81st Annual Meeting of the American Thyroid Association MEETING ABSTRACTS & AGENDA

1 Pediatrics, The Hospital for Sick Children, Toronto, ON, Canada 2 Psychology, University of Toronto, Toronto, ON, Canada 3 Neuropsychology, Toronto Western Hospital, Toronto, ON, Canada Oral 1 Maternal Hypothyroidism Contributes to Abnormal Hippocampal Function in Offspring During Autobiographical Recall

Thyroid and Development Thursday Oral Clinical 11:45 AM

The hippocampus is critically involved in remembering one's own personal memories, known as autobiographical memory (AM), and it is particularly vulnerable to early thyroid hormone (TH) deficiency. Despite animal evidence showing enhanced synaptic activity in hippocampi of rats exposed to maternal hypothyroidism during pregnancy (Gilbert and Sui, 2006), no study has as yet investigated hippocampal activation during AM retrieval in offspring of hypothyroid women (HYPO). This study sought to determine whether severity of maternal TH insufficiency during pregnancy predicts hippocampal activation during an AM retrieval task in their children.

Participants were 34 right-handed children aged 9 to 11 years, 15 HYPO and 19 typically developing controls. All underwent a 1-hour MRI session in a 1.5 T magnet that included fMRI testing. The fMRI paradigm included an individually programmed AM retrieval task containing yes/no questions about each child's past personal memories for specific events and a control condition containing yes/no questions assessing general semantic memory facts. The critical contrast was the difference in activations between AM and semantic fact retrieval conditions. For this study, multiple regressions were conducted in the HYPO group only using Statistical Parametric Mapping-5 software with a region-of-interest analysis (within the hippocampus), small volume correction at p<.10 uncorrected, and 5 contiguously active voxels restriction.

After controlling for total hippocampal volumes and accuracy, maternal TSH levels during first trimester of pregnancy significantly predicted hippocampal activations during AM versus fact retrieval. Higher maternal first-trimester TSH values significantly predicted greater left (p=.002) and greater right hippocampus activity (p=.042).

These results suggest that the hippocampi of children exposed to more severe maternal TH deficiency during early pregnancy worked harder and compensated more when later recalling past personal memories. These results provide critical new insight into the long-term specific effects of maternal TH deficiency on child hippocampal functioning and highlight the importance of maternal TH for normal hippocampal development.

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ORAL 1.

Significant correlations between first trimester maternal TSH levels and activations for autobiographical memory recall in child.

1 Oncology, Eisai Inc, Woodcliff Lake, NJ 2 Division of Endocrinology, The Johns Hopkins University School of Medicine, Baltimore, MD 3 Department of Endocrine Neoplasia and Hormonal Disorders, University of Texas M. D. Anderson Cancer Center, Houston, TX 4 Nuclear Medicine and Endocrine Oncology, Centrum Onkologii Instytut of Gliwice, Gliwice, Poland 5 Dipartimento di Medicina, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy 6 Dipartimento di Medicina Interna, scienze endocrine-metaboliche e biochimica, Azienda Ospedaliera Universitaria Senese, Siena, Italy 7 Hematology, Seattle Cancer Care Alliance, Seattle, WA 8 Department of Endocrinology, Royal North Shore Hospital, Leonards, NSW, Australia 9 Head & Neck Oncology, H. Lee Moffit Cancer Center, Tampa, FL 10 Division of Gastroenterology, Hepatology & Nutrition, Ohio State University School of Medicine, Columbus, OH 11 Department of Otolaryngology/Head and Neck Surgery, University of Arkansas, Little Rock, AR 12 Endocrinology Research Unit, The Royal Brisbane and Women's Hospital, Herston, Australia 13 Head, Neck and Thyroid Unit, Royal Marsden Hospital, Sutton, United Kingdom 14 Dipartimento di Endicrinologia e Metabolismo, UO Malattie Metaboliche e Diabetologia, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy Oral 3 A Phase II Trial of the Multi-Targeted Kinase Inhibitor Lenvatinib (E7080) in Advanced Radioiodine (RAI)-Refractory Differentiated Thyroid Cancer (DTC): Correlation of Treatment Outcomes with Tumor Genetic Analysis, Serum Biomarkers and Pharmacokinetics

Thyroid Cancer Thursday Oral Clinical 12:15 PM

Lenvatinib is an oral tyrosine kinase inhibitor targeting VEGFR1–3, FGFR1–4, RET, KIT and PDGFRβ. In phase I studies of lenvatinib partial responses (PR) were observed in thyroid as well as melanoma, endometrial, and renal cancers.

Between Oct 2, 2008 and Feb 5, 2010, patients (pts) with advanced, RAI-refractory DTC (papillary, follicular or Hurthle cell) and disease progression demonstrated by RECIST during the prior 12 months were enrolled. Pts may have received prior VEGFR targeted therapy. Pts were treated until disease progression or development of unmanageable toxicities. Primary end point was Response Rate (RR) by RECIST.

58 pts were enrolled (med age: 62; M: 59%, F: 41%) and confirmed PRs were observed in 50% (95% CI: 37–63) based on investigator assessment and 45% by independent radiographic review performed with 9 mo minimum follow-up. Correlation of clinical outcomes (RR, maximum tumor shrinkage (MTS) and PFS) with pharmacokinetic parameters, circulating cytokine and angiogenic factors (CAFs) and tumor gene mutation status were also performed. Lenvatinib concentration 2 hours post-treatment (Cmax) 29 days post-therapy weakly correlated with tumor shrinkage (r=−0.21, p=0.15). A panel of 43 serum CAFs was evaluated in serum samples collected pre-treatment (baseline), 8 and 36 days post-treatment. Lower baseline angiopoietin-2 (ANG-2) levels (r=0.309, p=0.033) and increase in FGF-2 (r=−0.347, p=0.021) and IL-10 (r=−0.38, p=0.020) levels 8 days post-treatment correlated with greater tumor shrinkage. A panel of 33 genes with a total of 443 mutations was examined in archival tumor tissue obtained from 23 pts. Mutations in 10 different genes in 16 pts were identified. Mutations in Ras (N- or K-) were found to be significantly associated with MTS (p=0.022) and RR (p=0.007). Ras mutation was also associated with longer PFS (p=0.027, HR=0.20 (CI:0.04–0.95)).

Tumor gene mutation status and serum CAF profiling may be informative in identifying patients who achieve greater tumor shrinkage and prolonged PFS with lenvatinib treatment. Further examination of these associations will be undertaken in an ongoing Phase III study of lenvatinib in patients with RAI-refractory DTC.

1 Department of Nuclear Medicine and Endocrinology, Institut de Cancérologie Gustave Roussy, Villejuif, France 2 Department of Biostatistic and Epidemiology, Institut de Cancérologie Gustave Roussy, Villejuif, France 3 Service of Endocrinology, CHU de Bordeaux, Bordeaux, France 4 Department of Nuclear Medicine, CLCC Toulouse, Toulouse, France 5 Department of Nuclear Medicine, CLCC Gauducheau, Nantes, France 6 Service of Endocrinology, Hopital Pitié-Salpétrière, Paris, France 7 Department of Nuclear Medicine, CLCC Caen, Caen, France 8 Service of Endocrinology, CHU Toulouse, Toulouse, France 9 Department of Nuclear Medicine, CLCC Reims, Reims, France 10 Department of Nuclear Medicine, CLCC Rouen, Rouen, France 11 Service of Endocrinology, CLCC Angers, Angers, France 12 Department of Nuclear Medicine, CLCC Nice, Nice, France 13 Service of Endocrinology, CHU Lyon, Lyon, France 14 Department of Nuclear Medicine, CLCC Bordeaux, Bordeaux, France 15 Department of Nuclear Medicine, CLCC Clermont-Ferrand, Clermont-Ferrand, France 16 Department of Nuclear Medicine, Hopital Saint-Louis, Paris, France Oral 4 Comparison of Four Strategies of Radioiodine Ablation on 752 Low-Risk Thyroid Cancer Patients: Final Results of the Estimabl Study

Thyroid Cancer Thursday Oral Clinical 12:30 PM

This study supported only by the French National Institut du Cancer compared four strategies of postoperative radioiodine ablation (RAI).

This randomized, controlled, phase III trial performed in 24 French centers compared 4 strategies for postoperative RAI in a 2*2 factorial design: each strategy combined a TSH stimulation method (either thyroid hormone withdrawal (THW) or rhTSH (Thyrogen^®, Genzyme)) and an activity of 131I (either 1.1 GBq or 3.7GBq). Study patients met the following criteria: age >18 yrs; total thyroidectomy for differentiated thyroid carcinoma performed 30–120 days before, treatment with LT4 for at least 30 days; TNM stage pT1<1cm, N1, pT1>1cm (any N) or pT2, N0; absence of distant metastasis. The primary endpoint was the rate of ablation at 6–10 months, which was assessed with neck-US and rhTSH-stimulated Tg determination (or whole-body scan in the presence of Tg antibodies). The four strategies were compared using an equivalence framework, with two-side α=0.05.

752 patients with written informed consent were included between April 2007 and February 2010: 79% were female, mean age was 49 years, 91% had papillary cancer; 30% of tumors were pT1N0, 18% were pT1N1, 39% were pT1,Nx and 12% were pT2,N0. 65 patients were excluded from the final analysis: 27 patients for persistent disease at ablation, 20 for consent withdrawal and 18 for incomplete follow-up. Among the remaining 687 patients, neck-US was normal in 655 patients (95%), stimulated Tg level was ≤1.0 ng/mL in 652 (95%) and thyroid ablation was complete in 633 patients (92%). The ablation rate was equivalent both for the I31I activity (difference 1.1 GBq / 3.7 GBq=−2.1%, IC=[−5.4%; 1.3%]) and for the TSH stimulation method (difference rhTSH/THW=−1.5%, IC=[−4.9%; 1.9%]). Among the other 54 patients, 18 had persistent disease, 25 had a normal subsequent work-up and 11 are still being followed.

These results validated the use of rhTSH and 1.1 GBq for ablation in low-risk patients.

1 Endocrinology, MSKCC, New York, NY 2 Pathology, MSKCC, New York, NY 3 Human Oncology and Pathogenesis Program, SKI, New York, NY 4 Medicine, MSKCC, New York, NY Oral 5 Tumor-Associated Macrophages Facilitate BRAFV600E Induced Papillary Thyroid Cancer Initiation and Progression in Transgenic Mouse Models

Thyroid Cancer Thursday Oral Basic 11:45 AM

A subpopulation of patients with BRAFV600E derived PTCs progress to more advanced stage disease, including to metastatic poorly differentiated thyroid cancers (PDTC) and anaplastic thyroid cancers. Understanding the biological processes that are associated with more aggressive disease in BRAFV600E PTCs is important for the development of successful therapeutic strategies in these patients.

We used models of BrafV600E activation in the thyroids of transgenic mice in combination with genetic approaches to deplete tumor-associated macrophages (TAMs) in order to examine the functional role of TAMs on PTC initiation and progression.

During acute activation of Braf in thyroids, expression of the macrophage chemoattractants colony stimulating factor-1 and CCL-2 is increased >1000-fold and 4-fold, respectively. This is accompanied by a dense infiltration of TAMs, which interdigitate with cancer-associated myofibroblasts (CAMs) to form a dense stroma within and surrounding the thyroid. Using diphtheria toxin receptor (DTR) targeted CCR2 mice (CCR2-DTR), we selectively depleted TAMs in PTCs with diphtheria toxin (DT). This was accompanied by a reduction in tumor size, and a more well-differentiated tumor phenotype with a lower mitotic index. Moreover, we observed a significant reduction in stromal CAM density. During PTC progression in Tg-braf/CCR2-DTR mice, PTCs are densely infiltrated with TAMs, are invasive, develop prominent tall cells and foci of PDTC. Following treatment with DT, TAM-depleted PTCs were 1) significantly smaller [0.018 g vs. 0.033 g in controls, p=0.0001]; 2) had fewer mitotic cells [0.54% vs. 0.77%/mm2 , p=0.04]; 3) had decreased total tumor cell volume 4) had a near absence of tall cells with less prominent papillae and more colloid and 5) had fewer foci of PDTC.

In summary, TAMs play key roles in PTC initiation and on PTC progression. To our knowledge, this is the first demonstration of a functional link between TAMs and CAM recruitment, activation and/or proliferation in any cancer type. Moreover, the impact of TAM depletion on tumor maintenance and progression identifies TAMs as a potentially important therapeutic target in patients with advanced, radioiodine refractory PTCs.

1 School of Clinical and Experimental Medicine, University of Birmingham, Birmingham, United Kingdom 2 Laboratory of Comparative Endocrinology, K.U.Leuven, Leuven, Belgium Oral 6 PBF is a Novel Regulator of the Thyroid Hormone Transporter MCT8

Thyroid Hormone Metabolism and Regulation Thursday Oral 12:00 PM

Within the basolateral membrane of thyroid follicular epithelial cells, two transporter proteins are important for thyroid hormone (TH) biosynthesis. Initially, sodium iodide symporter (NIS) delivers iodide from the bloodstream into the thyroid and, following biosynthesis, monocarboxylate transporter 8 (MCT8) mediates secretion of TH from the thyroid gland. NIS-mediated radioiodine uptake is also critical in the treatment of thyroid tumours and metastases. We have previously demonstrated that PTTG-binding factor (PBF), a proto-oncogene upregulated in thyroid cancer, binds NIS and modulates its subcellular localisation, impacting on its ability to uptake iodide. We have now investigated a potential relationship between PBF and MCT8.

Protein interactions were assessed using GST-pulldown and co-immunoprecipitation assays. Immunofluorescent studies were performed both on cell lines and frozen sections of mouse thyroid gland. MCT8 expression levels were quantified using real-time PCR and Western blot analysis.

A physical interaction between PBF and MCT8 was demonstrated in vitro. Further, immunofluorescent studies demonstrated a shift in subcellular localisation, with increased staining of MCT8 within intracellular vesicles following PBF over-expression in vitro. Within these vesicles, colocalisation between PBF and MCT8 was observed. A significant reduction in the amount of MCT8 at the plasma membrane was determined by cell surface biotinylation assays. Colocalisation between PBF and MCT8 was also observed in vivo in a mouse model of thyroid-specific PBF over-expression (PBF-Tg). Thyroidal MCT8 mRNA and protein expression were comparable with wild type mice. PBF-Tg mice developed significantly enlarged thyroid glands with both increased follicular diameter and thyroidal TH levels. Interestingly MCT8-KO mice also share this phenotype.

These data show that PBF binds and alters the subcellular localisation of MCT8. In vivo evidence suggests this may result in reduced TH secretion via MCT8. Overall, these studies identify PBF as a novel interacting partner of MCT8 and, alongside NIS repression, indicate PBF may regulate TH biosynthesis and secretion.

1 Medicine, Intermountain Healthcare, Murray, UT 2 Dept. of Physiology and Pharmacology, Oregon Health Sciences Univesity, Portland, OR 3 Medicine, Columbia U. College of Physicians and Surgeons, New York, NY Oral 7 The Effects of T2 and T3 on Cholesterol Metabolism in LDL Receptor Knock-Out (LDLR^−/−) Mice

Thyroid Hormone Action Thursday Oral Basic 12:15 PM

Animal and human studies conducted between 1923 and 1930 showed that thyroxine affects circulating cholesterol levels. More recent experiments have demonstrated that the effects of both T3 and thyroid hormone analogues on lipid metabolism are mediated by the nuclear receptor TR β. Several observations also suggest that the thyroid-mediated reduction in cholesterol involves the LDL receptor. 3,5 diiodo thyronine (T2), a naturally occurring iodothyronine, lowers plasma cholesterol levels in animals and humans; however T2's site of action is thought to be non-genomic.

We undertook a series of studies in wild type and Ldlr^−/− mice to characterize the lipid-lowering effects of T2, define the role of the LDL receptor as a mediator of thyroid hormone effects on lipids, and compare the effects of T2 to those of T3 on lipid metabolism. Adult mice were placed on a western diet one week prior to receiving therapy. Animals then received 0.75 mg/kg T3, 12.5 mg/kg T2 or by oral gavage for 1 week after which the animals were sacrificed. Plasma and lipoprotein cholesterol and triglyceride levels were determine before and after treatment.

Administering T2 and T3 led to significant (∼70%) and parallel reductions in circulating cholesterol in Ldlr^-/- and wild type animals. The reduction in cholesterol was associated with a reduction in both apoB100- and apoB48- containing lipoproteins, a result that suggests no change in apoB RNA editing. This was due almost exclusively to a reduction in VLDL and LDL; HDL levels did not change significantly. The decrease in circulating cholesterol levels was not associated with increased protein or mRNA expression of the alternative hepatic lipoprotein receptors: LDL receptor related protein (LRP1), VLDL receptor, scavenger receptor-B1, or syndecan 1, or increased expression of either hepatic lipase or lipoprotein lipase.

T2 and T3 decrease serum cholesterol and plasma apoB-lipoprotein levels through a mechanism which does not involve the LDL receptor pathway. Targeting this pathway with thyroid hormone agonists could represent a new treatment approach for patients with genetic defects in the LDL receptor.

1 Molecular, Cellular & Developmental Biology, The Ohio State University, Columbus, OH 2 Physiology & Cellular Biology, The Ohio State University, Columbus, OH 3 Endocrinology, Diabetes & Metabolism, The Ohio State University, Columbus, OH 4 Molecular Virology, Immunology & Medical Genetics, The Ohio State University, Columbus, OH 5 Integrated Biomedical Science Graduate Program, The Ohio State University, Columbus, OH Oral 8 The PI3K/AKT Signaling Axis Modulates Thyroidal Iodide Influx and Retention in TPO-Cre; PTENL/L Mice as well as TRβPV/PV Mice

Thyroid Cancer Thursday Oral Basic 12:30 PM

PI3K/Akt activation, including copy gain and activating mutations in the PIK3CA gene or PTEN inactivating mutations, is associated with benign follicular thyroid adenoma (FTA) and malignant follicular thyroid carcinoma (FTC). We and others have shown that PI3K and Akt1/2 inhibitors increase Na+/I- Symporter (NIS)-mediated radioactive iodide (RAI) uptake in cultured thyroid cells. In this study, we examined NIS-mediated RAI influx and retention in thyroids of mouse models manifesting aberrant PI3K/Akt signaling pathways.

