence of thyroid nodules in controls was excluded by ultrasonography. All the cases were submitted to single-nucleotide polymorphism (SNP) genotyping of pre-miR-146a and PTTG1, and risk association analyses were carried out. The genotypic and allelic frequencies of pre-miR-146a rs2910164 were not statistically different in the patients and controls, and this SNP was not in linkage disequilibrium with the investigated PTTG1 SNPs. Consistently, meta-analyses, the first including all the affected cases published to date, did not confirm the previously reported association of the heterozygous CG genotype with PTC. The PTTG1 SNPs exhibited the same allelic frequency in the patients and controls and were not associated with the disease. In conclusion, in a well-selected Italian population, neither pre-miR-146a rs2910164 nor PTTG1 rs1862391 and rs2910202 were found to be associated with the risk of developing PTC.

High-Resolution Melting Is a Sensitive, Cost-Effective, Time-Saving Technique for BRAF V600E Detection in Thyroid FNAB Washing Liquid: A Prospective Cohort Study

Objective: The diagnostic accuracy of thyroid fine needle aspiration biopsy (FNAB) can be improved by the combination of cytological and molecular analysis. In this study, washing liquids of FNAB (wFNAB) were tested for the BRAF V600E mutation, using the sensitive and cost-effective technique called high-resolution melting (HRM). The aim was to demonstrate the feasibility of BRAF analysis in wFNAB and its diagnostic utility, combined with cytology. Design: Prospective cohort study. Methods: 481 patients, corresponding to 648 FNAB samples, were subjected to both cytological (on cells smeared onto a glass slide) and molecular analysis (on fluids obtained washing the FNAB needle with 1 ml of saline) of the same aspiration. BRAF V600E analysis was performed by HRM after methodological validation for application to wFNAB (technique sensitivity: 5.4%). Results: The cytological results of the FNAB were: 136 (21%) nondiagnostic (THY1); 415 (64%) benign (THY2); 80 (12.4%) indeterminate (THY3); 9 (1.4%) suspicious for malignancy (THY4); 8 (1.2%) diagnostic of malignancy (THY5). The BRAF V600E mutation was found in 5 THY2, 2 THY3, 6 THY4 and 6 THY5 samples. Papillary carcinoma diagnosis was histologically confirmed in all BRAF+ thyroidectomized patients. BRAF combined with cytology improved the diagnostic value compared to cytology alone in a subgroup of 74 operated patients. Conclusions: HRM was demonstrated to be a feasible method for BRAF analysis in wFNAB. Thanks to its sensitivity and cost-effectiveness, it might be routinely used on a large scale in clinical practice. In perspective, standby wFNAB samples could be analyzed a posteriori in case of indeterminate cytology and/or suspicious findings on ultrasound.

The TRHR Gene Is Associated with Hypothalamo-Pituitary Sensitivity to Levothyroxine

Background: Thyroidectomized patients need variable doses of levothyroxine (LT4) to obtain target thyroid-stimulating hormone (TSH) levels. Individual feedback set-points have been hypothesized and the influence of several genes in the regulation of the pituitary-thyroid axis has been demonstrated. Objectives: We hypothesized that genetic variants of the TRHR gene could be associated with a different hypothalamo-pituitary sensitivity to thyroid hormone feedback. Methods: We retrospectively analyzed 84 thyroidectomized patients with no residual thyroid function and undetectable thyroglobulin levels. Patients were evaluated under LT4 resulting in TSH levels detectable but <0.5 μIU/ml. The two SNPs rs3134105 and rs3110040 were identified as informative markers of the TRHR gene. Genotyping was performed using high-resolution melting technology. Genotype distribution was compared between the patients and 99 euthyroid controls. Results: The selected SNPs were in linkage disequilibrium and only rs3134105 was further considered. A significant difference between the three possible genotypes for rs3134105 was found for TSH (p = 0.04) and free thyroxine (fT4)/TSH ratio (p = 0.02). Moreover, despite similar serum concentrations of free triiodothyronine (fT3) and fT4, carriers of at least one A allele of rs3134105 had significantly lower serum TSH levels (p = 0.01) as well as higher fT3/TSH (p = 0.01) and fT4/TSH ratios (p < 0.01). Conclusions: We demonstrated an association between serum TSH levels and discrete alleles of the TRHR gene in totally thyroidectomized patients under LT4 therapy. Therefore, the TRHR gene seems to be a determinant of hypothalamo-pituitary sensitivity to LT4.

