Classification of follicular cell tumors of the thyroid gland: analysis involving Japanese patients from one institute.

Prognostic analyses of thyroid carcinomas of follicular cell origin were carried out on patients treated at Kuma Hospital, Kobe, Japan. A new histopathological classification based on the prognostic evidence is proposed in this study, and it is applicable to the patients treated curatively. Major histological types of papillary carcinoma, follicular carcinoma and poorly differentiated carcinoma were combined into one single entity of follicular cell adenocarcinoma because (i) they have the same cell origin (follicular cell); (ii) clear-cut separation of papillary and follicular carcinoma is not always possible, and 10 year cause-specific survival was essentially similar when the patients were treated curatively; and (iii) poorly differentiated carcinoma usually has a background of either papillary or follicular carcinoma. This adenocarcinoma together with undifferentiated carcinoma was stratified into four prognostic groups using pure morphological criteria of the degree of cellular differentiation and histological grade. They are termed well-differentiated adenocarcinoma, moderately differentiated adenocarcinoma, poorly differentiated carcinoma and undifferentiated carcinoma of the thyroid. The 10 year disease-free survival rates were 86.3-93.1%, 65.4-78.7%, and 43.0-53.8%, and 0%, respectively. The 10 year cause-specific survival rates were 97.2-100%, 91.5-97.4%, and 71.2-80.0%, and 0%, respectively.

A novel homozygous missense mutation of the dual oxidase 2 (DUOX2) gene in an adult patient with large goiter.

OBJECTIVE: To describe the first adult case of large goiter associated with a novel R1110Q mutation in the dual oxidase 2 (DUOX2) gene. She was initially euthyroid, and developed hypothyroidism later in her forties. DUOX2 is an essential enzyme in iodine organification of thyroid hormone biosynthesis. Only infant cases of congenital hypothyroidism due to mutations of the DUOX2 gene have been reported. Biallelic mutation of DUOX2 is thought to lead to total iodine organification defect. PATIENTS AND MEASUREMENT: This 57-year-old woman became first aware of goiter around the age of 20 years. Since the goiter had enlarged gradually, she consulted us at the age of 32 years. Goiter was soft, and thyroid function was normal. Antithyroid antibodies were negative. Both physical and mental development was normal. Three of her nine siblings and her mother had large goiters. At the age of 44 years, thyroid function demonstrated subclinical hypothyroidism. She started to take levo-thyroxine at a dose of 100 mug/day to reduce goiter. At the age of 56 years, goiter size remained the same. The perchlorate discharge rate was 72.8%, suggesting partial iodine organification defect. Thus, thyroid peroxidase (TPO) gene and DUOX2 gene were analyzed. RESULTS: There was no mutation in the TPO gene, but a novel homozygous mutation (R1110Q) in the DUOX2 gene was identified. The same heterozygous mutation was detected in her two sons and two grandchildren. This mutation was not detected in 104 control alleles and was located at a site differing from any other reported mutations in the DUOX2 gene. CONCLUSIONS: This homozygous missense mutation can be associated with thyroid dysfunction and goiter formation of an enlarged thyroid gland.

Effect of levo-thyroxine replacement on non-high-density lipoprotein cholesterol in hypothyroid patients.

CONTEXT: Recently, non-high-density lipoprotein cholesterol (non-HDL-C), a measure of total cholesterol minus HDL-C, has emerged as a predictor of cardiovascular disease. OBJECTIVE: We evaluated the effect of L-T4 replacement on non-HDL-C levels in patients with primary hypothyroidism. METHODS: Thirteen patients with overt hypothyroidism and 26 patients with subclinical hypothyroidism participated in the study. The lipid profiles, including non-HDL-C, were measured in patients with hypothyroidism before and 3 months after L-T4 replacement was started. RESULTS: After L-T4 replacement, the serum concentrations of all lipoproteins, exclusive of lipoprotein (a) [Lp(a)], were significantly decreased in patients with overt hypothyroidism. In patients with subclinical hypothyroidism, the serum concentrations of total cholesterol, non-HDL-C, remnant-like particle cholesterol, and apolipoprotein B (Apo B) were significantly decreased, whereas no significant changes in the serum concentrations of low-density lipoprotein cholesterol, HDL-C, triglycerides, apolipoprotein A-I, and Lp(a) were observed. In all 39 patients, the reduction in the non-HDL-C levels correlated with the reduction in the low-density lipoprotein cholesterol, remnant-like particle cholesterol, and Apo B levels. However, the reduction in the non-HDL-C levels did not correlate with the reduction in the HDL-C, Lp(a), and apolipoprotein A-I levels. CONCLUSIONS: This study is the first to show that L-T4 replacement may reduce serum concentrations of non-HDL-C in patients with hypothyroidism. The study also suggests that such altered serum concentrations of non-HDL-C in hypothyroidism may be related to the disturbed metabolism of low-density lipoprotein, remnant lipoprotein, and Apo B.