Thyroidal RAI accumulation, shown as percentage of injected dose (%ID), was acquired by SPECT imaging at 1 hr (RAI influx) and at 24 hr (RAI retention) post-injection of Na123I in mice. Thyroid volume was measured by ultrasound imaging and further calibrated by visual volumetric measurements of excised thyroid/trachea. RAI accumulation per anatomic unit was shown as %ID/mm3. RAI retention index was %ID at t24 divided by %ID at t1.

Thyroid tumors of 2 month old TPO-Cre; PTENL/L mice (a mouse model of FTA) had reduced RAI influx (0.42±0.20%ID/mm3 vs. 0.70±0.18%ID/mm3, p=0.052) and reduced RAI retention index (1.78±0.43 vs. 3.68±1.29, p<0.05) as compared to PTENL/L littermates. Thyroid tumors of 9 month old TPO-Cre; PTENL/L mice had a greater extent of reduction in RAI influx (0.10±0.02%ID/mm3 vs. 0.25±0.07%ID/mm3, p<0.01) and RAI retention index (4.13±2.82 vs. 20.46±3.36, p<0.05), showing temporal dynamics of RAI influx and RAI retention with age and/or accumulated mutations. Thyroid tumors of 3–4 month old TRβPV/PV mice (a mouse model of FTC, in which both PI3K activity and TSH levels are increased) also had a mild reduction in RAI retention. However, thyroid tumors of 3–4 month old TRβPV/PV; Akt1-/- mice had increased RAI influx (4.08%ID/mm3 vs. 1.52±1.13%ID/mm3) and RAI retention index (3.28 vs. 2.07±0.78), compared to same age of TRβPV/PV mice.

This is the first report demonstrating that PI3K/Akt pathway inhibits thyroidal iodide influx and retention in living mouse models. The data suggests pharmacological inhibition of PI3K/Akt may have clinical benefit in increasing iodide influx and retention in thyroid cancer patients treated with 131I.

1 Dept of Science and Medico-Surgical Biotechnologies, “Sapienza” University of Rome, Latina, Italy 2 Endocrinology Unit, AUSL Latina, Latina, Italy Oral 9 Increased Need for Oral Levothyroxine Sodium is Often Due to Occult Gastrointestinal Disorders

Disorders of Thyroid Function Thursday Oral Clinical 2:15 PM

An efficient absorption of oral T4 is key to optimal and individually-tailored thyroxine treatment. However, a number of patients fail to attain the proper TSH level, requiring both additional diagnostic monitoring and often larger doses of levothyroxine sodium. Aim of this study has been to analyze the impact of occult gastrointestinal disorder on T4 treatment.

A total of 2018 sequentially examined adult patients (16–60 yrs) were treated with oral sodium levothyroxine (one brand) and followed for at least 24 months. All patients agreed to take thyroxine in fasting conditions, waiting at least one hour before eating or drinking. Patients who were pregnant, who used cosmetics, food and substances containing iodine or drugs interfering with T4 absorption were excluded.

The expected serum TSH has been obtained in the “responder” patients at a median thyroxine dose of 1.54 μg/kg/day in semi-suppressive mode(SM)(TSH=0.1–0.4 mU/l) and 1.31 μg/kg/day in replacement mode(RM)(TSH=0.4–2.5 mU/l). However, 335 patients (17%) still failed to reach the expected serum TSH. Once excluded the subjects still under investigation and those with poor compliance, 245 patients (12.1%; 222F/ 23M) were classified as “poor-responder”. These underwent an algorithm to diagnose gastrointestinal disorders. A gastric disease has been diagnosed in 152 patients (62%) (H.pylori infection or autoimmune gastritis), while an intestinal disorder (celiac or parasitic disease, lactose intolerance etc) has been detected in 47 patients (19%). The cause of malabsorption remained unknown in 46 patients. In patients with gastric disorders, the median therapeutic T4 dose required was increased by 30%(in RM) and by 37%(in SM)(1.73 vs 1.31μg/kg/day and 2.14 vs 1.54μg/kg/day). In patients with intestinal disorders, the median T4 dose was similarly higher (1.85 and 2.0μg/kg/day) than in reference group (+39%in RM and +28%in SM). Upon treatment of gastrointestinal disorders, the effect was reversed in 1/3 of patients.

We observed: •malabsorption or pseudomalabsorption of oral thyroxine in 1 out 5 treated patients; •most of T4 treatment failures were due to defined gastrointestinal disorders; •T4 malabsorption was reversible in about 1/3 of these patients.

1 Division of Endocrinology, Stanford University School of Medicine, Stanford, CA 2 Department of Medical Education, University of Illinois at Chicago, Chicago, IL 3 Division of Endocrinology, “V. Fazzi” Hospital, Lecce, Italy 4 Department of Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC Oral 10 Cost-Effectiveness of Universal and Risk-Based Screening for Autoimmune Thyroid Disease in Pregnant Women

Disorders of Thyroid Function Thursday Oral Clinical 2:30 PM

Hypothyroidism in pregnancy can lead to adverse maternal and fetal outcomes. Although screening of high risk women is advocated, universal screening for autoimmune thyroid disease (AITD) remains controversial. The objective of this study was to compare the cost-effectiveness of universal screening of pregnant women for AITD with screening of high risk women only and with no screening.

We developed a state-transition Markov model to compare the incremental cost per quality-adjusted life-year (QALY) between universal screening, high risk screening, and no screening. Screening occurred in the 1st trimester of pregnancy with anti-thyroid peroxidase (anti-TPO) antibodies and thyroid-stimulating hormone (TSH). It was followed by further testing if the screen was positive and treatment of hypothyroid women. The model accounts for adverse outcomes of miscarriage, preterm labor, postpartum thyroiditis, and progression to overt hypothyroidism. We performed a lifetime analysis taking a societal perspective. Using data from the literature, we made base-case assumptions regarding age of pregnancy (25 years), disease prevalence (11.2% for anti-TPO antibody positivity), cost of screening ($21 for anti-TPO and $25 for TSH), annual levothyroxine cost ($170) and other variables. We used data from randomized controlled trials to obtain probabilities for adverse obstetrical outcomes. All variables were varied in sensitivity analyses.

Universal screening was cost-effective relative to risk-based screening, with an incremental cost-effectiveness of $7,258/QALY. Risk-based and universal screening were both more cost-effective relative to no screening, with incremental cost-effectiveness ratios of $6,753/QALY and $7,119/QALY respectively. Screening remained cost-effective across a wide range of parameters varied, and even when we assumed that only overt hypothyroidism had adverse obstetrical outcomes. When we assumed that untreated maternal hypothyroidism decreased child IQ, while levothyroxine treatment prevented this, universal screening was cost-saving.

Universal screening of pregnant women in the 1st trimester for AITD is cost-effective not only compared with no screening, but also compared with screening of high risk women.

1 Department of Medicine, University of Manitoba, Winnipeg, MB, Canada 2 Section of Endocrinology, St. Boniface Hospital, Winnipeg, MB, Canada 3 Section of Endocrinology, Boston University Medical Center, Boston, MA 4 Department of Medicine, University of Toronto, Toronto, ON, Canada 5 Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada 6 Faculty of Arts, University of Western Ontario, London, ON, Canada 7 Department of Obstetrics and Gynecology, Mount Sinai Hospital, Toronto, ON, Canada 8 Division of Endocrinology, Mount Sinai Hospital, Toronto, ON, Canada Oral 11 The Status of Iodine Nutrition During Pregnancy in Toronto, Canada

Iodine Uptake and Metabolism Thursday Oral Clinical 2:45 PM

Increased thyroid hormone requirements during pregnancy rely heavily upon adequate maternal intake of dietary iodine. Studies in regions considered iodine sufficient, including the United States, have shown median urine iodine levels below the World Health Organization recommended range for pregnancy (150 to 249 ug/L). Iodine deficiency during pregnancy can lead to goiter and hypothyroidism and is associated with neurologic and intellectual impairment in the fetus, the extreme form of which is cretinism. Little is known about the current status of iodine nutrition in Canada. OBJECTIVE: To evaluate the status of iodine nutrition in a sample of pregnant women presenting for routine antenatal care, by determining the median urine iodine concentration (UIC) of this population.

A cross-sectional, observational study of 150 pregnant patients in the ambulatory obstetrical department at Mount Sinai Hospital in Toronto, Ontario, Canada. Each participant provided a spot urine sample; urine iodine concentration was measured by spectrophotometry using a modification of the method of Benotti et al.

150 pregnant women (mean age 33.8±4.4SD years, mean gestational age 29.0±8.1SD weeks) were recruited from 4 low-risk antenatal clinics. The median UIC was 227.1 ug/L; values ranged from 25.9 ug/L to 1812.7 ug/L. 42 (28%) women had urinary iodine levels below 150 ug/L and 6 (4%) were below 50 ug/L, consistent with iodine deficiency. After excluding the 8 women with a UIC above 800 ug/L due to the possibility of unrecognized contamination, the median UIC was 221.3 ug/L.

The median UIC of this population is within the recommended range for pregnancy, suggesting adequate iodine nutrition. The lower rates of iodine deficiency compared to those previously reported by U.S. centers may be due to universal salt iodization in Canada and/or other dietary and lifestyle factors. The status of iodine nutrition during pregnancy requires continued surveillance in Toronto and merits investigation in other regions of Canada.

1 Section of Endocrinology, Diabetes, and Nutrition, Boston University School of Medicine, Boston, MA 2 none, Boston University School of Medicine, Boston, MA Oral 12 Breastmilk Iodine, Perchlorate, and Thiocyanate Concentrations: Effects on Infant Thyroid Function

Iodine Uptake and Metabolism Thursday Oral Clinical 3:00 PM

Breastfed infants are reliant on maternal iodine for thyroid hormone production required for neurodevelopment. Dietary iodine among U.S. women of childbearing age may be insufficient. Perchlorate (ClO4), a competitive inhibitor of the sodium/iodide symporter (NIS), is ubiquitous in the U.S diet. Thiocyanate (SCN), from cigarette smoke and the diet, is a weaker NIS inhibitor. Environmental ClO4 and SCN exposures could decrease breastmilk iodine uptake by competitively inhibiting NIS in the lactating breast, thus impairing infants' iodine availability. They could also inhibit infants' thyroidal NIS to directly affect infant thyroid function.

Iodine, ClO4, and SCN levels in breastmilk, maternal and infant urine, and infant serum TSH and FT4 levels were cross-sectionally measured in Boston-area women and their 1–3 month-old breastfed infants. Univariate and multivariable analyses were performed to assess relationships between iodine, ClO4, SCN, log-transformed TSH, and FT4 levels.

64 mothers (mean age 28.7 yrs±7.9[ SD], 69% Black, 61% foreign-born, 6% smokers) and their breastfed infants (mean age 1.6 mos±0.5 [SD]) were recruited. Median (range) urinary iodine levels were 101.9 μg/L (27–570) in mothers and 197.5 (40–785) in infants (p<0.01). Levels of infant urinary iodine were positively correlated with breastmilk iodine (r=0.56, p<0.01) and maternal urine iodine (r=0.35, p<0.01). Median (range) ClO4 concentrations were 4.4 μg/L (0.5–29.5) in breastmilk, 3.1 μg/L (0.2–22.4) in maternal urine, and 4.7 (0.3–25.3) in infant urine. Breastmilk iodine was positively correlated with breastmilk ClO4(r=0.26, p=0.04) and SCN (r=0.51, p<0.01) and maternal urine iodine (r=0.35, p<0.01) levels. There were no significant correlations between infant TSH or FT4 and iodine, ClO4 and SCN levels in breastmilk, maternal urine, and infant urine. In multivariable analyses, only maternal urine SCN concentrations were positively associated with infant serum FT4 levels (p=0.04).

Boston-area mothers and their breastfed infants are generally iodine-sufficient. Although environmental ClO4 and SCN are ubiquitous, these results do not support the concern that maternal and infant ClO4 and SCN exposures affect infant thyroid function.

1 Microbiology&Immunology, University of Illinois at Chicago, Chicago, IL 2 Department of Surgery, Division of Surgical Oncology, University of Illinois at Chicago, Chicago, IL 3 Internal Medicine, Endocrinology&Metabolic Diseases and Biochemistry, University of Siena, Siena, Italy Oral 14 IG20 Knockdown, and Not the Inhibition of MAPK/PI3K/AKT Signaling Pathways, Enhance Trail-Induced Apoptosis of Anaplastic Thyroid Cancer Cells

Thyroid Cancer Thursday Oral Basic 2:30 PM

Anaplastic thyroid cancer (ATC) has a very poor prognosis that may not be significantly altered by the current treatment regimens. Therefore there is a compelling need to identify potential new therapies. TNF-related apoptosis inducing ligand (TRAIL) induces apoptosis selectively in cancer cells and may be useful in the management of ATC. IG20/MADD is highly expressed in thyroid cancer and confers TRAIL resistance; therefore, we aimed to investigate the effects of IG20/MADD knockdown on TRAIL induced-apoptosis.

A shRNA expressing lentivirus was used to selectively knockdown IG20/MADD in the human ATC cell lines: C643, CAL62 and HTh7 ATC-cell lines with RAS mutation, and the 8505C cell line with BRAF mutation. Cells were treated with TRAIL alone or in combination with kinase inhibitors targeting the two main pro-survival pathways, MAPK, and/or PI3K/Akt, in thyroid cancer. Apoptosis was assessed by detection of activated caspase-3 by flow-cytometry.

C643, CAL62 and HTh7 cells were sensitive to TRAIL induced apoptosis, while 8505C cells were resistant to even high doses of TRAIL (100 ng/ml). Combination of TRAIL with select Akt/mTOR (perifosine and everolimus) and/or MEK inhibitors (PD-0325901) showed an antagonistic effect on TRAIL-induced apoptosis in C643 cells, but had no effect on 8505C cells. Upon knockdown of IG20/MADD, C643 cells had increased sensitivity to TRAIL induced apoptosis (p=0.022) and rendered previously resistant 8505C cells sensitive to TRAIL (p=0.009).

IG20/MADD knockdown in TRAIL treated cells enhanced apoptosis in sensitive ATC cells and induced significant cytotoxicity in resistant ATC cells. This effect was not enhanced significantly in the presence of various inhibitors of the MAPK/PI3K/Akt signaling pathways. TRAIL treatment combined with IG20/MADD knockdown may be a potential therapeutic modality for anaplastic thyroid cancer.

1 Oral Health Research, University of Kentucky, Lexington, KY 2 Endocrinology & Molecular Medicine, University of Kentucky, Lexington, KY 3 College of Public Health, University of Kentucky, Lexington, KY 4 Thyroid Cancer Research Laboratory, Veterans Affairs Medical Center, Lexington, KY Oral 15 Lack of Evidence for Alterations in Relative Telomere Length and Telomerase Gene Number in Familial Nonmedullary Thyroid Carcinoma Patients in Kentucky

Thyroid Cancer Thursday Oral Basic 2:45 PM

Thyroid cancer is the fastest increasing incidence cancer amidst all cancers in both sexes. Nonmedullary (NMTC) accounts for ≈94% of cases and 3–6% of these appear familial (FNMTC). Alterations of the telomere-telomerase complex have been reported in association with several malignancies including thyroid cancer. Capezzone et al (JCEM 93:3950, 2008) reported short telomeres, hTERT gene amplification & increased telomerase enzymatic activity in their Italian cohort of FNMTC and we sought to replicate these findings in a different patient population.

We evaluated, in triplicate analyses, mean relative telomere length (RTL), telomerase gene copy number (TGCN) in 36 FNMTC (26 Papillary & variants, 10 Follicular & variants; 21 kindreds), 53 sporadic NMTC cases (43 Papillary & variants, 10 follicular & variants) and 24 healthy volunteers, utilizing DNA obtained from peripheral blood mononuclear cells. We assessed RTL using multiplex quantitative real-time PCR (qPCR; LightCycler^®480, Roche) and TGCN by standard qPCR, analyzed as a ratio (Pfaffl's method; Nucl Acids Res 29:2002, 2001) to results for reference single-copy genes (albumin & Colony Stimulating Factor 1 Receptor) with a ratio >2 considered demonstrative of gene amplification.

Data analysis shows no significant difference in RTL between the FNMTC samples and those of healthy volunteers (p=0.537, one-way ANOVA, adjusted for age and sex). On the other hand, the sporadic NMTC samples revealed a longer mean RTL (1.56) that was significantly different from the FNMTC samples and nearly significantly different from those of healthy volunteers (p=0.035 and p=0.068, respectively). We could not find any evidence for hTERT gene amplification in any of these subjects.

These results differ from the findings of Capezzone et al who found significantly shorter RTL in their FNMTC cohort than in their healthy volunteers and sporadic cases, rather than our finding of increased RTL in sporadic NMTC cases. Also, contrary to the report of Capezzone et al, there was no evidence of hTERT gene amplification in our FNMTC cohort. Our findings call into question whether the telomerase gene plays any role in producing a familial risk for nonmedullary thyroid carcinomas.