Serum Calcium to Phosphorous (Ca/P) Ratio Is a Simple, Inexpensive, and Accurate Tool in the Diagnosis of Primary Hyperparathyroidism

Primary hyperparathyroidism (PHPT) diagnosis is challenging and is based on serum calcium (Ca) and parathyroid hormone (PTH). Because serum Ca and phosphorous (P) are inversely related in PHPT, we investigated the diagnostic value of the serum Ca/P ratio in the diagnosis of PHPT. We report a single‐center, case‐controlled, retrospective study including 97 patients with documented PHPT and compared them with those of 96 controls (C). The main outcome measures were: serum PTH, 25‐OH vitamin D, Ca, P, albumin, and creatinine. Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of the serum Ca/P ratio were calculated. The results were verified using an independent, anonymous set of data extracted from a laboratory database containing over 900 million entries. A total of 35 (36.1%) PHPT patients had normocalcemic PHPT (NCHPT). Ca and PTH were significantly higher in PHPT than in C (p < 0.0001). P was significantly lower in PHPT than in C (p < 0.0001). The Ca/P ratio was significantly higher in PHPT than in C (p < 0.0001). Receiver‐operating characteristic (ROC) curves analyses identified a cutoff of 2.71 (3.5 if Ca and P are expressed in mg/dL) for Ca/P ratio with a sensitivity and specificity of 86% and 87%, respectively (p < 0.0001), confirmed by the independent, big data approach. In conclusion, Ca/P is a valuable tool for the diagnosis of PHPT and is of superior value compared to serum Ca alone, especially in NCPHT. Because Ca/P is simple, inexpensive, and easily accessible worldwide, this ratio is useful for PHPT diagnosis, especially in laboratory/medical settings relying on limited resources, such as low‐income countries.

Voluminosa cisti paratiroidea cervico-mediastinica di riscontro occasionale in paziente affetto da sindrome di Boerhaave

Un uomo di 67 anni giungeva alla nostra osservazione per riscontro a una TC torace di una voluminosa formazione colloido-cistica, che si approfondava nel mediastino verso sinistra con deviazione tracheale controlaterale. La TC era stata richiesta per controllo post-operatorio dopo terapia chirurgica d’urgenza per sindrome di Boerhaave (rottura completa della parete esofagea in assenza di patologia preesistente che si verifica per un improvviso aumento della pressione intraesofagea, associato a mancato rilassamento dello sfintere esofageo superiore). Una RMN collo-torace confermava la presenza di una raccolta fluida scarsamente vascolarizzata perifericamente e delimitata da esilissima parete di diametro di 60 × 63× 100 mm (Fig. 1). A un successivo controllo ecografico la cisti, interamente anecogena e non vascolarizzata, risultava essere esterna rispetto al tessuto tiroideo, sita inferiormente rispetto al polo inferiore del lobo tiroideo sinistro. Il margine inferiore non era valutabile a causa dell’approfondarsi nel mediastino antero-superiore. L’esame citologico su agoaspirato (eseguito in altra sede) non documentava presenza di cellule e tireoglobulina, calcitonina e paratormone (PTH) risultavano indosabili. Veniva eseguito un successivo agoaspirato presso la nostra Unità Operativa, anche a scopo evacuativo. Venivano aspirati 170 cc di liquido limpido “ad acqua di roccia”, suggestivo per cisti paratiroidea. Al termine dell’agoaspirato la lesione cistica appariva ecograficamente notevolmente ridotta, con diametro di 26,4 × 22,8 mm e interamente sita in regione cervicale. L’esame citologico confermava la natura amorfa del

Biologically active luteinizing hormone (LH) in Klinefelter's syndrome: response to gonadotropin-releasing hormone (GnRH) and effects of testosterone undecanoate.

Summary:  Basal and gonadotropin‐releasing hormone (GnRH)‐stimulated levels of biologically active and immunoreactive LH (bLH and iLH) were measured in six patients with Klinefelters syndrome (KS) (mean age 24.7 years). In the same patients the diurnal rhythm of serum testosterone (T) was investigated (morning values vs. evening values). The results were compared with those obtained in ten normal young men (mean age 29.3 years). Moreover, in one patient with KS we studied the effects of testosterone undecanoate (TU) administration on bLH and iLH basal levels. A sensitive “in vitro” bioassay, based on T production by mechanically dispersed mouse Leydig cells, was employed to assess LH bioactivity. Levels of iLH and T were determined by a double antibody radio‐immunoassay technique. Mean basal levels of bLH and iLH were significantly higher (p < 0.001) in the Klinefelter patients than in normal men, whereas the mean bioactivity to immunoreactivity (b/i) ratio of LH was similar in the two groups. The mean morning T concentration was significantly higher in normal men (p < 0.001) than in the Klinefelter group. The diurnal T rhythm was lost in the patients with KS. In the Klinefelter patients the relative maximum response of bLH to GnRH (bLH Δ %) was significantly lower (p < 0.02) than in the control men. In addition, the b/i ratio of GnRH‐stimulated Lh decreased significantly (p < 0.05) from basal values in the Klinefelter patients, whereas it remained unchanged in the control group. In the patient with KS treated with androgen replacement therapy, TU decreased iLH serum levels more than bLH concentrations, thereby increasing the b/i ratio of basally secreted LH.