Long-term follow-up for patients with papillary thyroid carcinoma treated as benign nodules.

BACKGROUND: The recent prevalence of ultrasonography and fine-needle aspiration biopsy (FNAB) has facilitated the detection and diagnosis of papillary thyroid carcinoma. However, there are still cases that are preoperatively misdiagnosed and treated as benign nodules because ultrasonographic and FNAB findings do not provide sufficient evidence for a malignant diagnosis. In this study, we investigated the clinical outcomes of patients with papillary carcinoma that had not been recognized preoperatively. PATIENTS AND METHODS: We investigated the prognoses of 56 patients with papillary carcinoma who underwent thyroidectomy without node dissection under a diagnosis of benign nodules. RESULTS: None of the patients underwent further surgery such as completion total thyroidectomy and node dissection after the pathological diagnosis of papillary carcinoma was established. However, to date, only 3 patients (5.3%) showed recurrence 116, 133 and 148 months after the initial surgery, respectively. Two patients showed recurrence in the remnant thyroid and one showed recurrence in the bone. None of the patients have died of thyroid carcinoma. CONCLUSION: Papillary carcinomas misdiagnosed as benign nodules on ultrasonography and FNAB are indolent and very slow-growing. Immediate further surgery is not needed for such cases, even if they were resected as benign nodules at the initial surgery.

S100A10 expression in thyroid neoplasms originating from the follicular epithelium: contribution to the aggressive characteristic of anaplastic carcinoma.

BACKGROUND: S100A10, a member of the S100 family, forms a heterotetramer with annexin IIH and promotes carcinoma invasion and metastasis by plasminogen activation. In this study, S100A10 and annexin II expression in thyroid neoplasms were demonstrated. PATIENTS AND METHODS: The expression levels of S100A10 and annexin II in 193 thyroid neoplasms were immunohistochemically investigated. RESULTS: S10A10 and annexin II were not expressed in normal follicular cells or any follicular adenomas. Cells stained positively in 14.6% and 20.8% of follicular carcinomas for S100A10 and annexin II, respectively, but their expression levels were always low. S100A10 and annexin II were expressed in all papillary carcinomas, but 88.2% and 82.8% ofpapillary carcinomas were classified in the low group. These expression levels were not linked to any clinicopathological features. S100S10 and annexin II were also expressed in all anaplastic carcinomas, with 83.3% of these lesions were classified in the high group. CONCLUSION: These findings suggest that S100A10 and annexin II contribute to the aggressive characteristics of anaplastic carcinoma, while playing a constitutive role in papillary carcinoma.

A novel thyrotropin receptor germline mutation (Asp617Tyr) causing hereditary hyperthyroidism.

Constitutively activating germline mutations of the thyrotropin receptor (TSHR) gene have been identified as a molecular cause of hereditary nonautoimmune hyperthyroidism. We describe here a Japanese kindred with two affected individuals who showed overt hyperthyroidism and mild goiter in the absence of TSHR antibodies. A novel heterozygous germline point mutation, identified in both individuals, resulted in an amino acid substitution of aspartic acid for tyrosine at codon 617 (Asp617Tyr) in the third intracellular loop of the TSHR. Screening of 7 additional family members led to the identification of the same mutation in 4 relatives: 1 had undergone thyroidectomy due to hyperthyroidism but 3 were asymptomatic with subclinical hyperthyroidism. In vitro functional studies of the Asp617Tyr TSHR demonstrated a constitutive activation of the cyclic adenosine monophosphate pathway, but not of the inositol phosphate cascade, with data similar to those of Asp619Gly, the first constitutively activating mutant TSHR identified. Treatment with inorganic iodine for 7 months successfully relieved all symptoms of hyperthyroidism in both patients.

