A study of recurrence and death from papillary thyroid cancer with 27 years of median follow-up.

BACKGROUND: Although recurrence and death can occur in patients with papillary thyroid cancer (PTC) several years after being diagnosed, the necessary duration of follow-up for these patients remains unclear. METHODS: This was a single-institution, retrospective review of 269 patients with PTC. Cox proportional hazards model and Kaplan-Meier curves were used to identify risk factors for recurrence and death. Risk predictors included age, sex, radiation exposure history, extent of operation, radioactive iodine treatment, follicular variant of PTC (FVPTC), extrathyroidal invasion, multifocality, TNM status, and stage. RESULTS: Median follow-up was 27 years. Of 269 patients, 180 (66%) were female, and 196 (73%) were ≤45 years of age. Recurrence and cancer-specific death rates were 28% and 9%, respectively. Time to recurrence (±SD) was 8.1 (± 8.3) years and to cancer-specific death was 9.0 (± 11.0) years; however, 11% of recurrences and 17% of deaths occurred after 20 years. Risk factors for recurrence were older age, FVPTC, T4 tumors, cervical lymph node involvement, metastases, and stage ≥ 4a. Predictors of death from PTC were older age, metastases, and stage ≥ 3. CONCLUSION: Both recurrences and death from PTC can occur more than 30 years after being treated, thus lifelong follow-up of patients with PTC is necessary.

Familial variation in episode frequency in bipolar affective disorder.

OBJECTIVE: Bipolar affective disorder is a familial illness characterized by recurrent episodes of mania and depression, but little is known about the familial nature of episode recurrence or its associated clinical features. The authors analyzed the recurrence frequency of affective episodes (episode frequency), along with associated clinical and demographic variables, in families with at least three members with a major affective disorder. METHOD: Members of 86 families ascertained through probands with bipolar affective disorder who had two or more first-degree relatives with a major affective disorder were interviewed by psychiatrists and assigned an all-sources diagnosis. Data for 407 subjects with a major affective disorder were analyzed. Episode frequency was estimated as the number of episodes of major depression, mania, and hypomania per year of illness. RESULTS: Episode frequency was smoothly distributed over the range of 0.02-20.2 episodes/year. Episode frequency was significantly correlated among relatives (r=0.56, p<0.004). Earlier age at onset, bipolar II disorder, hallucinations or delusions, alcoholism, and suicidal behavior were all more prevalent in the highest than in the lowest quartiles of episode frequency. Female gender and recurrent major depression were more prevalent in the lowest quartile. Panic disorder, substance abuse, and thyroid disease were all unrelated to episode frequency. Subjects with DSM-IV rapid cycling did not differ from other affected subjects for most of the variables tested. CONCLUSIONS: Episode frequency is a highly familial trait in bipolar affective disorder, associated with several indicators of severity, and may be useful in defining clinical subtypes of bipolar affective disorder with greater genetic liability. DSM-IV rapid cycling was not supported by these data as the best predictor of familiality or severity.

Viral mediated gene therapy for the management of metastatic thyroid carcinoma.

