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Clinical accuracy of midnight salivary cortisol measured by automated electrochemiluminescence immunoassay method in Cushing's syndrome

Background The diagnosis of Cushings syndrome (CS) represents a challenge for endocrinologists. Several screening tests are used, but none of them seems to be the gold standard for the diagnosis. The aim of this study was to confirm the diagnostic value of salivary cortisol (SC) as a first-level screening test and to evaluate the clinical performance of a electrochemiluminescence immunoassay (ECLIA) method. Methods In 33 patients with a strong clinical suspicion of CS, we evaluated urinary free cortisol, circadian rhythm plasma cortisol (PC) and morning PC after low-dose dexamethasone suppression test (LDDST). At the same sampling times, we evaluated SC analysed by the same automated method. Correlation studies were evaluated by Spearman index (significance P < 0.05). Results On the basis of biochemical results CS was confirmed in 21/33. SC was significantly correlated to PC at 12:00 and 23:00. Thus, we chose 8.3 nmol/L as midnight SC cut-off value with 100% sensitivity and 97.4% specificity. The cut-off chosen after LDDST was 1.7 nmol/L (100% sensitivity and 72% specificity). Conclusion SC assay showed a good clinical accuracy and the ECLIA method can be used in clinical routine to obtain fast results easily.

A case of metastatic struma ovarii treated with 131I therapy: Focus on preservation of fertility and selected review of the literature

Struma ovarii is a rare monodermal ovarian teratoma composed predominantly of mature thyroid tissue. We describe herein the case of a 22-year-old woman who underwent a right salpingo-oophorectomy for struma ovarii at the age of 12 years, who was admitted 8 years later with signs and symptoms of a left pelvic tumor. Laparoscopy detected a left ovarian endometriotic cyst and multiple nodules on the pelvic peritoneum, right lateral abdominal wall, diaphragm, vesical plica and liver. The diagnosis was abdominal and pelvic widespread dissemination of recurrent struma ovarii, with features consistent with the follicular variant of papillary thyroid carcinoma. The patient was treated with a combination of conservative surgery and two 131I administrations (cumulative activity of 350 mCi after dosimetric evaluation). Because of the high degree of hormonogenesis shown by the metastases, the first administration was performed following use of recombinant human (rh) thyroid-stimulating hormone (TSH) to reach adequate TSH levels. To avoid the ‘stunning effect’ and to obtain high-quality scintigraphy, a whole-body scan was performed with 123I after rh-TSH and before the 131I therapy. We also discuss the potential role and the possible benefit of using gonadotropin-releasing hormone analogs and ovarian tissue cryopreservation to preserve fertility in women treated with 131I for pelvic metastases from malignant struma ovarii.

Assessment of salivary free cortisol levels by liquid chromatography with tandem mass spectrometry (LC-MS/MS) in patients treated with mitotane.

OBJECTIVEMitotane is an adrenocytolytic agent used in adrenocortical carcinoma, inducing adrenal insufficiency, requiring replacement treatment. Such therapy is not easy to monitor because of mitotane interference. Salivary cortisol reflects a free fraction of plasma cortisol and may be useful in such patients.DESIGNThe aim of our study was to evaluate salivary cortisol by HPLC coupled to tandem-mass spectrometry (LC-MS/MS) and by an electrochemi-luminescence immunoassay (ECLIA) in patients treated with mitotane. We enrolled 6 patients receiving mitotane and 2 Addison disease patients as negative controls and determined salivary cortisol rhythm. We also determined the salivary cortisol rhythm in 8 healthy subjects. Salivary samples (n=112) were assayed by ECLIA, using Roche Modular E170, and by LC-MS/MS.RESULTSThe mean values obtained by ECLIA were significantly higher than those obtained by LC-MS/MS in the mitotane group (p<0.001). In fact, in the group measured by LC-MS/ MS, we observed several peaks eluting at a retention time different from the cortisol group, presumably due to cortisol-like analogues. In Addison disease, since steroidogenesis is absent, salivary cortisol values measured by the two methods did not show any significant difference (p=0.61).CONCLUSIONSSalivary cortisol measured by LC-MS/MS is a selective method, excluding cortisol analogues accumulating in treated patients. Therefore, LC-MS/MS offers an effective system to monitor replacement therapy in mitotane treated patients.