1 Dept. of Internal Medicine II, Ludwig-Maximilians-University, Munich, Germany 2 Dept. of Pharmacy, Center of Drug Research, Pharmaceutical Biology-Biotechnology, Ludwig-Maximilians-University, Munich, Germany 3 Dept. of Nuclear Medicine, Ludwig-Maximilians-University, Munich, Germany Oral 16 Epidermal Growth Factor Receptor-Targeted Non-Viral Delivery of the Sodium Iodide Symporter (NIS) Gene in Radioiodine-Refractory Differentiated and Anaplastic Thyroid Cancer In Vitro and In Vivo

Thyroid Cancer Thursday Oral Basic 3:00 PM

In contrast to radioiodine-refractory differentiated (DTC) and anaplastic thyroid cancer (ATC), radioiodine-sensitive DTC can be efficiently treated by the application of radioiodine based on the expression of the sodium iodide symporter (NIS). Due to limited therapeutic options for radioiodine-refractory DTC and ATC we have started to evaluate novel polyplexes for non-viral NIS gene delivery, aiming at establishment of radioiodine therapy in these cancer types.

We have used nanoparticle vectors based on linear polyethylenimine (LPEI), shielded by polyethylene glycol (PEG), and coupled with the synthetic peptide GE11 as an epidermal growth factor receptor (EGFR)-specific ligand, that have been demonstrated by our earlier work to own high potential for systemic gene delivery. First, we have analyzed EGFR expression levels in various radioiodine-refractory DTC and ATC cell lines (ATC: SW1736, HTh74; DTC: ML-1, B-CPAP, FTC-133) by FACS-analysis. Thyroid cancer cells were incubated with LPEI-PEG-GE11/NIS and control polyplexes (LPEI-PEG-Cys/NIS) lacking the EGFR-specific ligand, followed by analysis of transfection efficiency by iodide uptake assay.

SW1736 and ML-1 showed the highest levels, B-CPAP and HTh74 intermediate levels, and FTC-133 the lowest levels of EGFR expression. Transduction efficiency correlated well with EGFR expression levels reaching highest levels with a 7–10-fold increase in perchlorate-sensitive iodide uptake activity in SW1736 and ML-1 cells as compared to mock transfected cells. Incubation with untargeted polymers (LPEI/PEG-Cys/NIS) resulted in a very low iodide uptake activity in all cell lines, demonstrating the EGFR-specificity of these polymers. In preliminary in vivo experiments, we established subcutaneous xenografts derived from ATC cell lines SW1736 and HTh74 in nude mice. 24h after systemic (i.v.) LPEI-PEG-GE11/NIS application SW1736 and HTh74 xenografts accumulated approx. 5–6% ID/g ¹²³I as determined by γ-camera imaging.

In conclusion, our data clearly demonstrate the feasibility of establishment of radioiodine therapy for radioiodine-refractory DTC and ATC by tumor-selective systemic NIS gene transfer using EGFR-targeted synthetic nanoparticle vectors.

1 Thyroid Research Unit, James J Peters VA Medical Center, Mount Sinai School of Medicine, New York, NY 2 Medicine, Mount Sinai School Of Medicine, New York, NY Poster 17 TSH Receptor Antibodies Induce Fibroblast Proliferation and Apoptosis: Implications for Graves' Disease

Autoimmunity Thursday Poster Basic

Extra-thyroidal expression of the TSH receptor (TSHR) has been detected in a variety of cell types and appears to have potentially important physiological roles. Of great interest is TSHR expression in fibroblasts, adipocytes, and macrophages, each of which has been implicated in the pathophysiology of Graves' Orbitopathy (GO). In particular, it has been hypothesized that the TSHR autoantigen on fibroblasts and adipocytes may be responsible for selective targeting of the immune system to the retro-orbit. Antibodies (Abs) to the TSHR may have stimulating, blocking, or neutral activity when compared to TSH action and TSHR-Ab titers in patients with Graves' disease correlate with the extent of their GO. Since we have recently observed that neutral TSHR-Abs are far from “neutral” but rather have distinct signaling imprints in thyrocytes resulting in cell apoptosis (Endocrinology 2010, 151:5537), we have extended this evaluation to the study of fibroblast cultures.

Antibody-treated murine preadipocytes (3T3-L1 cells) were selected for their TSHR expression using magnetic beads bound to TSHR-mAb (RSR-1) after which they were >90% TSHR positive.

These cultures responded to TSH and stimulating TSHR-mAbs with enhanced proliferation over a 3 day culture. In contrast, neutral TSHR-mAb (Tab-16) activated stress signaling, as determined by the induction of ROS, and later induced widespread apoptosis in up to 50% of cells after 5 days (compared to ∼10% in controls), as measured by Annexin V and mitochondrial marker (JC-1) assays. This enhanced apoptosis was caspase dependent as evidenced by up to a 40% increase in total caspase activity (by FLICA).

These data show that while stimulating TSHR-Abs may contribute to fibroblast and adipocyte proliferation, neutral TSHR-Abs may aggravate the local inflammatory infiltrate within the thyroid and in the retro-orbit by inducing cellular apoptosis; a phenomenon known to activate innate and by-stander immune-reactivity via DNA release from the apoptotic cells. (Supported by DK 080459, DK052464 and DK069713).

1 First Department of Internal Medicine, Wakayama Medical University, Wakayama, Japan 2 Cellular and Molecular Biology, University of Rhode Island, Providence, RI 3 Epivax. Inc, Epivax. Inc, Providence, RI 4 Chesapeake-PERL, Chesapeake-PERL, Savage, MD Poster 19 Epitope Recognition in HLA-DR3 Transgenic Mice Immunized to TSH-R Protein or Peptides

Autoimmunity Thursday Poster Basic

Development of Autoimmune thyroid disease (AITD) including Graves' disease (GD) and Hashimoto's disease (HD) is related to expression of HLA-DRB1*0301(DR3). The extracellular domain (ECD) of human TSH receptor (hTSH-R) is a crucial antigen in GD.

DR3 transgenic mice immunized to recombinant hTSH-R-ECD protein or hTSH-R-ECD peptides were generated as an AITD model. Serum anti hTSH-R protein antibody, or anti hTSH-R peptide antibodies were titrated by ELISA to recognize B cell epitopes. hTSH-R peptide 37 (AA78–94) is an important immunogenic peptide in DR3 transgenic mice. A mutant hTSH-R peptide 37 (ISRIYVSIDATLSQLES:37m), in which peptide 37 HLA-DR3 binding motif position 5 was mutated V>A, and position 8 Q>S, was synthesized. 37m was predicted to bind to HLA-DR3, but not bind to T-cell receptors. DR3 transgenic mice were immunized with hTSH-R peptide 37 and 37m.

Mice immunized to hTSH-R protein developed strong TRAb, and weak TSI. Antisera from DR3 immunized transgenic mice reacted strongly with hTSH-R-ECD peptides 1 to 5, covering amino acid residues 20–94, sequences recognized as B-cell epitopes that react with human TRAb. In addition, antisera to hTSH-R protein recognized hTSH-R peptides 21 (258–277), 41 (283–297), 36 (376–389), and 31 (399–418). Antisera raised to peptide 37 provided striking results. The antisera bound to peptides 1–7 (20–112), 10 (132–150), 33 (137–150), 41, 23 (286–305), 24 (301–320), 36, and 31, as well as to hTSH-R-ECD protein. Antibody titers to peptide 37, and reaction of splenocytes to peptide 37, were significantly reduced in mice immunized to peptide 37 plus 37m, compare to mice immunized to peptide 37 alone (SI: 0.92±0.13 vs 1.77±0.87, P=0.0081).

Binding of anti hTSH-R-antibodies to the amino-terminal end of the ECD was confirmed in our DR3 transgenic mice. The ability of immunization to a single peptide to induce antibodies that bind whole TSHR protein, as well as multiple un-related peptides, is a unique observation. The mechanism may relate to developing immunity to host TSH-R, and epitope spreading along this antigen. Immunogenic reaction to peptide 37 could be partially suppressed by competing peptide 37m, and in theory this might contribute to immunotherapy of AITD.

1 Medicine I, Gutenberg University Medical Center, Mainz, Germany 2 R & D, Diagnostic Hybrids, Inc., Athens, OH Poster 25 Greater Analytical Sensitivity of Chimeric TSH-R Bioassay vs Anti-TSH-R Binding Antibodies

Autoimmunity Thursday Poster Clinical

We aimed to compare the analytical sensitivity of a FDA-cleared chimeric TSH-R bioassay that measures thyroid stimulating immunoglobulin (TSI) and TSH-R binding inhibitory immunoglobulin (TBII) assays.

Sera from patients with Graves' disease, positive for both TSI and TBII, were serially diluted into normal serum at final dilutions of 1:3, 1:9, 1:27, 1:81, 1:243, 1:729, 1:2187 and 1:6561 in triplicate. TSI levels were expressed as the percent specimen-to-reference-ratio SRR%. Two TBII methods were used (Brahms RIA and Roche ECLIA). Titres were expressed as the dilution of the serum that reduced the TSI or TBII level to below the cut-off of each assay (TSI SRR%<140; Brahms<1.0 IU/L and Roche<1.75 IU/L).

A total of 96 serum samples from 23 hyperthyroid patients with Graves' disease were prospectively evaluated prior to and during antithyroid treatment. A markedly higher analytical sensitivity for the TSI bioassay was observed in all undiluted sera (p=0.006) and at each dilution: 1:3 (p<0.001), 1:9 (p=0.002), 1:27 (p<0.001) and 1:81 (p<0.001; Chi-square test). At dilutions 1:243 and 1:729 four and two samples, respectively, were TSI-positive, whereas all samples were negative in the TBII-assays at 1:243. There was a close correlation between the undiluted values and the TSI titers. The mean (±SD) baseline TSI values of samples with TSI titres of 1:3, 1:9, 1:27, 1:81 and 1:243 were SRR% 223 (±66), 311 (±48), 397 (±76), 474 (±53) and 461 (±51). A “hook effect” was observed in samples with the highest titers. This may explain why the undiluted SRR% of the 1:243 dilution (461) is not higher than that of the 1:81 (474).

This dilution analysis demonstrates the high analytical sensitivity of the chimeric TSH-R bioassay. TSI titers closely correlate with the undiluted TSI values and offer additional information which may have clinical utility.

1 Oxidation Res, Cor.Con.International Srl, Parma, Italy 2 Pathology, Loyola University School of Medicine, Chicago, IL Poster 26 Massive Oxidative Stress Generated in Hypothyroid Rats Treated with T4 and T3S Given in Combination

Disorders of Thyroid Function Thursday Poster Basic

T3S (3,5,3′-triiodothyronine sulfate) has been shown to be a thyromimetic in surgically hypothyroid rats following daily ip injection in the nanomolar range. The activity of T3S was found to be about 1/5 of T3. However, there are no data about the modification of the oxidative balance and hs-CRP.

Fifty male rats Charles River weighing 200–220 g were used; 10 rats were considered as a control group (sham operated for thyroidectomy), whereas the remaining 40 rats underwent surgical thyroidectomy and were divided into 4 groups of 10 animals each (respectively A,B,C,D). Group A was the control group, group B was treated with T3S (50 mcg/kg/day); Group C was treated with T3S+T4 (respectively 50 mcg and 125 mcg/Kg/day); Group D was treated with T4 (125 mcg/Kg/day). All the treatment continued for 10 days. Body weight (g), serum TSH (ng/mL) and T3 levels (ng/mL), plasma d-ROMs test (for hydroperoxides in terms of U.CARR.-Carratelli Units) and serum hs-CRP (mcg/mL) were measured at baseline, 10 days after thyroidectomy, and finally 10 days after treatments with T3S and T4.

In the control group all the animals survived, whereas in the treatment groups the survived animals were from 8 to 10 (see table 1). After 10 days of treatment (20 days after thyroidectomy) the body weight increase was similar in the control group and in groups C and D, whereas it was significantly lower in the group A. Thyroidectomy causes a significant reduction of OS (oxidative stress) which, at the opposite, increases after the hormones treatment, with the maximum level in the combined treatment with T3S and T4 (Group C). The hs-CRP increase was evident in all the animals, and again the highest values were found in the Group C.

Both T3S and T4 administered to rats after surgical hypothyroidism causes OS, which becomes extremely high together with a concomitant increase of hs-CRP.

1 endocrinology, Scientific research institute of cardiology and internal illnesses, Almaty, Kazakhstan 2 endocrinology, Scientific research institute of cardiology and internal illnesses, Almaty, Kazakhstan Poster 31 Condition of Cardiovascular System at Patients with Hypothyroidism of Advanced Age

Disorders of Thyroid Function Thursday Poster

The research objective: studying of a condition of cardiovascular system in advanced age patients with hypothyroidism.

86 patients with subclinical (SHT), 132 with manifest hypothyroidism (OHT) and 18 practically healthy inspected. Levels of thyroid hormones were defined by standard methods in blood. For an estimation of a functional status of vegetative nervous system, cardiovascular system to patients spent analysis of variability people have been of intimate rhythms and measurement of levels systolic and diastolic arterial pressure (AP).

As a result of research it is revealed, that at patients with OHT level of TSH was in limits from 23.7±2.8 to 29.5±2.8 mME/ml and FT4 from 5.0±0.6 to 7.9±1.3 pg/ml at patients with overt hypothyroidism and TSH 7.3±0.8 to 9.2±1.6 mME/ml and FT4 from 11.9±2.2 to 14.3±1.9 pg/ml at patients with subclinical hypothyroidism. At 45.7% of elderly patients OHT the AP raised from 160/90 to 180/110 mmHg, at 15.2% of elderly patients with OHT the AP raised from 180/100mmHg to 220/130 mmHg. The same tendency was marked at 61.1% of patients SHT where increase both systolic is noted, and diastolic AP. It is necessary to notice, that increase in age at patients OHT met an arterial hypertension is more often. Only 4% of patients with OHT of advanced age had high blood pressure and 22%—low arterial pressure. By the data at all patients with hypothyroidism advanced age low levels of integrated indicators of a functional condition of vegetative system were defined. At patients with hypothyroidism the elderly age authentic decrease in indicators RMSSD (20.9±1.9ms) was observed, pNN50 (14.7±6.3%) in comparison with the same indicators of healthy faces (76.8±0.23 ms and 93.17±0.12% accordingly, P<0.05), that testifies to easing of parasympathetic influence of vegetative nervous system. At patients with hypothyroidism authentic increase of indicators AMo (52.7±2.4ms), relation LF/HF (2.5±0.4), that testifies to prevalence of sympathetic part of vegetative nervous system at elderly patients OHT.

Thus, patients with hypothyroidism advanced age most often have arterial hypertension, activation of sympathetic department and braking of parasympathetic department of vegetative nervous system.

1 Medical Endocrinology, Rigshospitalet, Copenhagen, Denmark 2 Department of Thyroid Related Disorders, National Institute of Endocrinology ‘C.I. Parhon’, Bucharest, Romania Poster 32 Enhancement of T4 Replacement in Hypopituitary Adults Improves Lipid Status Independently from Growth Hormone Replacement Effects

Disorders of Thyroid Function Thursday Poster Clinical

Since commencement of growth hormone (GH) treatment for adult hypopituitary pts, the adequacy of other pituitary deficiencies has been more in focus by clinicians. The purpose of this study was to evaluate if enhanced thyroid replacement in hypopituitary patients improves cardiovascular risk markers.

In all 85 hypopituitary patients (45 women) with GH deficiency; 7 had isolated GH deficiency, 15 had panhypopituitarism, while 25, 16 and 22 patients had 1, 2 and 3 additional deficits respectively. Biochemical and body composition assessment was performed at baseline (when patients were GH naïve), and at follow-up (median 4.7 years (3.0–5.5) after initiation of GH). Patients were divided into TSH sufficient (TSHsuff) (not on T4 and free T4>12 (n=23)), and TSH deficient (TSHdef), and further divided into tertiles according to baseline free T4.

Baseline free T4 was negatively associated with BMI (P=0.003) and total fat mass (P=0.01). TSHdef patients with lowest tertile free T4 had higher total (P=0.01) and LDL cholesterol (P=0.05) and triglycerides (P<0.01) compared to TSHsuff patients, also after adjustment for gender, age, BMI and IGF-I. At follow-up 9 patients initially defined as TSHsuff had initiated levothyroxine treatment. 53 and 28% of patients with free T4 from the low and median tertiles respectively, received an increased levothyroxine dose compared to baseline, whereas 40% of patients with free T4 from the median/high tertile groups had had a dose reduction. None recovered from TSHdef. Free T4 at follow-up was not significantly correlated to body-composition or cholesterol variables, nor were there any group differences among patients in the four groups according to TSH and free T4. Delta free T4 (follow-up−baseline) was negatively correlated to delta total cholesterol (r=−0.23; P=0.06) and LDL cholesterol (r=−0.30; P=0.01) and remained so after adjustment for the change in IGF-I (P=0.02).

After approx 5 years of GH replacement of adult hypopituitary patients, those with hypothyroidism were better adjusted also with respect to the thyroid axis. This was accompanied by an mprovement of the lipids of a higher magnitude than seen after GH replacement alone.

1 Endocrinology, Tokyo Health Service Association, Tokyo, Japan 2 Molecular Physiology & Biological Physics, University of Virginia, Charlottesville, VA Poster 34 Treatment of 14 Cases of Fetal Hyperthyroidism with Iodine in Women in Remission After Ablative Therapy

Disorders of Thyroid Function Thursday Poster Clinical

Fetal hyperthyroidism (FH) can occur in women who have reached remission status after ablative therapy for Graves' disease. FH in this setting has usually been treated by giving thionamides to mothers. We use iodine first, and add thionamides when fetal heart rates do not sufficiently decrease or increase after a transient fall. Reasons for iodine use are 1) Side effects by thionamides that are unnecessary for the mother should be avoided; 2) Iodine has prompt therapeutic effects; 3) Iodine may expose the fetus to a lower risk of hypothyroidism than thionamides (JCEM 75:738,1992).

We treated 14 cases of FH in women who were euthyroid with or without thyroxine after surgery or radioiodine therapy for Graves' disease. Iodine was initiated between 22 and 36 weeks of gestation because the development of FH was highly probable on the bases of TSAb, TBII values, and/or fetal heart rates. Ten of the 14 were treated with iodine alone (G1), and thionamides were added in the other 4 (G2).