Haplotype analysis reveals founder effects of thyroglobulin gene mutations C1058R and C1977S in Japan.

CONTEXT: Thyroglobulin (Tg) mutations were previously believed to be rare, resulting in congenital goitrous hypothyroidism. However, an increasing number of patients with Tg mutations, who are euthyroid to mildly hypothyroid, have been identified in Japan. OBJECTIVES: The purpose of this study was to investigate whether the three frequently found Tg mutations, namely C1058R, C1245R, and C1977S, were caused by a founder effect. RESULTS: We found 26 different mutations within the Tg gene in 52 patients from 41 families. Thirty-five patients were homozygous for the mutations, whereas the others were compound heterozygous. The occurrence of Tg mutation within the general Japanese population is one in 67,000. Patients with the C1245R mutation were found throughout Japan, whereas those with the C1058R mutation were confined to a small village on a southern island, and those with the C1977S mutation were restricted to a city. The eight patients with the C1058R mutation and the seven patients with the C1977S mutation all showed the same combinations of 18 single-nucleotide polymorphisms in the coding region of the Tg gene, which would appear in one in 810 million and one in 37 billion, respectively, control subjects. CONCLUSIONS: The frequently found mutations, C1058R and C1977S, were caused by founder effects. This result suggests that Tg mutations may provide a genetic basis for the cause of familial euthyroid goiter.

Coexistent anaplastic and differentiated thyroid carcinoma: an immunohistochemical study.

The aim of the present study was to clarify the underlying molecules that might contribute to the highly aggressive behavior of anaplastic thyroid carcinoma. We selected 5 cases of anaplastic thyroid carcinoma that had a differentiated area to determine differences in the molecules of undifferentiated and differentiated cancer cells. We immunohistochemically examined the localization of nuclear antigen (Ki-67), proliferating cell nuclear antigen (PCNA), p53, apoptotic protease-activating factor-1 (Apaf-1), CD26, galectin-3, E-cadherin, and CD147. We found increased Ki-67, PCNA, and p53 labeling indices; decreased levels of Apaf-1, CD26, galectin-3, and E-cadherin; and overexpression of CD147 in the undifferentiated area compared with the differentiated area. These findings indicate high proliferative properties, suppression of apoptosis, disruption of cell-cell interaction, and induction of matrix metalloproteinases in the undifferentiated areas. Thus the molecules examined might be useful for evaluating the aggressive nature of this tumor and the prognosis.

Decreased expression of tumor protein p53-induced nuclear protein 1 (TP53INP1) in breast carcinoma.

BACKGROUND: Tumor protein p53-induced nuclear protein 1 (TP53INP1) is a stress-induced protein and plays a role in cell cycle arrest and p53-mediated apoptosis. In this study, TP53INP1 expression in human breast carcinoma was investigated. MATERIALS AND METHODS: TP53INP1 and aberrant p53 expression were investigated immunohistochemically in 81 cases of breast carcinoma. RESULTS: Diffuse and intense TP53INP1 expression was observed in the normal mammary gland. Decreased TP53INP1 expression was found in 45 cases (55.6%) of breast carcinoma. The TP53INP1 expression level was inversely linked to tumor size, positive lymph node metastasis, high histological grade and aberrant p53 expression. CONCLUSION: Decreased expression of TP53INP1 is involved in breast carcinoma progression.

Inverse relationships between the expression of MMP-7 and MMP-11 and predictors of poor prognosis of papillary thyroid carcinoma.