Retrocardiac Catecholamine-Producing Paraganglioma

Paragangliomas (PGLs) represent about 20% of catecholamine-producing tumors (1). As reported by Erickson et al. (2), they are mostly found in the head and neck, whereas the retrocardial location represents an unusual finding (3–5). A 41-yr-old woman came to our attention because of hypertensive crises associated with headache, sweating, and tachycardia. Pheochromocytoma was suspected on the basis of elevated 24-h urinary normetanephrines of 3,418 g/d, normal value (n.v.) 90–445 (18,662 nmol/d, n.v. 491–2,430) and norepinephrines of 828 g/d, n.v. 12–86 (4,893 nmol/d, n.v. 71–507). With the integrated use of various radiological and nuclear medicine techniques, a 46-mm retrocardial PGL was diagnosed (Figs. 1 and 2). The patient did not have a family history of pheochromocytoma. Genetic testing excluded RET and SDHx subunit (SDHB, SDHC, and SDHD) mutations. After adequate treatment with doxazosin, cardiac surgery was performed in extracorporeal circulation. The surgical approach was through a median sternotomy. The aorta and the pulmonary artery were divided to access the tumor, which was posterior to the left atrium. Macroscopically, the tumor was encapsulated, and there was a plane of cleavage with the surrounding structures. Complete resection was achieved. Histology confirmed a PGL (chromogranin A and synaptophysin positive at immunohistochemistry; Ki 67, 2%). After surgery, the patient was treated with copious hydration, whereas antihypertensive therapy was withdrawn. Blood pressure was maintained in the normal-low range, and no hypertensive crises were documented. Biochemical evaluations performed 3 months after surgery confirmed the remission of the disease: normetanephrines were 112 g/d, n.v. 90 – 445 (611 nmol/d, n.v. 491-2430), and norepinephrines were 20 g/d, n.v. 12– 86 (118 nmol/d, n.v. 71–507).

Mouse models of medullary thyroid cancer and developing new targeted therapies.

Medullary thyroid cancer (MTC) is a rare thyroid tumor arising from neural-crest-derived parafollicular thyroid C cells and accounting for approximately 4% of all thyroid cancers [1]. In about 25% of cases, MTC is caused by inherited germlineactivating mutations of the rearranged during transfection (RET) proto-oncogene which constitutively activates cellular signaling, resulting in persistent cell proliferation and MTC. Therefore, this oncogene represents a key player both in MTC pathogenesis in preclinical models and as molecular target for drugs inhibiting the action of pathogenic oncoproteins.

Stimulating TSH receptor autoantibodies immunoassay: analytical evaluation and clinical performance in Graves’ disease:

Background Thyroid-stimulating hormone (TSH) receptor (TSHR) autoantibodies (TRAbs) are a heterogeneous group of antibodies (Abs) with different functionalities. Among all TRAbs, only the stimulating ones (S-TRAbs) are considered as the pathogenetic marker of Graves’ disease (GD). To date, the methods available for TRAbs testing are based on immunoassays (IMAs) which detect total serum TRAbs or bioassays which are not suitable in clinical practice, even though they discern Abs functionality. The aim of our work was to evaluate the analytical and clinical performance of a very recent IMA (Immulite TSI method), supposed to test only the serum concentration of S-TRAbs, in comparison with a current method for total TRAbs (Roche/Elecsys IMA). Methods We evaluated serum samples of 145 subjects: 46 with untreated (GD), 36 with chronic autoimmune thyroiditis, 3 with atrophic thyroiditis, 10 with multinodular non-toxic goiter and 50 healthy subjects. Results The method showed an optimal analytical sensitivity and high precision levels (LoB: 0.04 UI/L, LoD:0.07 UI/L, LoQ:0.14 UI/L, intra-assay CV: 4.2–5.9%, inter-assay: 4.5–7.2%). By receiver operating characteristics curve analysis, we obtained a value of 0.57 (sensitivity: 98.0%, specificity: 99.9%) as the best cut-off to distinguish GD, apart from four cases. Passing Bablok regression and Bland Altman analysis pointed out a good correlation and agreement with Roche method (R2 = 0.98, slope = 1.03, bias = −2.70). Conclusions The new method presents very promising analytical characteristics and could be adopted in clinical practice for GD diagnosis. Moreover, the test allows to accurately detect very low values of analyte with a further clinical utility in detecting earlier possible relapses.