At birth, thyroid function was suppressed in none of the 14 neonates. FT4 was normal in 2 and slightly or mildly above normal in the remaining 8 in G1: the highest FT4 level was 3.4 ng/dL. In G2, FT4 was normal in 3 and slightly above normal in the other one. After birth, neonatal hyperthyroidism developed in all 14 but one in G1.

It is concluded from these findings that, in the treatment of FH in women in remission status after ablative therapy, iodine mitigates or exerts sufficient therapeutic effects at a substantial frequency without inducing hypothyroidism. In order to add thionamides timely and in appropriate dose, development of the method that determine fetal thyroid status definitively and safely is essential.

1 Section on Molecular Morphogenesis, Laboratory of Gene Regulation and Development, Program in Cellular Regulation and Metabolism (PCRM), NICHD, National Institutes of Health (NIH), Bethesda, MD 2 Department of Breast Oncology, Saitama Medical University, Hidaka, Japan Poster 38 TR-Mediated Chromatin Remodeling in Development

Thyroid and Development Thursday Poster Basic

Thyroid hormone (T3) plays an important role in regulating multiple cellular and metabolic processes, including cell proliferation, cell death and energy metabolism in vertebrates. Mis-regulation of T3 signaling is manifested in developmental abnormalities, metabolic defects and even aberrant cell proliferation leading to cancer. T3 also plays a major role in tissue remodeling and organogenesis during postembryonic development throughout vertebrates. We are using T3-dependent intestinal remodeling during metamorphosis of Xenopus as a model to study how T3 governs tissue remodeling. It has been shown that T3 exerts its metamorphic effects through T3 receptors (TR)-mediated transcriptional modulation of downstream genes and that TRs recruit, in a T3-dependent manner, cofactor complexes that can carry out chromatin remodeling/histone modifications to regulate gene expressions. Whether and how histone modifications change during T3-dependent gene regulation during vertebrate development are largely unknown.

Here, we analyzed histone modifications at T3 target genes during intestinal metamorphosis, a process that involves essentially total apoptotic degeneration of the simple larval epithelium and de novo development of the adult epithelial stem cells, followed by their proliferation and differentiation into the more complex adult epithelium.

We demonstrated for the first time in vivo during vertebrate development that T3-induced gene activation is accompanied by the removal of core histones at the promoter region, accompanied by the recruitment of RNA polymerase. Furthermore, we showed that changes in histone modifications during gene activation by liganded TR correlate largely with the hisone activation and repression marks identified through global analyses in mammal cell cultures with at least one major difference.

Our findings suggest that chromatin remodeling plays an important role in developmental gene regulation by T3 in vivo.

1 Pediatrics, The Hospital for Sick Children, Toronto, ON, Canada 2 Psychology, University of Toronto, Toronto, ON, Canada 3 Psychology, Toronto Western Hospital, Toronto, ON, Canada Poster 39 Atypical Brain Activation During Visuospatial Processing in Adolescents with Congenital Hypothyroidism

Thyroid and Development Thursday Poster Clinical

Thyroid-deficient rodents and children with early-treated congenital hypothyroidism (CH) demonstrate compromised visual system development. Blasi et al (2008) showed 8–10 year old CH children on functional MRI (fMRI) engaged a distinct neural network from controls reflecting greater reliance on motor areas when solving visuospatial tasks than controls, suggesting more immature visual processing. However, Blasi's study was limited to a single (i.e., dorsal) visual pathway. Thus, we extended this research to compare CH and control adolescents on dorsal and ventral visual pathway fMRI tasks. Since previous research has shown a developmental shift toward a broader more bilateral neural network with greater frontal involvement between childhood and adulthood, we hypothesized controls would show a more adult-like pattern of neural activations and CH, a pattern resembling younger children.

Eight CH and 11 controls (10–16 years) were given in a 1.5 T magnet two fMRI paradigms that engage distinct visual neural pathways. One task involved judging whether differently rotated objects matched in orientation (dorsal) or identity (ventral) and the other, whether they were identical or mirror images (dorsal). Activation patterns were analyzed using the ANCOVA function of SPM-5 software with age and accuracy as covariates of no interest. Critical contrasts were Orientation/Rotation versus Fixation activations and Identity versus Fixation activations.

On orientation/rotation tasks, controls showed a broader more bilateral activation network with greater frontal and parietal involvement than CH, who relied more on subcortical (hippocampus, caudate) regions and more posterior regions than controls. On the identity task, controls engaged both right ventral and bilateral frontal regions more than CH, who showed no evidence of greater motor area involvement.

The difficulty CH show in visuospatial processing may be explained by compromised development of critical brain structures due to circumscribed lack of TH.

OPEN IN VIEWER

Glass brain patterns showing greater frontal activations in controls (left) than CH (right).

1 Clinical and Experimental Medicine, University of Birmingham, Birmingham, United Kingdom 2 Otolaryngology, Head and Neck Surgery, University Hospital Birmingham, Birmingham, United Kingdom 3 Endocrinology, University Hospital Birmingham, Birmingham, United Kingdom 4 Cancer Sciences, University of Birmingham, Birmingham, United Kingdom Poster 41 Novel Binding Partners of PBF in Thyroid Cancer Identified by Tandem Mass Spectrometry

Thyroid Cancer Thursday Poster Basic

PBF is a proto-oncogene implicated in the aetiology of thyroid cancer. PBF binds to several proteins, including PTTG and NIS, but its full function is unknown. Understanding the range of interactions PBF has within thyroid cells is therefore vital; these were explored by tandem mass spectrometry (MS/MS), which relies on the predictable fragmentation pattern of an amino acid chain to identify the proteins present in a sample.

K1 and TPC1 papillary thyroid cancer (PTC) cells transfected with HA-tagged PBF were lysed and immunoprecipitated with an anti-HA antibody, before being passed through MS/MS (n=4). 2587 proteins were identified. Those appearing in vector-only controls and those isolated by only 1 peptide in a single run were eliminated.

Ten proteins were stratified as being most likely to interact with PBF. Cortactin, an Src substrate, was identified by 8 peptides, as were FAK2 (2 peptides) and the serine/threonine kinases cMos (1 peptide, 3 runs) and SMG (9 peptides). Thyroglobulin was identified in all runs by 6 peptides. The Src family tyrosine kinase Lyn was identified by 2 peptides in the TPC1 immunoprecipitant but not the K1. This was supported by Western blotting, where K1 cells were shown to have a low expression of Lyn compared to TPC1 cells. Binding to FAP, CIT, ARAP, UACA and was also apparent. Preliminary studies using pull down assays and co-immunoprecipitation have supported the MS/MS findings for Src and on-going studies are seeking to validate the remaining results in an in vivo context.

We have recently identified PBF as a phosphorylated protein and interaction with Lyn, cMos and SMG may be critical to PBF phosphorylation. Given that PBF-transgenic mice demonstrate macro-follicles, the potential interaction between PBF and thyroglobulin may provide a mechanism for this phenotype. We are now validating these interactions, and evaluating their function alongside PBF in thyroid cancer.

1 Molecular Virology, Immunology, & Medical Genetics, The Ohio State University, Columbus, OH 2 Center for Biostatistics, The Ohio State University, Columbus, OH 3 Department of Veterinary Biosciences, The Ohio State University, Columbus, OH 4 Division of Endocrinology, Diabetes, & Metabolism, The Ohio State University, Columbus, OH Poster 43 Thyroid Specific Ablation of the Carney Complex Gene, PRKAR1A, Results in Hyperthyroidism and Follicular Thyroid Cancer

Thyroid Cancer Thursday Poster Basic

Carney Complex (CNC, OMIM #160980) is a dominantly inherited tumor syndrome characterized by spotty skin pigmentation and endocrine overactivity. CNC is caused by inactivating mutations in PRKAR1A which encodes the type 1a regulatory subunit of the cyclic-AMP dependent kinase (Protein Kinase A, PKA). A defining feature of CNC is the presence of thyroid nodules and/or cancer, which are observed in approximately 25% and 5% of patients, respectively. Mutations in PRKAR1A have also been identified in patients with sporadic thyroid cancer, indicating a central role for PKA in thyroid tumorgenesis.

In order to elucidate the mechanism by which overactive PKA elicits thyroid tumor formation, we have generated a mouse model harboring a thyroid specific deletion of Prkar1a.

At one year of age, the thyroid glands of these animals are grossly enlarged; pathologically, all animals exhibit follicular thyroid adenomas, with 43% of animals developing follicular thyroid carcinoma (FTC) (Figure 1). Ultrasound imaging revealed that the thyroids of these animals are significantly enlarged beginning as early as 3 months of age. Serum analyses showed that these animals are hyperthyroid, indicating that these tumors are secretory. Interestingly, these tumors do not show activation of the PI3K/AKT or ERK pathways, but do exhibit an increase in phosphorylated Stat3, suggesting that the mechanisms of tumorgenesis in the context of dysregulated PKA are distinct from that in previously described models of FTC. Microarray analyses suggest that altered regulation of transcription by the steroid hormone related receptor family may be involved in tumorgenesis. In vitro experiments with primary cultures of these tumors indicate that suppression of Stat3 inhibits cell growth, highlighting the potential importance of the JAK/STAT pathway in this model.

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POSTER 43.

Thyroid specific ablation of the CNC gene, Prkar1a, results in hyperthyroidism and FTC.

This study demonstrates that loss of Prkar1a in the murine thyroid leads to hyperthyroidism and follicular adenoma and carcinoma formation. The model of FTC described here adds to our understanding of the molecular mechanisms involved in FTC development and may help guide the development of new therapies for not only the rare CNC patients, but also for those with sporadic thyroid cancer.

1 Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN 2 Laboratory Medicine, Mayo Medical Laboratories, Andover, MA Poster 46 Evaluation of Thyroglobulin Interference in Various Anti-Thyroglobulin Immunoassays

Thyroid Cancer Thursday Poster Clinical

Thyroglobulin (Tg) and anti-thyroglobulin autoantibodies (TgAb) show mutual interference in their respective immunoassays. The need of performing a TgAb measurement with every Tg test, to rule out false low Tg results due to TgAb interference, is well recognized. By contrast, the effect of Tg on accurate measurements of TgAb levels is not widely appreciated. The objective of this study was to determined Tg interference in the following TgAb assays: Beckman Coulter, Roche, Siemens-Centaur, and Siemens-Immulite.

Two immunometric (Beckman Coulter and Siemens-Immulite) and two competitive (Roche Elecsys and Siemens-Centaur) immunoassays were compared. TgAb negative samples with a range of different Tg concentrations were tested with these TgAb assays to identify potential Tg interference.

While there was poor numerical correlation between the TgAb assays (r2 ranges 0.09–0.47), they showed reasonable categorical agreement with each other (67–100% concordance) for samples with Tg levels <2000 ng/mL, using clinically validated cut-offs for TgAb positivity (Immulite 20 IU/mL, Centaur 44 IU/mL, Roche 22 IU/mL, and Beckman Coulter 4 IU/mL). The Beckman and Immulite assays remained unaffected by Tg concentrations >2000 ng/mL. However, the Roche assay showed significant differences to the two immunometric assays in these samples, with apparent increases in TgAb levels that correlated with the Tg concentrations (r2=0.99). The Centaur assay showed a similar TgAb increase that was Tg concentration dependent.

TgAb competitive assays are more susceptible to Tg interference than immunometric assays. In patients with a high level of Tg, the TgAb result might be falsely positive/elevated due to this interference. While these false elevations are unlikely to result in misdiagnosis of a recurrent or persistent disease, they might cause confusion and may trigger unnecessary additional tests.

1 Otolaryngology & Head-Neck Surgery, Chosun university hospital, Gwangju, Republic of Korea 2 Laboratory Medicine, Chosun university hospital, Gwagnju, Republic of Korea Poster 48 Intra-Operative Molecular Diagnosis of BRAF V600E Using Direct High Resolution Melting Analysis Without DNA Purification

Thyroid Cancer Thursday Poster Clinical

BRAF V600E is a molecular biomarker of papillary thyroid cancer. We developed an intra-operative molecular diagnostic system of BRAF V600E using direct high resolution melting (HRM).

The 96 patients with thyroid nodule suggesting papillary thyroid cancer by fine needle aspiration biopsy were enrolled in the study. After resection of thyroid lobe with suspicious nodule, surgeon excised each part of suspicious region. Thyroid tissue was placed in microcentrifuge tube containing rapid RBC lysis solution. After tissue homogenization, each lysate was washed and supernatant was discarded. After resuspension, we measured a turbidity of lysate using a spectrophotometer for estimation of template quantity. After adjusting absorbance of lysate, the lysate was repeatedly lysed by bead beating for 2 min. The crude lysate was used directly in the PCR. Direct HRM with the BRAF primers were performed by direct PCR buffer system. We also compare this HRM assay to sequencing and restriction fragment length polymorphism (RFLP) using purified DNA.

Positivities of BRAF V600E in cancerous region were 58/96 (60.4%), 45/96 (46.8%), and 59/96 (61.5%) in direct HRM, sequencing with cutoff of 15%, and RFLP, respectively. Total experiment time was only 50 min.

Direct HRM for intra-operative detection of BRAF V600E is a rapid, reliable, and economic technique.

1 Translational Research Laboratory, Gustave Roussy Institute, Villejuif, France 2 Medical Biology and Pathology Dpt, Gustave Roussy Institute, Villejuif, France 3 CNRS UMR8200, Gustave Roussy Institute, Villejuif, France 4 Medical Imaging Dpt, Gustave Roussy Institute, Villejuif, France Poster 49 Prevalence of KRAS and HRAS Mutations in Medullary Thyroid Carcinomas

Thyroid Cancer Thursday Poster Clinical

Medullary thyroid carcinoma (MTC) could occur either as resectable localized tumors or as refractory metastatic tumors. Like many other cancers, these disparities of agressiveness could be explained by differences of molecular profiles. Until now, the only abnormalities described in MTC were activating mutations in the RET oncogene, leading to an increase in proliferation of C-cells. Recently, Leite et al. have reported mutations in exons 2 and 3 of RAS genes family, in RET wild-type tumors [1].

In order to explore this type of mutations in our cohort of tumors, we analyzed by direct Sanger sequencing BRAF (exons 11 and 15), KRAS (exons 2, 3 and 4), HRAS (exons 2 and 3) and NRAS (exons 2 and 3) genes in a collection of 33 clinically well-defined frozen-tumors, collected at the Gustave Roussy Institute.

The analysis did not show any mutations in BRAF or NRAS genes and none of the 20 tumors carrying a RET mutation has shown any other abnormality. However, amoung 13 RET-negative samples, 7 were mutated in KRAS or HRAS (4/13 and 3/13 samples respectively). Overall, only 6 out of 33 tumors did not harbor any mutation neither for RET nor for RAS genes. Interestingly, 2 of 4 KRAS mutations were located in exon 4, at codon 146 (p.Ala146Val). According to our knowledge, KRAS exon 4 mutation was not previously reported in MTC. Nevertheless, this variant has already been associated with resistance to targeted therapies in colon carcinomas.

Thus, at the sight of the results obtained in our collection of MTC, it seems important to search for mutations in exons 2, 3 as well as exon 4 of RAS genes in non-RET mutated tumors. In addition, since the GTPases encoded by these genes are located in the signaling pathway downstream of tyrosine kinase receptors, these mutations could explain the resistance to RET inhibitors—targeted therapies recently developed for MTC treatment—observed in some patients.

1 Division of Endocrinology and Metabolism, Mayo Clinic, Jacksonville, FL 2 Division of Biostatistics, Mayo Clinic, Jacksonville, FL 3 Division of Endocrinology and Metabolism, Mayo Clinic, Rochester, MN Poster 53 In Patients with Undetectable (<0.1 NG/ML) T4-Suppressed Sensitive Serum Thyroglobulin, Neck Ultrasonography is Superior to Recombinant Human TSH Stimulation in Detecting Persistent Thyroid Cancer

Thyroid Cancer Thursday Poster Clinical

Thyroid cancer is increasing in incidence, partly due to early detection from imaging performed for unrelated reasons. Differentiated thyroid cancer (DTC) has an excellent prognosis requiring long term surveillance achieved with serum thyroglobulin (Tg) (indicating residual/recurrent disease or thyroid bed remnant) and neck ultrasonography (US) to detect cervical lymph nodes, the most likely location for recurrences. To increase the sensitivity of detection, recombinant human TSH (rhTSH) stimulated Tg values (Tg-stim) have been used.

Utilizing an automated chemiluminometric assay with functional sensitivity of 0.1 ng/mL, we identified 163 patients status post thyroidectomy and one or more radioactive iodine treatments, who had Tg on L-T4 (Tg-supp)<0.1 ng/mL and rhTSH stimulated thyroglobulin test within 60 days. Neck US was performed in all but two patients, with fine needle aspirates on suspicious lesions.

Post rhTSH stimulation, Tg remained <0.1 ng/mL in 93 (57%), increased to 0.1–0.5 in 57 (35%), >0.5–2.0 in 9 (6%) and >2.0 ng/mL in 4 (2%) patients. Serial Tg-supp levels (n=497) were obtained in 131 patients followed up to 8.8 (mean=3.6) years. Serial neck US were performed on 161 patients. When suspicious sonographic features were observed fine needle aspirates were done for cytology. FNAs were performed in 13 patients, 6 had cytology suspicious for persistent/recurrent disease. All 6 positive FNAs were identified around the time of the initial rhTSH test. No patient with unremarkable US at the time of rhTSH testing developed an abnormality leading to a suspicious FNA subsequently. Recurrent/persistent disease was detected in one patient with Tg-stim >2.0 ng/mL, one with Tg stim >0.5–2.0 and in 4 whose Tg-stim was ≤0.5 ng/mL. All local recurrences were detected by US. Only one high risk patient with Stage 3 Hürthle cell carcinoma, who had an undetectable Tg-stim, had distant disease detected by chest x-ray.