Thyroid cancers are of special interest in gene therapy, since it is possible to direct gene expression specifically to the thyroid derived cells by using promoters with limited expression, and secondly, because destruction of the normal tissue by introduction of a toxic gene would have no important adverse effect. A variety of methods for gene delivery are available. Adenovirus is a well studied and widely used vector and is useful for targeting genes because it infects many cell types, including differentiated thyroid cancer and medullary thyroid cancer cells. Strategies that have been employed successfully in animal models include adenoviral mediated expression of thymidine kinase under control of a thyroglobulin promoter, similarly expression of the cytokine IL-2, and perhaps most effectively, expression of IL-12. Combinations of vectors expressing thymidine kinase and IL-12 under control of a strong but non-tissue specific CMV promoter effectively destroy a model anaplastic thyroid tumor in Wistar rats. Replicating adenoviruses, in contrast to the non-replicating form commonly used, have also been used to infect tumor cells and express P-53 protein, leading to apoptosis of tumor cells. Medullary thyroid cancer provides a target much like differentiated thyroid cancer because it is possible to address gene expression specifically to the medullary thyroid cells by the use of a modified calcitonin promoter. Animal models of this tumor are available in a mouse and Wag/Rij rat model. In the latter system, treatment with adenoviruses expressing genes under control of the modified calcitonin promoter and expressing thymidine kinase or IL-12 leads to destruction of growing medullary thyroid cancer tumors, destroy distant tumors after injection in one tumor, and cause induction of long lasting immunity to subsequent tumor development in the animals. There are many ongoing studies of gene therapy in humans using various genes such as thymidine kinase, IL-2, and now IL-12. Although none of these trials to date shows complete eradication of metastatic tumors in humans, there are reports showing distinctly that the viral mediated gene therapy approach can effectively destroy human tumors after in vivo administration. Tumors that have been treated include melanomas, glioblastomas, breast tumors, and prostate carcinomas. In the latter studies, it has been possible to show objective responses documented by a fall in serum PSA levels of 50% or more that are sustained for prolonged periods. Gene therapy using the adenoviral vectors appears to be safe in studies reported so far. A problem is prior or induced immunity to adenoviral proteins, but direct injection of the vector into a tumor nodule largely circumvents this problem. New genes and new vectors under development will certainly lead to the established use of these methods in the therapy of human thyroid carcinomas in the near future.

Adenovirus-mediated tumor-specific combined gene therapy using Herpes simplex virus thymidine/ganciclovir system and murine interleukin-12 induces effective antitumor activity against medullary thyroid carcinoma.

The present treatment of advanced and metastatic medullary thyroid carcinoma (MTC) is unsatisfactory. Tissue-specific cancer gene therapy is a novel alternative approach. We developed a recombinant adenovirus expressing Herpes simplex type 1 thymidine kinase (HSVtk) driven by a modified CALC-I promoter TCP (AdTCPtk). Infection with this virus showed efficient cytotoxic effect on MTC cell lines (rMTC and TT cells) after treatment with ganciclovir (GCV) in vitro. In a syngenic WAG/Rij rat model, the combination of AdTCPtk/GCV treatment with administration of murine interleukin-12 (mIL-12) expressing adenovirus under control of TCP (AdTCPmIL-12) resulted in effective growth suppression of tumor at the treated site and also at a distant untreated site, in comparison to treatment with AdTCPtk/GCV or AdTCPmIL-12 alone. Moreover, intravenous injection of AdTCPtk, or AdTCPtk+AdTCPmIL-12, followed by administration of GCV, did not cause evident toxicity after administration of GCV. These results indicate that this combined system can provide an effective therapy for metastatic MTC with minimal toxicity.

Tumor-specific gene therapy for undifferentiated thyroid carcinoma utilizing the telomerase reverse transcriptase promoter.

A tumor-specific targeting system for cancer gene therapy was studied using the human telomerase reverse transcriptase (hTERT) promoter. Telomerase activity is increased in most tumors but not detected in most normal cells. We developed the recombinant adenovirus, carrying human herpes simplex virus thymidine kinase gene under the control of the hTERT promoter (AdhTERTtk) to obtain restricted expression of a suicide gene only in tumor cells. We found that transcriptional activity of hTERT was 2- to 9-fold higher in undifferentiated thyroid carcinoma cell lines than that of the Simian virus 40 promoter in transient transfection assay. Undifferentiated thyroid carcinoma cell lines were infected with AdhTERTtk, and sensitivity to ganciclovir (GCV) was analyzed. Cell viability was decreased in a GCV dose-dependent manner after treatment with AdhTERTtk/GCV. The cell-killing ability of AdhTERTtk in all thyroid or nonthyroid carcinoma cell lines tested was similar to AdCMVtk, which carries herpes simplex virus thymidine kinase gene driven by the cytomegalovirus promoter. However, normal cell lines were largely unaffected by AdhTERTtk/GCV, whereas these cells were also sensitive to GCV after infection with AdCMVtk. A xenograft model was established by transplanting human differentiated or undifferentiated thyroid carcinoma cells into Balb-C nude mice. The injections of AdhTERTtk into tumors and ip administration of GCV showed significant inhibition of tumor growth, similar to AdCMVtk/GCV treatment. Systemic administrations of adenovirus and GCV to normal rats demonstrated remarkable increase of serum liver transaminase levels and severe hepatic damages in pathological examinations in AdCMVtk-injected rats but not in the AdhTERTtk group. These results indicate that the AdhTERTtk/GCV system is a promising therapy for undifferentiated thyroid carcinoma, which is one of the most malignant tumors, without damage to normal tissues.