Ginecomastia, non solo un problema di estetica

La ginecomastia è caratterizzata da un aumento di volume della ghiandola mammaria nel sesso maschile. Questa condizione può essere fisiologica (nascita, infanzia e/o adolescenza, per un’aumentata produzione di ormoni steroidei sessuali) ed in molti casi rappresenta un fenomeno autolimitantesi e che regredisce spontaneamente, senza necessità di terapia. Talvolta la ginecomastia può essere associata a dolore, ipersensibilità del capezzolo, tensione mammaria. Soprattutto nel periodo adolescenziale, questa condizione può creare disagi prevalentemente di tipo psicologico. Essa va distinta dalla pseudoginecomastia (o falsa ginecomastia), tipica dei soggetti sovrappeso/obesi, dovuta all’aumento della componente adiposa a livello della mammella maschile senza un reale aumento della componente ghiandolare.

Fine Needle Aspiration Biopsy

Fine needle aspiration biopsy (FNAB) is a diagnostic test routinely used in the evaluation of thyroid nodule disease and it is crucial to stratify the risk of malignancy. Furthermore, FNAB can also be used to evacuate large cystic nodules and is helpful in patient with thyroid cancer to detect lymph nodes metastases. FNAB is a minimally invasive procedure with low risks and can be usually performed on an outpatient basis by experienced physicians. It is fundamental to obtain an adequate signed consent after the patient has been fully informed. US guidance is routinely used. Biopsy specimens may be obtained with two widely used acquisition methods. The choice between “nonaspiration” and “aspiration” is a matter of operator preference. The only serious contraindication is hemorrhagic diathesis.

Pediatric Cushing's Disease and Pituitary Incidentaloma: Is This a Real Challenge?

Cushings disease (CD) is the most common cause of endogenous Cushings syndrome in children and adolescents and represents a rare cause of short stature. A 14-year-old boy came to our attention for progressive weight gain and short stature. At examination, height was 140 cm (3rd centile) and weight was 37.7 kg (10th centile). Tanner stage was G2, PH 3, testis 3 mL. Hypothyroidism and growth hormone deficiency were excluded. A marked increase of urinary free cortisol, a nonsuppressible serum cortisol after Liddle 1 test, and an elevated ACTH value confirmed the diagnosis of ACTH dependent Cushings syndrome. Pituitary magnetic resonance imaging (MRI) showed a left microadenoma and a right focal area of lesser enhancement. Therefore, bilateral inferior petrosal sinus sampling (BIPSS) with CRH stimulation was performed to obtain an accurate preoperative localization of the adenoma: the interpetrosal sinus ACTH gradient indicated lateralization of ACTH secretion to the left side. The patient underwent transsphenoidal surgery with selective microadenomectomy, with an immediate ACTH decline in the postoperative phase. Histology confirmed the diagnosis of corticotrophic pituitary adenoma. Glucocorticoid replacement therapy was instituted. Clinical examination demonstrated a rapid catch-up growth (10th centile), with a normalization of body mass index and an adequate pubertal development.

Peripheral neuropathy and 46XY gonadal dysgenesis: Confirmation of a heterogeneous entity

Gonadal dysgenesis (GD) is a sexual differentiation disorder haracterized by a male karyotype (46,XY) and a female phenotype. his disorder, in about 20% of cases, is caused by point mutations r micro-deletions in the SRY (sex determining region Y) gene. Four ases of association between 46,XY GD and peripheral neuropathy ave been described [1–4]. In two cases [1,2] sural nerve biopsy evealed minifascicles formation (MF) and in one of these cases a utation in DHH (desert hedgehog homolog) gene was found [1]. his gene plays an important role in male sex determination and is ssential for the structural and functional integrity of the peripheral erve. No mutations of DHH were found in the other reported cases 2–4]. Herein we described clinical, electrophysiological, pathologcal and genetic findings of a further patient with GD and peripheral europathy in which no mutations of DHH gene were detected.