We believe that in patients with DTC whose T4-suppressed serum Tg is <0.1 ng/mL, long-term monitoring with annual Tg-supp and periodic neck ultrasound may be adequate. Therefore rhTSH testing may not be needed as, in our experience, the results do not impact or change management.

1 Medicine, University of Toronto, Toronto, ON, Canada 2 Clinical Epidemiology, McMaster University, Hamilton, ON, Canada 3 Psychosocial Oncology, University of Toronto, Toronto, ON, Canada 4 Radiation Oncology, University of Toronto, Toronto, ON, Canada 5 Surgery, University of Toronto, Toronto, ON, Canada 6 Otolaryngology, University of Toronto, Toronto, ON, Canada 7 Endocrinology, University Health Network, Toronto, ON, Canada 8 Psychosocial Oncology, University Health Network, Toronto, ON, Canada 9 Radiation Oncology, University Health Network, Toronto, ON, Canada 10 Surgery, University Health Network, Toronto, ON, Canada 11 Otolaryngology, University Health Network, Toronto, ON, Canada Poster 54 Thyroid Cancer Patients' Involvement in Adjuvant Radioactive Iodine Treatment Decision-Making and Decision Regret: An Exploratory Study

Thyroid Cancer Thursday Poster Clinical

Decision-making about adjuvant radioactive iodine treatment (remnant ablation) can be complex. The impact of the process of this decision-making on subsequent regret in thyroid cancer survivors is not known. We explored regret in patients with a history of early stage papillary thyroid carcinoma, relating to the decision to accept or reject adjuvant radioactive iodine treatment.

We recruited patients with a recent diagnosis of early stage papillary thyroid carcinoma, in whom treatment decisions on adjuvant radioactive iodine had been finalized. We asked participants who made the final decision on radioactive iodine treatment, and they completed a Decision Regret Scale questionnaire (scores varying from: 0 to 100, 100=maximal regret). We explored the relationship between decision regret and: a) degree of involvement in decision-making, and b) receipt of radioactive iodine treatment.

We included 44 individuals, more than half of whom received adjuvant radioactive iodine treatment (26/44). Participants reported that the final treatment decision was made by the following: patient and doctor (52.3%, 23/44), completely the patient (27.3%, 12/44), or completely the physician (20.5%, 9/44). Decision regret was generally low (mean=22.1, standard deviation [SD], 13.0). Decision regret significantly differed according to who made the final decision: the patient (mean 19.0, SD11.3), patient and doctor (mean=19.5, SD 7.4), and the doctor (mean 32.9, SD 20.37) (F=4.569, degrees of freedom=2, 41, p=0.016). There was no significant difference in decision regret between patients who received radioactive iodine and those who did not (mean difference=2.5, 95% confidence interval=10.6, 5.6, p=0.540).

Thyroid cancer patients who reported being involved in the final treatment decision on adjuvant radioactive iodine, had less regret than those who did not.

1 nuclear medicine, AZ Turnhout, Turnhout, Belgium 2 pneumology, AZ Turnhout, Turnhout, Belgium 3 pathology, AZ Turnhout, Turnhout, Belgium Poster 55 Endobronchial Ultrasound (EBUS) and Qualitative Biochemical Analysis (QBA) in Lower Cervical and Mediastinal (PARA)Thyroid Pathology

Thyroid Cancer Thursday Poster Clinical

Definite preoperative definite diagnosis is needed in lower cervical or upper mediastinal mass of suspected (para)thyroid origin. Ultrasound guided (US)FNAC may be impossible. Cytology may be equivocal, e.g. in medullary thyroid carcinoma (MTC), parathyroid tissue.

US-FNAC of masses may be technically impossible e.g deep in the neck or in the upper mediastinum (too deep; presence of bone, vessels, trachea). EBUS is a safe, minimally-invasive procedure for transtracheal/transbronchial FNAC of mediastinal masses, e.g. staging of lung cancer. After appropriate imaging (NM,PET,CT,US) and before surgery, there may be a need for (cytological) confirmation. After smearing for cytology and immunocytochemistry (ICC), we do QBA : aspiration of 1 ml of saline and analysis of appropriate markers in the rinsing fluid of the FNAC-syringe: thyroglobulin (TG), calcitonin (CCT), CEA, parathormone (PTH). This is not a quantitative, but a qualitative analysis.

3 case reports with applications of both easy EBUS-FNAC and QBA: see table for results of cytology, ICC and QBA. 1. rising CCT in followup of MTC: imaging: Gallium-dotatate-PET/CT: single, paratracheal lower neck lymph node; postop. drop of CCT in serum. 2. primary hyperparathyroidism with upper posterior mediastinal mass: dual isotope-scintigraphy: ectopic parathyroid adenoma; CT-scan: possible neurogenic tumour. 3. incidental, inhomogeneous, upper anterior mediastinal mass on CT with probable connection with the thyroid: possible substernal goiter.

In neck and upper mediastinal masses of suspected (para)thyroid origin: 1. EBUS adds to US for FNAC. A node/mass may be anatomically out of reach for US-FNAC. EBUS-FNAC samples are of excellent quality. 2. QBA of the rinsing fluid of the FNAC-syringe adds to cytology and ICC, pointing to MTC (CCT and CEA), parathyroid (PTH), or thyroid or thyroidCa (TG). QBA may help to counter: a) sampling error b) equivocal cytology (parathyroid, MTC) c) technically bad smears (cystic component; bloody; drying artefacts).

1 Institute of Cancer Epidemiology, Danish Cancer Society, Copenhagen, Denmark 2 Department of Gynaecology, Rigshospitalet, Copenhagen University, Copenhagen, Denmark 3 Medical Endocrinology, Rigshospitalet, Copenhagen University, Copenhagen, Denmark Poster 58 Does the Increased Incidence of Papillary Thyroid Cancer in Denmark, 1943–2008, Relate to the Iodine Fortification?

Thyroid Cancer Thursday Poster

Thyroid cancer incidence has increased worldwide during the previous decades. In this nationwide study we aimed to identify the overall incidence of thyroid cancer in Denmark from 1943 to 2008 and incidences of the four main histological types of thyroid cancer from 1978 to 2008.

Data were obtained from the Danish Cancer Registry, which was established in 1943. Reporting of new cancer cases has been mandatory since 1978. From this computerized register, we identified all cases of thyroid cancer from 1 Jan 1943 to 31 Dec 2008. The registry includes information on topography, morphology, date of diagnosis and personal identification number on each patient. It is linked to The National Patient Registry and The Causes of Death Registry to ensure completeness, and coverage is close to 100%. In this study special attention was given to the period after implementation of compulsory iodine supplementation in 2000.

Overall, 1925 men (30%) and 4599 women (70%) were diagnosed with invasive thyroid cancer from 1943 to 2008, with a median age of 59 years. Age-standardised incidence rose from 0.22 to 1.73 per 100,000 in men and from 0.57 to 4.30 per 100,000 in women, with an annual percentage change of 1.3 (95% CI, 1.1–1.6) and 1.4 (95% CI, 1.2–1.6), respectively. The rise was almost exclusively caused by papillary carcinoma, and it was particularly high during the last decade coinciding with commencement of iodine supplementation. Mortality from thyroid cancer was not increased during the same period (previous study using the same Registry).

Papillary cancers were responsible for a marked increase in thyroid cancer incidence seen particularly after the introduction of salt iodization, but the rise may both be real and/or artificial, since several factors could be responsible. Thus, both more prevalent use of thyroid imaging, discovering very small tumours, and other factors causing an artificially increased incidence may be responsible, possibly along with known and/or unknown risk factors for thyroid cancer. The lack of increased mortality from thyroid cancer indicates that the increased incidence is most likely accounted for by small non-lethal thyroid cancers.

1 Surgery, Division of Head and Neck Surgery, UCLA David Geffen School of Medicine, Los Angeles, CA 2 Surgery, Anacapa Surgical Associates, Ventura, CA Poster 59 A Systematic Review of Risk Factors for Cervical Lymph Node Metastasis in Papillary Thyroid Microcarcinoma

Thyroid Cancer Thursday Poster Clinical

The optimal management of papillary thyroid microcarcinoma (PTMC) continues to evolve as more studies focus on the disease, treatment, and prognosis. There has been controversy in the thyroid surgical community regarding routine inclusion of prophylactic central neck dissection (PCND) in patients without clinical lymph node metastasis (LNM). Presence of LNM at diagnosis is a well-established significant risk factor for locoregional recurrence and distant metastasis, however the impact on survival is unclear. If predictive factors for LNM could be identified, it would be possible to stratify high-risk from low-risk PTMC patients, which would enable more precise, tailored surgery.

A systematic review of the English language literature published between 2001–2011 identified through the Pubmed database.

Eleven papers were reviewed that analyzed a series of patients with PTMC with specific attention to identifying factors that predict LNM. The incidence of cervical LNM ranged from 3–40% with the most common site being the central compartment. Consistently significant predictors of cervical LNM include: capsular invasion (CI), size >5mm, multifocality, male gender, and nonincidental diagnosis with CI being the most commonly identified predictor (6/11 studies). Other predictors that showed weak association were lymphovascular invasion and extrathyroidal extension, while age was an inconsistent factor. Overall survival was excellent in all series, with no studies reporting disease related death at follow up; however, recurrence rates ranged from 0–4.7%.

Cervical LNM is common in PTMC, occurring in up to 40% of cases based on this review. While LNM does not appear to impact overall survival, it can lead to disease relapse and may be addressed by using a decision-making algorithm based on significant risk factors to decide which patients would best benefit from PCND.

1 Internal Medicine, Asan Medical Center, Seoul, Republic of Korea 2 Nuclear Medicine, Asan Medical Center, Seoul, Republic of Korea 3 Pathology, Asan Medical Center, Seoul, Republic of Korea 4 Surgery, Asan Medical Center, Seoul, Republic of Korea 5 Internal Medicine, Dongnam institute of Radiological and Medical Sciences Cancer Center, Pusan, Republic of Korea Poster 60 Long-Term Consequence of Elevated Stimulated Serum Thyroglobulin in Differentiated Thyroid Cancer Patients Who Initially Underwent Total Thyroidectomy and Remnant Ablation

Thyroid Cancer Thursday Poster Clinical

The aims of this study were to describe the natural course of patients who had no clinical evidence of disease (NCED) and elevated stimulated thyroglobulin 1 yr after total thyroidectomy and remnant ablation (sTg1), and to evaluate the role of repeated sTg measurement to predict spontaneous biochemical remission (BR, stimulated thyroglobulin <1 ng/ml) or clinical recurrence.

Total 183 patients who had sTg1 greater than 2 ng/ml and NCED were included in this study. All patients had negative I-131 scan and NCED confirmed by neck US, FDG-PET, or chest CT. The second sTg measurement (sTg2) was performed 1–2 years after sTg1. sTg slope was defined as the ratio of sTg2 divided by sTg1. Patients were classified into 4 groups according to sTg1 value as follow; between 2 and 4 (group A), 4 and 10 (B), 10 and 30 (C), and higher than 30 ng/mL (D). Patients were also classified into 3 groups according to sTg slope value as follow; lower than 0.5, between 0.5 and 1, and higher than 1. sTg were measured every 1–2 years until BR or clinical recurrence. We evaluated BR and clinical recurrence-free survival rate according to sTg1 and sTg slope categories.

In patients remained NCED, their serial sTg level generally decreased. Finally, 47% patients in group A, 19% in group B, 10% in group C and no one in group D achieved spontaneous BR. In group A, median time from sTg1 measurement to BR was within 72 months. It took more time for the other patients with greater sTg1 to achieve BR. During follow-up, 31% patients had recurrent disease. Among groups of sTg1 and sTg slope, the group with higher value of sTg1 and sTg slope had a greater clinical recurrence rate (p=0.013 and p<0.001).

This study demonstrated that spontaneous BR is achieved in 47% of patients with sTg1 between 2–4 ng/ml and their median time from sTg1 measurement to BR is within 72 months. sTg1 and sTg slope seem to be a good predictor for BR and clinical recurrence. The repeated sTg measurement is useful method for predicting prognosis.

OPEN IN VIEWER

POSTER 60.

Long-term consequence of elevated sTg in DTC patients who initially underwent total thyroidectomy and remnant ablation.

1 Surgery, University of Southern California Keck School of Medicine, Los Angeles, CA 2 Surgery, Beth Israel Deaconess Medical Center, Boston, MA 3 Surgery, University of Miami Leonard Miller School of Medicine, Miami, FL Poster 62 Clinic Based Ultrasound Can Predict Malignancy in Pediatric Thyroid Nodules

Thyroid Cancer Thursday Poster Clinical

Thyroid nodules in pediatric patients may carry a greater risk for malignancy than in adults. Most nodules >1 cm in patients 21 years of age or younger may require thyroidectomy for definitive diagnosis. Although clinic based ultrasound (CBUS) has been shown useful in the evaluation of thyroid nodules in adults, its utility in evaluating nodules in the pediatric population remains unclear.

Prospectively collected data of 50 patients ≤21 years who underwent preoperative CBUS and initial thyroidectomy at a single institution were retrospectively reviewed. All CBUS were performed by thyroid surgeons certified in basic and cervical ultrasonography. Preoperative CBUS characteristics of pediatric thyroid nodules were analyzed with respect to final pathology.

Of 50 patients ≤21 years who underwent surgery for a dominant thyroid nodule, there were 45 females and 5 males with an average age of 17.4 years (range: 10–21 years). On univariate analysis, microcalcifications (p<.001), abnormal lymph nodes (P<.001), and taller>wider shape (p=.033) were individual CBUS characteristics predictive of thyroid malignancy. All 9 patients with abnormal lymph nodes on CBUS had malignant disease on final pathology. Multiple thyroid nodules, a cystic component, and echogenicity did not help predict malignancy; regular borders trended towards predicting benignity (p=.066). When the presence of classically malignant CBUS features were analyzed (hypoechoic, irregular borders, microcalcifications, shape taller>wider), having one malignant feature predicted malignancy with an odds ratio of 2.0, while having ≥2 features held even greater significance (p=.004, OR 4.0). All patients with ≥3 malignant features had thyroid cancer on final pathology.

CBUS may be useful in determining malignancy status of thyroid nodules in patients ≤21 years of age. CBUS should therefore be employed as part of a standard, initial assessment of any pediatric patient presenting with a thyroid nodules to help guide further management.

1 Surgery, Wonju College of Medicine, Yonsei University, Wonju, Republic of Korea 2 Pathology and DNA analysis, Scientific Investigation Laboratories, Crime Investigation Command, Ministry of National Defence, Seoul, Republic of Korea Poster 67 Suggestion of New Staging System that Can Predict the Recurrence of Papillary Thyroid Carcinoma

Thyroid Cancer Thursday Poster Clinical

There are many clinical pathologic factors and staging systems are used when classifying the severity of thyroid cancer and analyzing a variety of biological characteristics. Identifying these factors that affect the recurrence of papillary thyroid carcinoma and using the staging system that can appropriately reflect the prognosis can be useful in high risk patients by carrying out a proper treatment plan, and in low risk patients by avoiding any unnecessary studies and treatments. With this, this study creates a new staging system through risk model that use clinicopathologic factors, associated with recurrence, checked by preoperative clinical information and imaging study and was compared with other staging systems

A review was conducted of patients who have previously performed thyroidectomy and were able to undergo follow-up sessions between January 1, 1983 and September 31, 2007 at Yonsei University Wonju Medical Center. There were a total of 599 patients.

The Risk model that are associated with the recurrence included six variables abbreviated by age, sex, tumor size, extrathyroidal extension, lymph node metastasis, and distant metastasis. The final prognostic score was defined as New staging system=0.03×age+0.06×tumor size (in centimeters), +0.8 (if male), +0.6 (if locally invasive), +0.6 (if lymph node metastases present), +2.6 (if distant metastases). In comparing the other staging systems, proportion of variation explain (PVE) was calculated for each, and was ranked in order. Out of the seven, New staging system appeared to be the most accurate prognosis predictor with 21.6%. University of Chicago clinical staging system in second with 18.9%. AJCC/UICC TNM staging system in third with 16.7%.

New staging system can predict recurrence very well and has the advantage can use preoperatively. Those patients diagnosed as high risk patients through new staging system should be treated with aggressive surgical treatment, and with close follow-up.

1 Otorhinolaryngology-Head and Neck Surgery, Pusan National University Hospital, Busan, Republic of Korea 2 Internal Medicine, Pusan National University Hospital, Busan, Republic of Korea Poster 68 Skip Lateral Cervical Lymph Node Metastasis Beyond the Central Lymph Node in Papillary Thyroid Cancer

Thyroid Cancer Thursday Poster Clinical

Nodal metastasis of papillary thyroid cancer (PTC) has been known to occur from the central- to lateral lymph node compartments. However, lateral cervical lymph node metastasis (LNM) without central lymph node (CLN) metastasis is not infrequently. This study was designed to investigate the pattern of skip metastasis and to determine the relationship between skip metastasis and clinicopathologic factors.

We reviewed PTC 131 patients who underwent total thyroidectomy with CLN dissection and selective lymph node dissection (SND) between January 2004 and June 2009. Clinical diagnosis of LNM was confirmed by ultrasonography and CT. Tumor location was classified in three areas based on the results of preoperative ultrasonography. We analyzed the relationship between tumor location and nodal metastasis pattern. The relationships between metastasis pattern and clinicopathologic parameters were analyzed.

All skip metastases occurred in patients whose tumors had been on the upper part of the thyroid (P<0.001). Level III lymph nodes were the most frequent site of metastasis, regardless of tumor location. LNM from tumors in the upper portion of the thyroid were relatively common in level II lymph nodes (not significant). Level III lymph nodes (6/9) were the lymph nodes that were most frequently involved in skip metastasis, followed by level II nodes, level IV nodes, and level V.