AIMS: Matrix metalloproteinases (MMPs) have various functions that play roles in carcinoma development. In this study, we investigated the expression of two representative MMPs, MMP-7 and MMP-11, in papillary thyroid carcinomas. METHODS: We immunohistochemically investigated the expression of these MMPs in 196 cases of papillary carcinoma. RESULTS: A high level of MMP-7 expression was observed in 56 cases (28.3%). The expression level was significantly decreased in cases showing large tumour, N positivity, large pT and poor differentiation. MMP-11 expression was high in 119 cases (60.1%). The expression level was inversely related to tumour size, N factor, pT factor, pN factor, extrathyroid extension, and poor differentiation. CONCLUSIONS: In contrast to other MMPs, MMP-7 and MMP-11 are inversely linked to aggressive characteristics of papillary thyroid carcinoma and their down-regulations may even be a marker of poor prognosis in patients.

High level of tumour protein p53-induced nuclear protein 1 (TP53INP1) expression in anaplastic carcinoma of the thyroid.

AIMS: Tumour protein p53-induced nuclear protein 1 (TP531NP1) is a stress-induced protein and plays a role in cell cycle arrest and p53-mediated apoptosis. In this study, we investigated TP531NP1 expression in human thyroid neoplasms. METHODS: We immunohistochemically investigated TP531NP1 in 197 cases of various thyroid neoplasms. RESULTS: Normal follicles did not express TP531NP1. All 39 (20 minimally invasive and 19 widely invasive) follicular carcinomas and 20 adenomas were negative for or expressed only low levels of TP531NP1 except for one widely invasive follicular carcinoma. Of 100 papillary carcinomas, only four (4%) expressed high levels of TP531NP1, and the remaining 96 (96%) were classified into the low group. There were no significant relationships between TP531NP1 expression and clinicopathological features of papillary carcinoma. However, 36 of the 38 (94.7%) anaplastic carcinomas expressed high levels of TP531NP1 and the incidence was significantly higher (p<0.0001) than that in other neoplasms. CONCLUSIONS: These findings suggest that TP531NP1 plays a significant role in the progression of anaplastic carcinoma or contributes to anaplastic transformation from papillary or follicular carcinoma, which is in sharp contrast to findings in previous in vitro and in vivo studies.

Delta Np73 expression in thyroid neoplasms originating from follicular cells.

AIMS: p73, a homologue of p53, is known as a negative regulator of tumour progression. However, delta Np73, an isoform of p73 lacking the NH2-terminal transactivation domain plays an oncogenic role by interfering with the activity of p53 and TA (full-length transactivating isoforms) p73. In this study, we investigated the expression of delta Np73 in human thyroid neoplasms originating from follicular cells. METHODS: We immunohistochemically investigated delta Np73 expression in 223 thyroid neoplasms. Delta Np73 expression level was evaluated as the sum of positivity score and intensity score. RESULTS: Normal follicular cells did not express delta Np73, but 27.3% of follicular adenoma, 85.4% of follicular carcinoma, 99.2% of papillary carcinoma, and 95.7% of anaplastic carcinoma were positive for the transcript. Delta Np73 expression level did not differ between widely invasive and minimally invasive follicular carcinomas. In papillary carcinoma, the level was inversely linked to tumour size, extrathyroid extension, and clinically apparent metastasis. Furthermore, in anaplastic carcinoma, delta Np73 expression level was significantly lower than that in papillary carcinoma. CONCLUSIONS: Our findings indicate that delta Np73 plays a role predominantly in the early phase of papillary carcinoma progression.

Thyrotoxicosis caused by weight-reducing herbal medicines.

The weight-reducing herbal medicines "Dream Shape" and "Ever Youth" became available in Japan in 2000. Herein, we describe 12 patients who developed thyrotoxicosis after taking them. The thyroid hormone content of 1 capsule or tablet of herbal medicine, measured following Pronase digestion and ethanol extraction, was approximately 1 mug of triiodothyronine and 3 to 4 mug of thyroxine. Two of us took 10 capsules or tablets of Dream Shape or Ever Youth, and changes in thyroid hormone levels were observed during the first 24 hours. Serum free triiodothyronine levels began to rise 2 hours after ingestion and reached peak levels at 4 to 8 hours; changes in free thyroxine and thyrotropin levels were small during the first 24 hours. Similar herbal medicines may have been distributed to other countries via the Internet. Resultant factitious thyrotoxicosis can create diagnostic and therapeutic confusion, particularly in patients with thyroid disease.