Painful Hashimoto's thyroiditis as an indication for thyroidectomy: clinical characteristics and outcome in seven patients.

Patients with chronic lymphocytic thyroiditis, or Hashimoto's thyroiditis (HT), usually present with goiter, hypothyroidism, or both. Thyroid pain and tenderness are rare and suggest an alternative diagnosis of subacute granulomatous thyroiditis or other forms of thyroiditis. We report seven patients with painful HT who had temporary or no relief from L-thyroxine replacement or steroid treatment and required surgical intervention for unremitting pain. Antithyroid antibodies were elevated in all except one patient, in whom fine-needle aspiration and surgical pathology were diagnostic of HT. All patients underwent either a subtotal or near-total thyroidectomy. Pathology showed lymphocytic thyroiditis in all specimens, with varying degrees of fibrosis. Giant cells and granulomas characteristic of subacute thyroiditis were not seen. After surgery, four patients obtained total and permanent relief of pain after subtotal (two patients) or near total (two patients) thyroidectomy, whereas one patient had minimal residual discomfort. One patient had relapse of pain, despite adjunct radioiodine ablation. In this patient with documented total thyroid ablation but persistent pain, the overall clinical picture suggested a strong psychological element in her medical problem. In conclusion, thyroidectomy is an uncommon but necessary therapy for patients with painful HT not responding to medical therapy.

Gene therapy of a rat follicular thyroid carcinoma model with adenoviral vectors transducing murine interleukin-12.

Interleukin-12 (IL12) is a heterodimeric cytokine that plays an important role in the development of cellular immunity. We previously reported the antitumor activity of mouse IL12 (mIL12) transduced by adenovirus in a medullary thyroid carcinoma model. In this study, a rat thyroid follicular cancer cell line (RTC-R2) was employed to develop tumors after sc injection in Wistar rats. In five of five animals, RTC-R2 cells infected with mIL12 transducing adenovirus (AdCMVmIL12) in vitro failed to be tumorigenic in vivo in syngenic rats, whereas four of five animals developed tumors after injection of luciferase transducing adenovirus (AdCMVLuc)-infected cells. After intratumoral treatment with AdCMVmIL12 at 1 x 10(9) plaque-forming units per rat, 90% (26/29) of animals bearing small (<100 mm(3)) tumors were apparently cured. Larger tumors treated by injection of AdCMVmIL12 became significantly smaller than AdCMVLuc-treated animals, and growth stabilized. Challenge studies showed that only 3 of 28 animals previously treated and cured with AdCMVmIL12 developed a tumor after sc reinjection of RTC-R2 cells, whereas all animals developed tumors in naïve animals. Thus, AdCMVmIL12-treated animals developed long-term antitumor immunity. We also studied animals with two tumors, injecting virus in one. Tumors regressed at both sites in five of six animals after treatment of one tumor with AdCMVmIL12, and in the sixth animal one site tumor regressed and another tumor continued to grow. In AdCMVLuc-treated animals, both tumors regressed in only one animal, and the reminder continued to grow. To detect toxicity to liver and other tissues after administration of AdCMVmIL2, the vector was administrated intratumorally or iv at the dose of 2 x 10(9) plaque-forming units per rat. No change in behavior was observed in any of the treated animals. Rats were killed at different time after virus administration. An overt increase of spleen size was observed 7 d after infection in all animals treated with AdCMVmIL12. All animals given virus IV had some lymphocyte infiltration in the sinusoids and triads of the liver, whereas AdCMVmIL12 injected intratumorally did not cause this effect. Spleens of some virus-treated animals showed decreased white pulp, with apparently increased hematopoiesis. No specific changes were found in lungs and kidneys. Iv administration of AdCMVmIL12 induced a moderate increase of glutamic-oxalacetic transaminase and glutamic-pyruvic transaminase, whereas AdCMVmIL12 injected intratumorally did not. This study confirms the efficient antitumor activity of an adenovirus expressing mIL12 after in vivo delivery in an animal model and indicates the possibility of application to patients because of the low toxicity.