Primary tumors in the upper portion of the thyroid are closely linked to skip metastasis. Careful preoperative evaluation of lateral cervical lymph nodes is necessary when a tumor is in the upper portion of the thyroid.

1 Thyroidology Department, Belarussian Medical Academy of Postgraduate Education, Minsk, Belarus 2 Endocrinology Department, Republican Centre of Radiation Medicine and Human Ecology, Gomel, Belarus 3 Endocrinology Department, Belarussian Medical Academy of Postgraduate Education, Minsk, Belarus 4 Department of Molecular Medicine, Atomic Bomb Disease Institute, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan Poster 71 Thyroid Cancer in Gomel Region of Belarus: Any New Characteristics Due to Latency Period?

Thyroid Cancer Thursday Poster Clinical

Thyroid carcinoma is the most common endocrine malignancy. There are still a lot of debates about the reason of increased number of differentiated thyroid carcinoma in young population of Belarus. The aim of the study was to analyze retrospectively clinical data and ultrasound characteristics of thyroid carcinomas in follow up patients of Gomel region of Belarus in dependence of age at the moment of the Chernobyl accident and age at the verification of malignancy and surgery.

A total of 117 patients in dynamic follow up after thyroidectomy because of differentiated thyroid carcinoma, living in Gomel region of Belarus and being under 18 years old at the moment of the Chernobyl NPP accident were enrolled in the study. Age varied from 26 to 31 years. None of the enrolled patients had a family history of thyroid cancer. They were followed up and examined regularly after the thyroidectomy. Subjects were diagnosed and operated during 1991–1996 years (1st group) and during 1997–2006 years (2nd group). Diagnosis of thyroid carcinoma was histologically proved after the surgery. Male to female ratio was 1:2,4 in the 1st and 1:1,3 in the 2nd groups. Serum levels of TSH, thyroglobulin (Tg), fT4, fT3, TPOAb, TgAb were checked regularly. The diagnostic I131 whole body scan was done after the surgery in all patients.

The Me of the age at the moment of the Chernobyl NPP accident differed in this two groups - it reached in 1-st group 3,38 yrs (1,40; 5,39) and 2.03 (1.01;3.19) in the second (p=0,003). The Me of the age at the moment of verification of malignancy was 11.00 (9.00; 13.00) and 9.00 (8.00; 10.00). The latent period was longer in the second group - Me was 13.98 (12.65; 15.95), p=0,001. There were differences in ultrasound pattern and morphological characteristics of thyroid cancer cases in two groups. Thyroid volume was higher but nodular size lower in the second group.

Interestingly, we faced the fact that patients with longer latent period were younger at the moment of the accident and had a coexistence of malignant and multiple nonmalignant thyroid nodules. This fact still requires some additional research in the aspect of variable variants thyroid carcinoma types due to radiation induction.

1 Surgery, Kuma Hospital, Kobe, Japan 2 Internal Medicine, Kuma Hospital, Kobe, Japan Poster 72 Serum Thyroglobulin-Doubling Time is a Potent Prognostic Indicator for Patients with Papillary Thyroid Carcinoma and Associates with Age at Surgery

Thyroid Cancer Thursday Poster Clinical

Tumor size, extrathyroidal extension, node and distant metastasis, age and gender are prognostic factors for papillary thyroid carcinoma (PTC). Recently we have reported that serum thyroglobulin-doubling time (Tg-DT) was the most powerful prognostic indicator in patients with PTC who underwent total thyroidectomy and who do not have detectable thyroglobulin antibody (Tg-Ab) (Thyroid, 2011, to be published). Tg-DT was calculated from serum Tg levels measured at TSH suppressed condition. The classical prognostic factors and Tg-DT were significant prognostic factors for survival on univariate analysis, but Tg-DT remained the only independent factor on multivariate analysis. Tg-DT implies speed of tumor growth. Here, we analyze factors that associate with Tg-DT.

Between January 1998 and December 2004, 1515 patients with PTC underwent total thyroidectomy in Kuma Hospital. After excluding patients with other thyroid cancers and anti-Tg antibody, 426 patients with 4 or more serum Tg measurements at TSH<0.1 mIU/L condition were selected for further analysis. There were 349 females and 77 males, aged from 14 to 81 years with a mean of 51.5 years. Tg-DT was computed. Univariate and multivariate analyses were performed to find factors that associate with Tg-DT.

Tg-DT showed a wide range of variation, being <2 year, 2 to 6 years, >6 years, and a negative value due to decrease in Tg values in 33, 20, 17 and 72 patients, respectively. For 88 patients with 3 or fewer detectable Tg levels, Tg-DT was not calculated, and 196 patients demonstrated undetectable Tg levels only. Among the 142 patients with calculable Tg-DT, Tg-DT <2 years, indicating rapid tumor growth, was associated with only age and not with classical prognostic factors (Table). Patients 55 year or older were 5.6 times likely to have Tg-DT<2 years than patients younger than 55 years (p=0.00035). The proportion of patients with Tg-DT<2 years increased with age, being 5.9% in those younger than 40 years, 14.8% in those between 40 and 60 years, and 46.8% in those 60 years or older.

Only age at surgery independently associated with Tg-DT, indicating that patients with rapidly growing tumors increase with age.

1 University of Pisa, Pisa, Italy 2 Biochemistry, University of Wisconsin-Madison, Madison, WI 3 Physiology and Pharmacology, Oregon Health & Science University, Portland, OR 4 Zoology, University of Wisconsin-Madison, Madison, WI Poster 75 Breath Natural Abundance of 13CO2/12CO2 Markers: A Tool to Investigate the Metabolic Response to Chronic 3-Iodothyronamine (T1AM) Administration in Mice

Thyroid Hormone Action Thursday Poster Basic

T1AM is an endogenous compound structurally related to thyroid hormone.In mammals, acute treatment with exogenous T1AM has been found to decrease carbohydrate metabolism, heart rate, and temperature. In the present study, we analyze the breath metabolic response to chronic low-dose T1AM administration in mice by using Cavity Ring Down Spectrometry (CRDS).

Mice were treated for a week with 10 mg/Kg/day T1AM, monitoring food intake and body weight up to 35 days. All animals were injected daily from day 0–7 intraperitoneally with either 10mg/kg T1AM or vehicle. Real-time sampling of breath carbon in exhaled CO2 (13CO2/12CO2 delta value) was performed by CRDS (CSN-015 Cavity Ringdown Spectrometer Picarro, Sunnyvale, CA, USA). All animals were sampled for a total of 6 hours per injection. Plasma was also collected on day 0, day 7, and day 35 and analyzed by NMR spectroscopy. Prior to data collection samples were treated with ice-cold methanol (2:1, v/v), placed at −20°C for 20–30 minutes, centrifugated at 15000 rpm for 5 min. The supernatant was then removed from the protein pellet and dried. Supernatant was then reconstituted by adding a 20 mM PBS containing 1 mM DSS, 0.1 mM NaF, pH 7.4. All NMR spectra were collected by a Varian NMR system 600 MHz spectrometer.

Exogenous T1AM administration was associated with a body weight loss trend in mice (−8.2% of initial body weight by day 9; p=0.076). After T1AM withdrawal, mice regained only part of lost weight (±1.8% of initial weight regained) in the following 2 weeks, indicating long-lasting effects of this natural molecule. No difference in food intake was observed during and after treatment. After administration of T1AM the breath delta value dropped significantly (−1.8%) within 80 minutes of injection, indicating a switch from carbohydrate to lipid metabolism, as a leading contribution to weight loss. NMR spectroscopy revealed key metabolites in lipid catabolism that are altered following T1AM treatment.

Metabolic switching leading to lipid mobilization by physiological dose T1AM may provide a new opportunity for development of this endogenous compound as an effective human weight-loss drug.

1 Medicine, Oregon Health & Science University, Portland, OR 2 Oregon Clinical and Translational Research Institute, Oregon Health & Science University, Portland, OR Poster 77 Effects of TSH-Suppressive Doses of Levothyroxine on Metabolic Function and Body Composition

Thyroid Hormone Action Thursday Poster Clinical

Patients with benign and malignant thyroid diseases are often treated with doses of levothyroxine (L-T4) to suppress TSH levels below the normal range. It is not clear whether this mild exogenous thyrotoxicosis affects metabolism or body composition.

To address this, we recruited otherwise healthy women into two age and BMI-matched groups: 1. L-T4-treated hypothyroid women with normal TSH levels (T4Tx-Nl, N=53), and 2. L-T4-treated hypothyroid women with low or suppressed TSH levels and normal free T4/T3 levels (T4Tx-Low, N=16). Women in the second group had treated thyroid cancer with no evidence of disease (N=9) or benign disease (N=7). Subjects underwent measurements of Resting Energy Expenditure (REE), respiratory quotient (RQ), and Thermic Effect of Food (TEF) by indirect calorimetry, and body composition by DEXA.

Groups differed in thyroid function as expected. The T4TX-Low group had higher REE, but not TEF, than the T4TX-Nl group, with lower BMI and a trend toward lower LBM (see table). By correlation analysis, log free T4 was directly related to REE (Pcorr=0.23, p=0.06), but inversely related to TEF (Pcorr=−0.28, p=0.03). Log fT4 was also inversely related to BMI (Pcorr=−0.22, p=0.07) and lean body mass (Pcorr=−0.24, p=0.05). Log fT3 was only directly related to % body fat (Pcorr=0.33, p<0.01).

Utilizing sensitive techniques, women receiving suppressive doses of L-T4 had increased resting energy expenditure compared to euthyroid women receiving L-T4. These preliminary data suggest that such increases may affect BMI and body composition.

1 Endocrinology and Metabolic Service, Walter Reed Army Medical Center, Washington, DC 2 Division of Endocrinology, Mayo Clinic, Jacksonville, FL 3 Endocrinology, Tripler Army Medical Center, Honolulu, HI 4 Clinical Investigation, Walter Reed Army Medical Center, Washington, DC Poster 78 Thyroxine and Triiodothyronine Content in Commercially Available Thyroid Health Supplements

Thyroid Hormone Metabolism and Regulation Thursday Poster Basic

The use of herbal/natural supplements is rising in the United States and these substances are not closely regulated by the FDA under the Dietary Supplement Health and Education Act (DSHEA) 1997. We examined the thyroid hormone content in over-the-counter (OTC) health supplements marketed as a “thyroid support”. There are no previous reports detailing thyroid hormone content in OTC supplements.

Ten commercially available thyroid supplements were purchased from the local stores and online distributors. The ten most popular thyroid health products identified on an internet search were selected. Thyroid supplements were dissolved in 10 ml of acetonitrile and water with 0.1% trifloroacetic acid and analyzed using HPLC. The selected products were analyzed for the presence of thyroxine (T4) and triiodothyronine (T3) using levothyroxine and liothyronine as a positive control.

The amount of T4 and T3 was measured separately for each supplement sample. Nine out of ten supplements showed a detectable amount of T3 (1.3–25.4 mcg/tablet). Taken at the recommended dose, five supplements delivered T3 quantities of greater 10 mcg/day, and four delivered T4 quantities ranging from 8.57 to 91.6mcg/day. Among the five thyroid supplements labeled as containing bovine thyroid tissue, extract or concentrate, one had no detectable level of T3 or T4, two contained T3 only, and two showed detectable amounts of both T3 and T4.

Most of the OTC thyroid supplements studied contained clinically significant amounts of T4 and T3, some of which exceeded common treatment doses for hypothyroidism. This potentially exposes patients to risk of iatrogenic hyperthyroidism by taking easily accessible OTC supplements not requiring prescription. The current study results emphasize the importance of patient and provider education regarding the use of OTC herbal supplements and highlights the need for greater regulation of OTC supplements potentially dangerous to the public.

1 Oncology, Georgetown University Medical Center, Washington, DC 2 Medicine, OBGYN & Pharmacology, Georgetown University Medical Center, Washington, DC Poster 79 The Association Between Thyroid Hormones, Steroids, Inflammation and Tobacco Smoke Exposure in Women of Reproductive Age

Thyroid Hormone Metabolism and Regulation Thursday Poster Clinical

The harmful effects of tobacco smoke exposure on pregnancy outcomes associated with infertility, preterm delivery, stillbirth, low birth weight, and sudden infant death syndrome have been documented. The objective of this study is to examine whether cigarette tobacco smoke exposure is associated with lower thyroid hormone levels and inflammation.

Serum thyroid hormones, thyroid-stimulating hormone (TSH) and C-reactive protein (CRP), a non-specific marker of acute inflammation, were measured in 300 healthy, non-pregnant women of reproductive age (18–45y). Associations between CRP levels, thyroid hormones, TSH and steroid hormones (cortisol, aldosterone, estrone and progesterone) were also explored. Serum concentrations of CRP were determined using an immunoturbidimetric high sensitivity CRP (hsCRP) assay. Serum thyroid hormone, steroids and cotinine levels were measured by isotope dilution tandem mass spectrometry (LC/MS/MS).

In general, all hormone levels were within the normal ranges. A significant, positive correlation between hsCRP and cotinine levels was observed. Cotinine explained approximately 3% in the variance in hsCRP. BMI was a significant predictor of hsCRP after adjusting for age. No significant correlations were observed between hsCRP levels and TSH, aldosterone, estrone and progesterone.

The results observed suggest that smoking intensity (represented by the nicotine metabolite cotinine) plays an important role in inflammation. Additionally, higher BMI was associated with higher hsCRP levels in healthy women of reproductive age. While cigarette tobacco smoke was associated with changes in hormone levels, there lacked a correlation between the levels of the hormones examined and hsCRP. This suggests that a mechanism independent from the one leading to inflammation, may underlie the changes in hormone levels seen in women who are exposed to cigarette tobacco smoke. Further studies examining the inter-relationships between hsCRP and thyroid and sex hormones are essential in determining a possible role for inflammation in women's health.

1 Endocrinology, Harbor-UCLA, Torrance, CA 2 Radiology, Harbor-UCLA, Torrance, CA Poster 82 Bronchiectasis and Associated Mycobaterium Chelonae Colonization Masquerading as Metastatic Thyroid Cancer on I-131 Scan

Thyroid Imaging Thursday Poster Clinical

A 71-year-old Filipino female underwent thyroidectomy after fine needle aspiration of a thyroid nodule was noted to be suspicious for malignancy. Surgical pathology revealed multifocal disease, with a mixed follicular and papillary pattern. The patient's post radioactive iodine ablation scan showed intense uptake in the thyroid bed as well as in the right middle lobe of the lung concerning for pulmonary metastasis.

Repeat I-131 scan one year post initial therapy again disclosed abnormal right middle lobe uptake. Thyroglobulin and anti-thyroglobulin antibodies were consistently undetectable under conditions of both thyroid hormone suppression and stimulation, and the patient was asymptomatic. Work-up was initiated to elucidate the etiology of her abnormal pulmonary iodine uptake. Careful pulmonary history revealed that the patient had previously been diagnosed with bronchiectasis and atypical mycobacterium colonization (Mycobacterium chelonae) when she had presented with a cough and hemoptysis. A CT scan confirmed the presence of extensive cystic bronchiectasis in the right middle lobe of the lung which coincided anatomically with the iodine-avid area noted on scan. No other lesions concerning for malignancy were identified. The same area of abnormality was identified by ventilation/perfusion and gallium scans. A bronchoscopy was negative for malignant cells. Sputum consistently revealed colononization with M chelonae. Therefore, the diagnosis of a false positive I-131 scan secondary to bronchiectasis and coincident mycobacterial colonization was highly suspected.

The most common cause of false positive I-131 uptake in the lungs are primary lung carcinoma followed by infectious and inflammatory causes. Conditions such as upper respiratory tract infections, interstitial lung disease, bronchiectasis, mycobaterial infection and rheumatoid arthritis have been reported to yield a false positive result. Iodine excretion into alveolar/bronchial inflammatory exudates has been postulated to be the mechanism underlying iodine localization in the lungs.

False positive iodine scans can occur and may lead to overtreatment of thyroid cancer if not suspected when standard thyroid cancer follow-up data do not correlate.

1 Nuclear Medicine, Medical University of Bialystok, Bialystok, Poland 2 Endocrinology, Diabetology and Internal Medicine, Medical University of Bialystok, Bialystok, Poland Poster 84 The Outcome of Radioiodine Therapy (131I) After Five Years in Patients with Non-Toxic Nodular Goitre

Thyroid Nodules and Goiter Thursday Poster Clinical

The aim of our study was to evaluate the efficacy of radioiodine therapy in patients with non-toxic nodular goitre.

We treated 160 patients, aged 20–76 years; 87% of the studied groups were female and 13% male; Iinitial 24 h radioiodine uptake (RAIU) was ranged between 22–44%, and thyroid volume ranged between 44–170ml, effective half-life was more than 3 days at the time of treatment. Malignant changes were excluded in all nodules by fine needle aspiration biopsy. The activity dose was calculated by the use of Marinelli's formula and ranged between 200–800 MBq. The absorbed dose ranged between 150 and 260 Gy. Thyroid ultrasonography, and thyroid scan with RAIU at 24 and 48-hours was done before, after 6, 12 month and yearly for four year of radioiodine therapy. Follow up control with evaluation of fT3, fT4, TSH was done every 6 weeks in the first year. Then every 6 months for four years.

After 12 months of radioiodine therapy a mean thyroid volume reduction of 46% was achieved. Euthyroidism persist in 92% of patients, and hypothyroidism develop in 8% of patients. After 3 years of radioiodine therapy 9% of patient develop hypothyroidism. After 5 years of radioiodine therapy a mean thyroid volume reduction of 49% was achieved and 11% of patients develop hypothyroidism. All patients were highly satisfied; the compressive symptoms relieved and exercise tolerance improved.

Radioiodine is non-invasive, safe and cost effective method of therapy for reduction of large non-toxic goitre and should not be restricted to patients with high operative risk, but should be used as first choice in every patient with non toxic nodular goitre with thyroid volume >40 ml. The reduction of thyroid volume with low percent of hypothyroidism, were due to well accurate measurement of administered activity, relatively high effective half-life, and well-organised follow up.