Detection of monoclonality of the immunoglobulin heavy chain gene in thyroid malignant lymphoma by vectorette polymerase chain reaction.

Distinguishing between thyroid malignant lymphoma and lymphocytic thyroiditis (Hashimoto's thyroiditis) is quite difficult and problematic. B cell lymphomas display clonal Ig heavy-chain (IgH) gene rearrangement, and Southern blot hybridization (SBH) is often used for detection of the monoclonality of the IgH gene. However, SBH is often problematic because it requires a large volume of samples. We examined the efficiency in detecting the monoclonality of IgH gene in thyroid malignant lymphomas by vectorette PCR, which we started with only 200 ng of genomic DNA. Monoclonality was detected in 36 of 47 (76.6%) malignant lymphomas, whereas it was not detected in 10 samples of tissue of Hashimoto's thyroiditis. The sensitivity was almost the same as that with SBH in which monoclonality was detected in 33 of 45 (73.3%) malignant lymphomas. These results suggest that vectorette PCR may be a substitute for SBH, and because it requires only a small volume of samples, it may be used in the analysis of aspiration biopsies.

Decreased relative expression level of trefoil factor 3 mRNA to galectin-3 mRNA distinguishes thyroid follicular carcinoma from adenoma.

The expression level of trefoil factor 3 (TFF3) mRNA is a marker for distinguishing thyroid follicular adenomas from carcinomas. However, when measuring the expression level of TFF3 mRNA in fine needle aspiration biopsies, an appropriate internal control mRNA, of which expression is restricted in thyroid epithelial--derived cells, is necessary, since they are often contaminated with a considerable number of blood cells, which do not express TFF3 mRNA. In this study, we evaluated the efficiency of molecular-based diagnosis of thyroid follicular carcinoma by measuring the relative expression of TFF3 mRNA by real-time quantitative reverse transcription-polymerase chain reaction (RT-PCR) using galectin-3 mRNA as an internal control. The TFF3/galectin-3 mRNA ratio (T/G ratio) was measured in 54 follicular adenomas and 29 follicular carcinomas. It was markedly decreased in 7 follicular carcinomas of widely invasive type and with evident distant metastases. When the cutoff point was set at 16.0 by a receiver operator characteristic curve, the TG ratio showed good agreement with the pathological diagnosis [kappa=0.55; 95% confidence interval (CI), 0.34-0.77]. This agreement was better when the pathologically questionable cases were excluded (kappa=0.72; 95% CI, 0.49-0.95). Quantification of the T/G ratio may be a useful tool for the distinction between follicular adenomas and carcinomas, which is the most difficult in thyroid pathology.

Phosphorylation and inactivation of Tob contributes to the progression of papillary carcinoma of the thyroid.

Tob, a member of the Tob/BTG family, is a novel anti-proliferative protein, but it becomes inactive when phosphorylated. In this study, we investigated whether Tob is phosphorylated and inactive in various thyroid neoplasms in order to elucidate how this event plays a role in their progression. Tob phosphorylation was only occasionally seen in normal follicular cells. A high level of Tob phosphorylation was observed in 42.1% of follicular adenoma, 14.3% of follicular carcinoma. In papillary carcinoma, the Tob phosphorylation level was elevated more frequently than that in follicular carcinoma, and 39.7% of specimens were classified in the high group. Tob phosphorylation level in papillary carcinoma was directly linked to tumor size, lymph node metastasis, extrathyroid extension and the presence of poorly differentiated lesion. In anaplastic carcinoma, surprisingly, Tob phosphorylation was not observed in any cases, but the deficiency of Tob expression was also observed in all these cases. These results suggest that (1) Tob phosphorylation contributes to the progression of papillary carcinoma especially in the later phase through cancellation of its anti-proliferative function, and (2) the deficiency of Tob expression is attributable to the lack of Tob phosphorylation in anaplastic carcinoma.

Expression of cdc25B and cdc25A in medullary thyroid carcinoma: cdc25B expression level predicts a poor prognosis.