CTLA-4 AT-repeat polymorphism reduces the inhibitory function of CTLA-4 in Graves' disease.

Graves' disease (GD) is thought to be an autoimmune disease with a strong genetic component. Candidate genes include human leukocyte antigen (HLA) class II genes and CTLA-4. The CTLA-4 gene has a variable length AT-repeat polymorphism in the 3'-untranslated region. We previously found that the AT-repeat of 104 bp or longer was associated with GD. In this study, we categorized patients with GD and normal controls (NC) by genotyping the CTLA-4 AT-repeat and investigated the function of CTLA-4. Peripheral blood mononuclear cells (PBMC) and DNA were prepared from adult Caucasians (NC = 34, GD = 37). Genotypes of the AT-repeat polymorphism were divided into three groups according to their alleles. We related the CTLA-4 polymorphism in each genotype to augmentation of T-cell proliferation induced by a soluble anti-CTLA-4 antibody during incubation with irradiated Epstein-Barr virus (EBV)-transformed B cells. Proliferation of T cells from subjects with the 86/86 bp (shorter) allele was less than T cells from patients with longer alleles. The length of the AT-repeat allele correlated inversely with augmentation of proliferation after CTLA-4 blockade in subjects with GD. The CTLA-4 AT-repeat polymorphism affects the inhibitory function of CTLA-4. The long AT-repeat allele is associated with reduced control of T-cell proliferation and thus contributes to the pathogenesis of GD.

A tandemly repeated thyroglobulin core promoter has potential to enhance efficacy for tissue-specific gene therapy for thyroid carcinomas.

Recombinant adenoviruses, carrying herpes simplex virus thymidine kinase (HSVtk) genes, were developed to evaluate the possibility of tissue-specific gene therapy for thyroid carcinomas. The HSVtk gene was driven by a minimal thyroglobulin (TG) promoter (AdTGtk) and a tandemly repeated minimal TG promoter (Ad2 x TGtk) to obtain thyroid-specific cell killing ability. The transduction of HSVtk genes by infection with Ad2 x TGtk followed by ganciclovir (GCV) treatment showed more powerful cytotoxicity for TG-producing FRTL5 cells, a rat normal thyroid cell line, and FTC-133 cells, a human follicular thyroid carcinoma cell line, than when infected with AdTGtk in vitro. The cell killing ability of Ad2 x TGtk was 10- to 30-fold higher than that of AdTGtk and similar to that of AdCMVtk, which carries HSVtk under the control of CMV promoter. Whereas after treatment with adenovirus/GCV to non-TG-producing cell lines (undifferentiated thyroid carcinoma cell lines and carcinoma cell lines from other tissues), Ad2 x TGtk and AdTGtk needed more than 100-fold concentrated GCV to reach IC(50) compared to AdCMVtk. We confirmed the enhanced efficacy of Ad2 x TGtk for tissue-specific cytotoxicity in vivo. After adenovirus/GCV treatment for FTC-133 tumor-bearing nude mice, Ad2 x TGtk enhanced tumor growth inhibition and survival rates compared to AdTGtk. Tumor growth inhibition and survival rates by Ad2 x TGtk were similar to that by AdCMVtk. Moreover, any toxic effect for rat normal tissues was not revealed after intravenous injections with Ad2 x TGtk and intraperitoneal administrations with GCV in vivo, whereas severe liver damages were observed after treatment with AdCMVtk/GCV. These data indicate a beneficial effect of Ad2 x TGtk for tissue-specific gene therapy for TG-producing thyroid carcinomas without toxicity for normal tissues.