1 Department of Medicine, Maruyama Hospital, Hamamatsu, Japan 2 Second Division, Department of Internal Medicine, Hamamatsu University School, Hamamatsu, Japan Poster 87 Hemorrhagic Thyroid Cyst Causing Right Recurrent Laryngeal Nerve Palsy

Thyroid Nodules and Goiter Thursday Poster Clinical

Thyroid cyst can be classified into simple colloid and complex cysts, including hemorrhagic cysts, cysts with epithelial component or cysts filled with transudate. The common clinical manifestation of hemorrhagic cysts is an anterior neck mass, sometimes accompanied by cervical pain.

This is a clinical case report from Hamamatsu University School of Medicine.

In September 2007, a 61-year-old man was referred to our hospital because of a right thyroid cyst of 5.3cm maximum diameter found on ultrasonography at a medical checkup. Palpation revealed a firm thyroid nodule but no subjective symptoms were noted. Since fine needle aspiration biopsy showed benign cytology, he stopped consulting our hospital. In April 2009, he was admitted to another hospital with acute myocardial infarction. His manifestations improved after emergent pericutaneous coronary intervention, and subsequent antiplatelet therapy with 100mg aspirin plus 75mg clopidogrel was started. He was referred to our hospital again for evaluation of the right thyroid cyst. Ultrasonography exhibited negligible changes. In May 2010, he visited our hospital with complaints of vague anterior neck pain and hoarseness. Computed tomography delineated a low-density mass of 6.8 cm maximum diameter causing tracheal deviation as well as compressing the right common carotid artery and brachial artery (see figure). Subsequent laryngoscopy revealed right vocal cord palsy. Emergency hemithyroidectomy was performed and surgical exploration revealed that a non-invasive firm nodule had deviated the brachial artery below, resulting in compression of the right recurrent laryngeal nerve. Histological findings confirmed the diagnosis of hemorrhagic thyroid cyst. His complaints gradually improved and normal recurrent laryngeal nerve function was observed two months after surgery.

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We report here a very interesting patient with hemorrhagic thyroid cyst causing right recurrent laryngeal nerve palsy. Physicians should be aware of the possible risk of hemorrhagic cyst, especially in patients treated with antiplatelet or anticoagulation therapy, since it can lead to potentially life-threatening vocal cord palsy.

1 Otolaryngology, Head and Neck Surgery, University Hospital Birmingham, Birmingham, United Kingdom 2 Clinical and Experimental Medicine, University of Birmingham, Birmingham, United Kingdom Poster 88 Trainee Outcomes in Thyroid Surgery

Thyroid Nodules and Goiter Thursday Poster Clinical

In the UK, trainees in Otolaryngology and Endocrine Surgery are required to gain skills in thyroid surgery. As trainee numbers are increasing and the duration of training decreasing, there is concern that trainees are not receiving sufficient experience and supervision in thyroidology. We set out to determine whether operations performed by trainees differed in complication rate, length of stay and duration compared with consultants.

A prospectively collected database of all thyroid operations performed at our tertiary referral centre was analysed. Operations performed by trainees were compared with those performed by consultants, specifically examining the operation length, complication rate and length of stay.

1470 patients from 1994–2009 were included in the analysis. 1139 cases were performed by a consultant and 331 by a trainee. The percentage of trainee cases per year increased slightly over the study period (R²=0.03). The overall complication rate was 21% for consultant cases and 14.5% for trainees. Temporary hypocalcaemia rate was 28% and 32% for consultants and trainees respectively, while temporary RLN palsy rate was 2.4% for consultants (1523 nerves at risk) and 2.1% for trainees (387 nerves at risk). There was no significant difference in length of stay for hemi-thyroid surgery between the two groups, although the duration of surgery was significantly shorter for consultant procedures (69 mins vs 75 mins, P<0.001). For total thyroid surgery, duration of surgery did not differ significantly; length of stay was longer for the consultant group (3.2 days vs 2.7 days, p=0.03), likely reflecting the fact that the consultant cases tended to be more complicated.

We have demonstrated that there is no increased risk of complication when thyroid surgery is performed by a trainee, provided that there is an appropriate level of supervision and that cases are selected to match the trainee's level of experience. Trainees learning thyroid surgery should be under the supervision of an experienced thyroid surgeon to ensure complications are minimal.

1 Subdireccion de Investigacion, Facultad de Medicina U.A.N.L., Monterrey, Nuevo Leon, Mexico 2 Posgrado, Universidad Juárez del Estado de Durango, Durango, Mexico Poster 89 Prevalence of Thyroid Nodules in Mexican Patients with Systemic Lupus Erithematosus

Thyroid Nodules and Goiter Thursday Poster Clinical

Systemic Lupus Erythematosus (SLE) is an autoimmune disease whose prognosis has improved in recent decades due to advances in diagnosis and treatment, which has been associated with improvement in quality of life, survival and as consequence the development of co-morbidities such as cancer. Thyroid nodules (TN) are a common clinical problem, whose prevalence is reported up to 7%. Its clinical importance is the need to exclude thyroid cancer which occurs in 5–15% of TN depending on diverse risk factors. In patients with SLE a reported prevalence of 25% of TN has been found. The purpose of this study is to report the prevalence of TN in a group of patients with SLE in a single hospital.

We developed an observational, transverse, analytic study at the University Hospital in Monterrey N.L. during August 2010-May 2011. We included 19 patients over 18 years of age, with diagnostic criteria for SLE. We documented clinic, demographic and anthropometric characteristics. All patients underwent a thyroid ultrasound to document the presence of TN. We calculated the prevalence of TN in SLE patients and compared it with the one found in a previous study in our population. We considered significant a p≤0.05.

We included 19 female patients; average age was 37±9 years old, with a BMI of 27±7 kg/m², 21% with overweight and 21% with obesity. The time since the diagnosis of SLE was 9±6 years. 21% patients had family history of thyroid disease, 5% smoke, and 16% the diagnosis of primary hypothyroidism. The prevalence of TN in our study population was 32% (95% CI, 15.4–54.3) with a nodular size ranged in 2–8 mm. We did not find any association between the presence of TN and the studied variables.

There is a high prevalence of TN in SLE Mexican patients compared to the one found in the general population.

1 Pathology, MDACC, Houston, TX 2 Endocrine Neoplasia and Hormonal Disorders, MDACC, Houston, TX 3 Radiology, MDACC, Houston, TX Poster 90 Leukemic Infiltration of the Thyroid Gland

Thyroid Nodules and Goiter Thursday Poster Clinical

Chronic lymphocytic leukemia (CLL) is characterized by clonal proliferation of small mature B-lymphocytes that infiltrate bone marrow, blood, lymph nodes and spleen. In advanced stages, CLL can involve other organs such as the skin and lungs. Thyroid involvement has not been described. We describe a rare case of CLL infiltration of the thyroid gland associated with primary hypothyroidism and Hashimoto's thyroiditis.

A 71-year-old woman with a two-year history of CLL and no history of thyroid disease presented with a markedly enlarged thyroid gland. Thyroid function tests revealed subclinical hypothyroidism with a TSH of 10 MCU/ML. A thyroid iodine-scan revealed nodular foci of increased uptake in the lower pole of the right thyroid lobe and mid aspect of the left lobe with diminished tracer uptake throughout the remainder of the thyroid parenchyma. Ultrasound revealed an enlarged non-homogenous thyroid with increased vascularity.

Fine needle aspiration showed leukemic infiltration of the thyroid gland with histologic staining positive for CD19, CD20, CD5, CD23 and CD38. The patient had elevated titers of thyroid peroxidase antibodies 27358 IU/ML and thyroglobulin antibodies 6612 IU/ML. Patient was treated with lenalidomide. After 6 months of therapy, the patient exhibited a partial remission of the CLL. Thyroid ultrasound revealed a substantial decrease of the thyroid size with normalization of thyroid function tests and decreased titers of thyroid peroxidase antibodies (1346 IU/ML) and thyroglobulin antibodies (2294 IU/ML).

CLL may infiltrate the thyroid gland predisposing to a reversible Hashimoto's thyroiditis and primary hypothyroidism if responsive to systemic therapy. This case illustrates the role of B-cells in Hashimoto's thyroiditis pathogenesis and an unexpected benefit derived from lenalidomide on this disease.

1 Department of General Surgery, Wuhan Union Hospital, Wuhan, China 2 Department of Pathology, Wuhan Union Hospital, Wuhan, China Oral 92 What a Role Does Multifocality Play in Papillary Thyroid Microcarcinoma(PTMC)?

Thyroid Cancer Friday Oral Clinical 2:30 PM

Prophylactic central neck dissection (CND) is gaining acceptance in treating papillary thyroid carcinoma (PTC) as studies have shown nodal disease increases the rate of local recurrence. But surgical indication of PTMCs is still controversial. Most PTMCs follow an indolent clinical course, but a few present with lymphadenopathy. It's important to indentify the subgroup of PTMCs with high risk to experience lymph node metastasis (LNM) especially subclinically.

From 2003 to 2011, 1456 PTC patients received surgeries in our institution. 212 PTMCs who were received primary treatment here and underwent total thyroidectomy (TT) associated with CND were included in this study. The frequency of LNM was analyzed according to age, gender, tumor size, multifocality and extrathyroidal extension. All pathological results were reviewed by a pathologist. For multifocal lesions, the analysis was first performed according to the largest dominant tumor as previous study, then we calculate the total diameter of each foci as overall diameter of the specimen for further analysis (Table 1). At last we performed a meta-analysis comparing the LNM between mutifocal and unifocal PTMCs in patients that all underwent thyroidectomy associated with cervical lymph node dissection.

With use of univariate and multivariate analysis, age, gender, local infiltration and multifocality were independent correlates of LNM in PTMCs. In further analysis, the proportion of LNM was similar in multifocal PTMCs with overall diameter less than 1cm and unifocal PTMCs (37.5% vs. 30%, P>0.05), also similar in multifocal PTMCs with overall diameter less than 2 greater than 1cm and solitary tumors with diameter equivalent to the former (1–2cm) (56.82% vs. 64.96%, P>0.05), however significantly higher in mulifocal PTMCs with overall diameter greater than 1 cm than unifocal PTMCs (60.42% vs. 30%, P<0.01). Using random effects model, a meta-analysis of nine publications with a total 1586 PTMCs demonstrated that multifocality was significantly associated with LNM risk with an OR of 1.842 (95% CI, 1.318–2.574).

Patients who have multifocal PTMC with overall diameter greater than 1cm can not be considered low risk. TT associated with routine CND may be the best surgical approach.

1 Head and Neck, Memorial Sloan-Kettering, New York, NY 2 Pathology, Memorial Sloan-Kettering, New York, NY 3 Radiation Oncology, Memorial Sloan-Kettering, New York, NY 4 Endocrinology, Memorial Sloan-Kettering, New York, NY Oral 95 Poorly Differentiated Thyroid Carcinoma Presenting with Gross Extrathyroidal Extension: 1986–2009 Memorial Sloan-Kettering Cancer Center Experience

Thyroid Cancer Friday Oral Clinical 3:15 PM

Purpose: To describe the outcome of patients with poorly differentiated thyroid cancer (PDTC) presenting with gross extrathyroidal extension (ETE).

Materials and Methods: Retrospective data were collected in a consecutive series of 27 patients with PDTC and gross ETE (T4a) treated by primary surgical resection with or without adjuvant therapy from 1986–2009. Of 27 patients, 52% were female. The median age was 70 (range 27–87). 41 % of patients presented with N0, 6 (22%) N1a and 10 (37%) N1b neck disease. Ten patients (37%) presented with distant metastases; seven to the bone with three also with lung metastases and three only with lung metastases. All patients were managed by extended total thyroidectomy except for two managed by subtotal thyroidectomy. 20 patients (74%) had central compartment neck dissection and more than half of them (11) also had lateral neck dissection. 21 patients (77%) had adjuvant therapy: 15 (55%) RAI only, 3 (11%) postoperative radiation (PORT) only and 3 (11%) both RAI and PORT. Overall survival (OS), disease specific survival (DSS), local recurrence free survival (LRFS) and regional recurrence free survival (RRFS) were calculated by the Kaplan Meier method.

Median follow-up time was 57 months (range 1–197 months ). The 5 year OS and DSS were 47% and 49% respectively. This poor outcome was due to distant metastatic disease; 10 patients had distant metastases at presentation and a further 6 patients developed distant metastases during follow up. Locoregional control was good with a 5 year LRFS and RRFS of 70% and 62% respectively. Overall, 8 patients (30%) had recurrences: 2 had distant alone, 2 regional, 2 regional and distant, 1 local and distant, and 1 had local, regional and distant recurrence.

Aggressive primary surgery in patients with PDTC showing gross ETE resulted in satisfactory locoregional control. Due to the small proportion of patients who received PORT (22%), it is not possible to analyze its benefit on locoregional control. Of significance is the observation that the majority of patients (60%) present with or subsequently develop distant metastases and eventually die of the distant disease. Further improvements in outcome therefore require new systemic therapies to target distant metastatic disease.

1 Surgery, University of Pittsburgh, Pittsbuth, PA 2 Medicine, Section on Decision Sciences and Clinical Systems, University of Pittsburgh, Pittsburgh, PA 3 Pathology, University of Pittsburgh, Pittsburgh, PA 4 Endocrinology, University of Pittsburgh, Pittsburgh, PA Oral 96 Cost Impact of Routine Molecular Testing for Indeterminate Thyroid Nodule Fine Needle Aspiration Biopsies

Thyroid Cancer Friday Oral Clinical 3:30 PM

To exclude or confirm thyroid cancer, accurate evaluation of thyroid nodules is important. Molecular testing of fine needle aspiration (FNA) specimens can help diagnose thyroid cancer although the added cost has not been studied. Our objective was to ascertain if routine molecular testing of FNA specimens in two indeterminate categories (follicular lesion of undetermined significance and follicular neoplasm) can be cost-saving.

A decision tree model was constructed to compare the estimated costs of thyroid nodule evaluation according to the current ATA guidelines either with routine molecular testing (MT) or without (standard of care, StC). Estimates of the probability values were based on a comprehensive review of recent literature and were limited to studies that used the Bethesda 2007 classification system. Cost of surgeries (thyroid lobectomy, total thyroidectomy, and completion thyroidectomy) were calculated from inpatient hospital costs obtained from the Healthcare Costs and Utilization Project, included surgical complication rates, and accounted for an estimated proportion of outpatient surgeries. Estimates for physician fees, outpatient laboratory and medication costs were based on median 2010 Medicare Reimbursement rates for the corresponding CPT code.

Compared to StC, MT use was associated with a decrease in the number of necessary diagnostic lobectomies (StC 11.6% v. 8.2%). In this distributed risk model, initial total thyroidectomy was more frequent with MT use (19.6% v. StC 16.1%). Although MT use added a diagnostic cost of $2,936 to the cost of total thyroidectomy ($11,383), the additive cost was less than the comparable cost in the StC cohort of performing a lobectomy ($7,684) and completion thyroidectomy ($11,954) when indicated by final histologic results. When the cost of MT was varied in sensitivity analysis, cost-savings were demonstrated if molecular testing cost remained less than $1303.

Routine molecular testing of cytologically indeterminate FNA results can be cost-saving because of reduction in two-stage thyroid surgery. Appropriate use of emerging molecular testing techniques may help avoid unnecessary surgery to optimize patient care and improve resource utilization.

1 Radiology/Nuclear Medicine, Univ Michigan, Ann Arbor, MI 2 Surgery/Endocrine Surgery, University of Michigan, Ann Arbor, MI 3 VA Medical Center/Nuclear Medicine, University of Michigan, Ann Arbor, MI Oral 97 Diagnostic 131-I Fusion SPECT-CT Imaging in Post-Operative Thyroid Cancer Patients: What is the Impact On Staging?

Thyroid Cancer Friday Oral Clinical 3:45 PM

We assessed the contribution of post-operative diagnostic 131-I SPECT-CT to staging in patients (pts) with differentiated thyroid cancer (DTC).

We studied 320 pts (219F; 101M, mean age 47.3±16.4, range 10–90) with DTC (289 papillary, 22 follicular and 9 Hurthle cell) with diagnostic 131-I planar and SPECT-CT. Initial staging using AJCC TNM 7th ed. was based on clinical and pathology data (pTNM). Restaging then incorporated the findings from 131-I imaging. Results were analyzed separately according to age: young pts, age<45, n=138 (43%) and older pts, age≥45, n=182 (57%).

Initial pTNM staging classified all young pts (100%) as stage 1. However, imaging detected distant metastases (mets) in 5/138 (4%) thereby restaging to stage 2, while 133 (96%) remained stage 1. In 95 young pts with central neck dissection, histology revealed 20 (14%) without node mets (pN0), and 75 (54%) with nodal mets (pN1). In 43 (31%) without neck dissection (pNx), SPECT-CT characterized 33 as N0, and 10 as N1. Nodal disease was seen on imaging in 43 (31%) pts: 18 with pN0 or pNx changed to N1 due to detection of unsuspected nodal mets, and 25 with pN1 had additional nodal mets after surgery. The older pts were initially pTNM staged as: 48 (26%) stage 1; 23 (13%) stage 2; 65 (36%) stage 3; 45 (25%) stage 4A/B; 1 (<1%) stage 4C. After imaging pts were restaged as: 33 (18%) stage 1; 19 (10%) stage 2; 52 (29%) stage 3; 58 (32%) stage 4A/B; 20 (11%) stage 4C. Imaging upstaged 46 older pts owing to detection of distant mets in 19 (10%) and of regional mets in 27 (15%). In 119 older pts with central neck dissection, histology revealed 45 (25%) without node mets (pN0), and 74 (41%) with nodal mets (pN1). In 63 (35%) without neck dissection (pNx), SPECT-CT characterized 51 as N0, and 12 as N1. Distant disease was seen on imaging in 20 (11%) pts, and nodal disease in 37 (20%) pts: 19 with pN0 or pNx changed to N1 due to detection of unsuspected nodal mets, and 18 pN1 had additional nodal mets after surgery.