Cdc25B and cdc25A phosphatases are prominent stimulators of cell cycle progression and have been suggested to play oncogenic roles. In this study, we immunohistochemically investigated the expression of these phosphatases in medullary thyroid carcinoma. Cdc25B was positive in 35.8% of cases examined. Its positivity was linked only to patient age. However, patients with cdc25B-positive tumors showed a significantly worse disease-free survival rate (P=0.0210) than those with cdc25B-negative tumors. Cdc25A was positive in only 17.2% of cases and was not related to clinicopathological parameters or prognosis. These findings suggest that cdc25B can be regarded as having prognostic significance and as a novel marker of biologically aggressive characteristics in this carcinoma.

Successful use of iodine and levothyroxine to treat Graves' disease in a pregnant patient with allergy to antithyroid drugs and high thyrotropin-binding inhibitor immunoglobulin after radioiodine therapy.

High titer of thyrotropin-binding inhibitor immunoglobulin (TBII) in patients with Graves' disease can cause fetal hyperthyroidism during pregnancy. Prevention of fetal hyperthyroidism by administration of antithyroid drug (ATD) and levothyroxine (LT(4)) to pregnant patients who previously received ablative therapy has been reported. We administered iodine and LT(4) to a patient during gestation, because she had a severe adverse reaction to ATD. Although gestation proceeded normally, the infant showed transient neonatal hyperthyroidism right after birth. We believe that the fetus would have developed hyperthyroidism if we had not administered iodine to the mother. Administration of iodine and LT(4) to a pregnant patient with Graves' disease showing a high TBII after ablative therapy should be considered in rare patients with allergy to ATD.

Acute suppurative thyroiditis after fine-needle aspiration causing thyrotoxicosis.

A case of thyrotoxicosis caused by acute suppurative thyroiditis after repeated fine-needle aspiration (FNA) is described. A 39-year-old woman with atopic dermatitis showed rapid enlargement of a left thyroid cyst after a third FNA. She had a high fever, painful swelling of the left thyroid, and elevated thyroid hormone levels. Ultrasonography revealed abscess formation in the left thyroid cyst. The cytologic examination of an FNA specimen showed abundant neutrophils, and culture of the aspirate yielded Staphylococcus aureus. Because antibiotic treatment for 1 month failed to improve the inflammatory findings, the patient subsequently underwent left thyroid lobectomy, which resulted in the normalization of thyroid function and the resolution of inflammation. Thyroid infection had possibly been induced by needle-track seeding, because atopic skin favors colonization by S. aureus because of local immunologic deficiency. FNA is a useful and safe technique for aspirating fluid from thyroid cysts, but special care is required in patients with atopic dermatatis to avoid bacterial infection.

Transcutaneous iodine absorption in adult patients with thyroid cancer disinfected with povidone-iodine at operation.

Povidone-iodine is used as disinfection in patients undergoing many kinds of operations. Several cases of thyroid dysfunction induced by transcutaneous absorption of povidone-iodine have been reported in small infants. However, transcutaneous absorption was not clearly reported in adults. The aim of this study was to assess transcutaneous absorption of iodine in patients who received single topical application with povidoneiodine and serial changes of urinary iodine excretion under the condition with a simple iodine-restricted diet in Japan, an iodine-sufficient area. Sixty-eight patients with thyroid carcinoma undergoing total thyroidectomy received single skin disinfection with either povidone-iodine (group A; n = 47) or chlohexidine gluconate, a noniodine containing biguanide (group B; n = 21). In group A, urinary iodine excretion on the first day after operation increased up to 7 times that of the preoperative value. The amounts of urinary iodine correlated positively with operating time. Increased urinary iodine, however, returned to preoperative values on the third or fifth day after operation. In group B, there was no increase in urinary iodine excretion and urinary iodine excretion was ranged from 54 to 193 microg/g of creatinine on the third day of operation. In conclusion, a large amount of povidone-iodine was absorbed through healthy skin even in adults. This may possibly interfere with scintigraphy or radioactive iodine treatment, or cause thyroid disinfection in susceptible patients.