Cell-specific viral gene therapy of a Hurthle cell tumor.

We evaluated the effectiveness of a replication-defective adenovirus-transducing thymidine kinase (TK) gene under the control of the rat Tg (rTg) promoter (AdrTgtk) in therapy of a human Hurthle cancer (XTC-1 cell) in vitro and in vivo. The ganciclovir (GCV) sensitivity of infected XTC-1 cells was assessed in vitro by H(3)-thymidine incorporation assay and Trypan-blue exclusion, and by an in vivo tumor development assay. Proliferation was strongly inhibited by adding GCV into the culture medium of infected cells, but not uninfected cells, proving cell infection and expression of TK in the XTC-1 cells. AdrTgtk, and also viruses that have the noncell-specific cytomegalovirus (CMV) promoter-directing expression of TK (AdCMVtk), or luciferase (AdCMVLuc), were used to transduce XTC-1 cells to evaluate killing effects. After infection with AdCMVtk or AdrTgtk, followed by GCV treatment, 70% of infected cells were killed in the presence of GCV, compared with less than 20% of cells infected by AdCMVLuc and treated with GCV. In vivo toxicity was studied in BALB/c mice. When adenovirus is given iv, liver is the major organ infected. No significant changes of the serum transaminase levels and no histological abnormalities were found in animals treated with AdrTgtk/GCV given iv, compared with control animals. High levels of serum transaminases, lymphocyte infiltration, some Kupffer's cell prominence, and extensive single-cell hepatocyte death were found in AdCMVtk/GCV-treated animals, indicating severe liver damage induced, as expected, by the noncell-specific CMV promoter. XTL-1 cells (2 x 10(6)) were injected sc into BALB/c-severe combined immunodeficient mice (BALB/c-SCID), and the mice developed tumors after 3 wk. After intratumoral injection of AdrTgtk and treatment with GCV, tumors stabilized in 15 of 17 mice within 3 wk, 9 tumors remained stabilized after 5 wk of treatment, and 2 disappeared during observation. In AdCMVLuc/GCV-treated control mice, almost all tumors grew continuously. The average tumor size in AdrTgtk-treated mice was significantly smaller than that of control animals after 2 wk of treatment. Our data confirm the effectiveness and specificity of an adenovirus using rTg promoter to express TK, and support its future application to thyroid cancer gene therapy in humans.

Subclinical Hypothyroidism and Euthyroid Sick Syndrome in Patients with Moderate-to-Severe Congestive Heart Failure.

Thyroid function tests were performed on baseline plasma that had been taken from 34 patients with NYHA Class II or Class III congestive heart failure (CHF). All patients were negative for thyroid disease on history and physical examination and none was taking medication known to alter thyroid metabolism. Analysis of thyroid function revealed abnormalities in 16 of 31 patients. These abnormalities fell into two categories: nine patients had elevated baseline thryroid stimulating hormone (TSH) above the normal limit while only one of these nine had subnormal thyroxine (T(4)) concentrations, suggesting the possibility of subclinical hypothyroidism. Seven patients demonstrated changes consistent with euthyroid sick syndrome (ESS). Weak correlations were observed between age and concentrations of T(4) and tri-iodothyronine (T(3)) and this suggests that changes in thyroid function cannot be explained solely on the basis of age. Although previous studies have demonstrated the presence of ESS in CHF, the present study suggests the possibility of a significant prevalence of subclinical hypothyroidism.