Diagnostic 131-I SPECT-CT detected regional disease in 22% and distant mets in 8% of pts. This led to upstaging in 4% of young and 25% of older pts. Compared with pTNM staging alone, 131-I hybrid imaging leads to more accurate staging.

Diagnostic 131-I hybrid imaging in a 56 year old woman with 1.2 cm papillary thyroid cancer without capsular invasion, no extra-thyroidal extension and negative surgical margins; no pathologic evidence for nodal disease (0/3 central nodes submitted); pT1b,N0,M0 stage I. Planar scan (A) depicts focal neck activity (arrowhead) corresponding on SPECT-CT (B) to thyroid remnant; and focal activity in the liver (arrow) corresponding on SPECT-CT (C) to 0.8 cm hypodense lesion also confirmed on liver US and MRI, consistent with hepatic metastasis, restaging: pT1b,N0,M1 stage IVC disease. Subsequent 131-I scan (D) obtained at 6 months after 200 mCi (5.4 GBq) 131-I therapy documents interval resolution of liver metastasis and of thyroid remnant tissue; there is physiologic tracer distribution throughout the body.

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1 Signal Transduction Laboratory, Ordway Research Institute, Albany, NY 2 Pharmaceutical Research Institute, Albany College of Pharmacy and Health Sciences, Albany, NY 3 Radiation Oncology, The Cleveland Clinic, Cleveland, OH Oral 99 Crosstalk Between Integrin αVβ3 and Estrogen Receptor-α Mediates Thyroid Hormone-Induced Proliferation of Human Lung Cancer Cells

Thyroid Hormone Action Friday Oral Basic 2:45 PM

A cell surface receptor for thyroid hormone that activates extracellular-regulated kinase (ERK 1/2) has been identified on integrin αvβ3. We examined the actions of thyroid hormone, initiated at the integrin, on proliferation of human NCI-H522 non-small cell and NCI-H510A small cell lung cancer cells.

The methods have been described in our prior publications.

At a physiologic total hormone concentration (10–7 M), T4 significantly increased proliferating cell nuclear antigen (PCNA) abundance in these cell lines; 3,5,3′-triiodo-L-thyronine (T3) at a supraphysiologic concentration also enhanced proliferation. Neutral-izing antibody to integrin αvβ3 and an integrin-binding Arg-Gly-Asp (RGD) peptide each blocked thyroid hormone-induced PCNA expression. Tetraiodothyroacetic acid (tetrac) lacks agonist thyroid hormone function, but inhibits binding of T4 and T3 to the integrin receptor; tetrac eliminated thyroid hormone-induced lung cancer cell proliferation and ERK1/2 activation in both cell lines. In these estrogen receptor-α (ERα)-positive lung cancer cells, thyroid hormone (T4>T3) caused phosphorylation of ERα. The specific ERα antagonist ICI 182,780 (fulvestrant) blocked T4-induced, but not T3-induced, ERK1/2 activation. ICI 182,780 also inhibited thyroid hormone stimulation of ERα phosphorylation, proliferating-cell nuclear antigen (PCNA) expression and hormone-dependent thymidine uptake by tumor cells. In summary,in ERα-positive human lung cancer cells, the proliferative action of thyroid hormone initiated at the plasma membrane is mediated by ERα.

Thyroid hormone may be one of several endogenous factors capable of supporting proliferation of lung cancer cells. In ERα-positive human lung cancer cells, enhancement of cell proliferation by T4 requires crosstalk with the estrogen receptor. Activity as an inhibitor of lung cancer cell proliferation induced at the integrin receptor makes tetrac a novel anti-proliferative agent.

1 Physiology and Neurobiology, Dartmouth Medical School, Lebanon, NH 2 Medicine, Dartmouth Medical School, Lebanon, NH Oral 101 Fasting-Induced Changes in Circulating Thyroid Hormone Levels Result in Part From Retention and Metabolism of Thyroxine and 3,5,3′-Triiodothyronine in Tissues

Thyroid Hormone Metabolism and Regulation Friday Oral Basic 3:15 PM

Fasting induces rapid changes in thyroid hormone (TH) economy characterized in rodents by decreases in serum thyroxine (T4) and 3,5,3′-triiodothyronine (T3) levels, whereas the serum TSH level remains normal. The types 1, 2 and 3 deiodinases (D1, D2, D3) have been postulated to play important roles in these changes. The goal of these studies was to examine the mechanisms underlying these phenomena.

Experiments were performed in transgenic mice deficient in one, two or all three deiodinases, Mice were fasted for 30h. Serum TH and TSH levels, and tissue TH contents were measured by radioimmunoassay. 5-Deiodinase activity was determined by our published method.

Mice deficient in either the D1, D2 or both enzymes (D1/D2KO) showed fasting-induced decreases in serum T4 and T3 levels equal to or greater than that observed in wild type (WT) animals (43% decrease in T4, 23% decrease in T3). The serum TSH level in all groups was unchanged, as was the tissue contents of T4 and T3 in liver, kidney and muscle. Following an injection of [125I]T4 or [125I]T3 into WT mice, the content of radioactivity in the majority of tissues in the fasting state was increased approximately 2-fold or 4-fold, respectively, due presumably to the accumulation of iodothyronines other than T4 and T3. D1/D2KO mice showed the same distribution of radioactivity. D3 activity was increased in kidney, muscle and liver up to 4-fold during fasting and the production of rT3, a reaction product of the D3, was significantly increased. Notably, fasted mice deficient in only the D3, or in all three deiodinases (D1/D2/D3KO), still showed significant decreases in serum T4 and T3 levels compared to fed animals.

In conclusion, alterations in D1 and D2 activities observed during fasting appear to play little, if any role in the characteristic pattern of serum TH and TSH levels observed in this condition. Rather, the decreases in circulating T4 and T3 appear secondary, in large part, to an increased retention and metabolism of TH in tissues, which may be due in part to enhanced D3 activity.

1 NIDDK, NIH, Bethesda, MD 2 Clinical Center, NIH, Bethesda, MD Oral 102 Triiodothyronine Serum Levels Changes During Controlled Weight Loss in Overweight Humans

Thyroid Hormone Metabolism and Regulation Friday Oral Clinical 3:30 PM

Obesity is a source of considerable morbidity and early mortality in the U.S., and it is the result of a sustained imbalance between energy intake and energy expenditure (EE). In sedentary individuals, resting energy expenditure (REE) may account for up to 85% of total energy expenditure. Thyroid hormone (TH) and particularly triiodothyronine (T3) play a critical role in the modulation of REE and substrate metabolism. Limited information is available on the effects of prolonged weight loss on TH homeostasis. The aim of the study was the evaluation of changes in TH homeostasis in response to a controlled weight loss dietary intervention.

32 Control (19M, 13F, BMI 21.9±1.9 kg/m²) and 47 overweight Subjects (15M, 32F, BMI 34.12±4.6 kg/m²), aged 25–45 years were enrolled in the study. All volunteers were healthy, as determined by medical history and laboratory tests, with no history of thyroid disease. Baseline procedures included: blood and urine sampling, anthropometry, body composition by DEXA, and REE evaluation by indirect calorimetry. Overweight subjects underwent a one-year individualized calorie-restricted diet (≈600 Kcal/day deficit) and were encouraged to increase physical activity, achieving an average rate of weight loss of 0.8±2.3 kg/month. Measurements were performed at 0, 1.5, 3, 6, 9, and 12 months. To date 27 subjects completed the study, 5 subjects completed 5, 8 subjects completed 4, and 7 subjects completed 3 follow-up visits.

Baseline T3 levels in overweight and control subjects correlated with fat mass (r²=0.073, p<0.02). Over the study period the dietary intervention resulted in a decrease in T3 levels (11.14±19.7 ng/dL), which correlated significantly with the weight loss (r²=0.114, p<0.0001). In contrast, no significant correlations were observed between fat mass and free thyroxine (T4) or thyroid-stimulating hormone (TSH) levels.

Our results indicate that T3 is a sensitive index of body weight changes, and that weight loss produces sustained changes in this parameter without affecting TSH or free T4. Taken together, the data suggest that weight loss affects the peripheral conversion of T4 into T3 with limited effects on the central TH homeostasis.

1 Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN 2 Endocrinology, Mayo Clinic, Rochester, MN Oral 103 Increased Heterophile Antibody Interference in the Beckman Coulter, Inc. (BCI) Access^® TSH Assay Causes Potential Clinically Significant Errors in TSH Reporting

Disorders of Thyroid Function Friday Oral Clinical 3:45 PM

Heterophile antibodies, or human anti-animal antibodies, are known to affect a variety of immunoassays, including commonly used assays for thyroid stimulating hormone (TSH). Because TSH is widely used as the primary tool to detect thyroid disease, erroneous TSH results caused by heterophile antibody interference could pose a risk to accurate diagnosis and treatment of patients. In the latter half of 2010, Mayo Clinic Laboratories noted a sustained increase in potentially erroneous TSH results using the BCI Access^® Assay. We therefore sought to evaluate the prevalence of heterophile antibody interference in patient samples using this assay and to determine its clinical impact.

All physician-ordered TSH samples received with results ≥10.0 mIU/L (Oct–Dec 2010; n=388 from 14,600 total tests) were re-assayed using the alternative Roche Elecsys^® TSH immunoassay. Potential heterophile antibody interferences were identified when BCI and Roche TSH results differed by ±20% and confirmed by treating samples with Scantibodies HBT heterophile antibody blocking reagent and retesting. In addition, 970 consecutive physician-ordered TSH samples with BCI TSH results <9.9 mIU/L were tested in the same way.

For the samples where the BCI TSH results were ≥10.0 mIU/L, heterophile antibody interference using the BCI assay was confirmed in 17/388 (4.4% prevalence). Results were concordant between the BCI and Roche methods in 970 TSH samples with results <9.9 mIU/L. Of the 17 samples with confirmed heterophile antibody interference, accurate TSH concentrations were actually <10.0 mIU/L in all cases (3 patients <0.10 mIU/L, 9 patients 0.3–5.0 mIU/L, 5 patients 5.0–10.0 mIU/L).

The prevalence of heterophile antibody interference with the BCI Access^® TSH assay in samples with TSH results ≥10.0 mIU/L was 4.4%. In all cases of confirmed heterophile antibody interference, the accurate TSH concentration was <10.0 mIU/L. These patients were therefore at risk of having erroneous diagnoses of hypothyroidism or having preexisting treatment with thyroid hormone adjusted inappropriately. Laboratories using the BCI Access^® TSH assay need to be aware of the prevalence of heterophile antibody interference and potential risk to patients.

1 Dept. of Molecular Medicine, Nagasaki University, Nagasaki, Japan 2 Dept. of Ophthalmology, University of Duisburg-Essen, Essen, Germany 3 Dept. of Medicine and Molecular Science, Gunma University, Maebashi, Japan Poster 104 Adoptive Transfer of Anti-Thyrotropin Receptor (TSHR) Autoimmunity from TSHR Knockout Mice to Athymic Nude Mice

Autoimmunity Friday Poster Basic

We have recently shown that wild type (wt) mice are highly tolerant, while thyrotropin receptor (TSHR) knockout (KO) mice are susceptible, to immunization with the mouse (m) TSHR, the autoantigen in human Graves' disease. However, because TSHR KO mice lack the endogenous TSHR in their thyroids, Graves'-like hyperthyroidism cannot be expected in these mice. Therefore, we performed adoptive transfer of splenocytes from TSHR KO mice immunized with adenovirus expressing mTSHR A-subunit (Ad-mTSHR A-subunit) into immune-deficient athymic nude mice expressing the endogenous TSHR in their thyroids as well as in orbital tissues.

TSHR KO BALB/c mice were immunized with Ad-mTSHR A-subunit twice at 3-week-intervals. A group of mice was also treated by anti-CD25 antibody. Splenocytes were prepared 2 weeks later, and adoptively transferred to nude BLAB/c mice. Bloods were taken regularly for T4 and TSHR antibody measurements. Thyroid and retro-orbital histology were also examined.

Circulating anti-TSHR autoantibodies were detected in ∼50 % recipient nude mice 4 weeks after adoptive transfer of splenocytes (5x10e7/mouse) from TSHR KO mice immunized with Ad-mTSHR A-subunit and persisted for 24 weeks. Depletion of regulatory T cells by anti-CD25 monoclonal antibody in donor mice increased successful transfer rates without increasing TSHR antibody levels. Some recipient nude mice showed a transient increase in T4 levels 4–8 weeks after transfer, but many became hypothyroid (subnormal T4 and high TSH) 24 weeks later. Moreover, in addition to sparse lymphocyte infiltration in the thyroid glands, macrophage infiltration was observed in the retro-orbital fat tissues and extraocular muscles in a small fraction of the recipients.

Our findings demonstrate successful adoptive transfer of anti-TSHR autoimmune response from TSHR KO mice to nude mice. Although development of hyperthyroidism was transient and infrequent, induction of orbital lesions suggests that anti-TSHR immune response appears to at least partly play a role for the development of Graves' orbitopathy.

1 Medicine I, Gutenberg University Medical Center, Mainz, Germany 2 R & D, Diagnostic Hybrids, Inc., Athens, OH Poster 108 Thyroid Stimulating Immunoglobulin Levels During Therapy for Graves' Disease—A Prospective Trial

Autoimmunity Friday Poster Clinical

Limited data exist on the role of thyroid stimulating immunoglobulins (TSI) in the management of Graves' disease (GD). In a prospective clinical trial, we aimed to test the hypothesis that TSI levels are useful for predicting response to therapy and/or relapse.

Seventy untreated hyperthyroid subjects with GD were treated with antithyroid drugs (ATD) for 24 weeks. Subsequently, patients were divided into responders (normal thyroid hormone levels) and non-responders. In responders ATD were terminated whereas non-responders remained on treatment for additional 12 weeks. Serum TSI levels were measured at baseline, at 4, 8, 12, 24 and 36 weeks after starting ATD with a FDA-cleared TSHR bioassay (Thyretain) and expressed as the percent specimen-to-reference-ratio (SRR%).

To date 45 hyperthyroid GD patients (35 female, 28 with orbitopathy, GO) have completed the 24 week ATD treatment (interim analysis). 15 of 45 (33%) were responders, 10 female (66%), 9 younger than 50 (60%), 7 (46.7%) with GO. Of 30 non-responders, 21 (70%) had GO, 25 were female (83.3%) and 19 were younger than 50 (63.3%). In the non-responder group, baseline TSI levels were markedly higher in GD+GO vs. GD patients (median SRR% 425 vs. 358, 18.7%), whereas this difference was larger in the responder group (410 vs. 300, 37%). At week 24, TSI levels decreased markedly in all responders (374 vs. 218, Δ minus 41.7%, p<0.05). The decrease was more significant in those with GD only (300 vs. 195, Δ minus 35%) compared to GD+GO (410 vs. 341, Δ minus 16.8%). In contrast, TSI levels increased in all non-responders from 397 to 445, Δ plus 12%).

Response to ATD is higher in patients with thyroidal GD only and is accompanied with significant decrease in TSI levels. In contrast, TSI levels remain unchanged or increase in non-responders, most of whom have systemic GD.

1 Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea 2 Severance Executive Healthcare Clinic, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea Poster 109 Baseline Vitamin D Level Could be a Short-Term Prognostic Marker in Patients with Graves' Disease

Autoimmunity Friday Poster Clinical

The role of vitamin D as an immune modulator has been emphasized in recent years, and low levels of the hormone were observed in several autoimmune diseases. Vitamin D levels were found to be lower in patients with AITDs than in healthy volunteers in one study, and in Graves' disease patients when compared to patients with non-AITDs. Significantly low levels of vitamin D were documented in patients with AITDs that were related to the presence of anti-thyroid antibodies and abnormal thyroid function tests, suggesting the involvement of vitamin D in the pathogenesis of AITDs and the advisability of supplementation. To determine the effect of baseline serum vitamin D level on hyperthyroidism in patients with untreated Graves' disease, we performed retrospective study.

44 patiens were divided by 2 groups based on baseline serum 25-hydroxy-vitamin D (25(OH)D) level (vitamin D deficient group (25(OH)D<10 ng/mL), n=21, vitamin D non deficient group (10 ng/mL≤25(OH)D), n=23). All patients receive a daily dose of 15 mg methimazole (MMI). These treatment regimens were continued. Mean follow up duration was 24 weeks. Physicians were allowed to adjust MMI dosage during follow up visits. Blood samples were collected, and serum concentrations of free triiodothyronine (FT3), free thyroxine (FT4), T3, thyrotropin (TSH), TSH-receptor antibody (TRAb), and Thyroid stimulating antibody (TSAb) were determined.

All patients became euthyroid after treatment. The dose of MMI was not significantly different between these two groups. In contrast, decreases in mean serum T3 and FT4 levels were greater in vitamin D non deficient group. Correspondingly, the reciprocal increase in the mean TSH level was more prominent in vitamin D non deficient group. Mean TRAb and TSAb levels did not differ between the two groups at baseline. However, decreases in TRAb and TSAb levels were greater in vitamin D non deficient group.

We suggest that baseline vitamin D level may affect the outcome of Graves' disease.

1 Internal Medicine, Maryknoll Medical Center, Busan, Republic of Korea 2 Internal Medicine, Dongnam Institute of Radiological & Medical Sciences Cancer Center, Busan, Republic of Korea 3 Internal Medicine, Asan Medical Center, Seoul, Republic of Korea Poster 110 Association Between Thyroid Autoimmunity and Helicobacter Pylori Infection

Autoimmunity Friday Poster Clinical

There have been controversial reports linking Helicobacter pylori (H pylori) infection to autoimmune thyroid disorders (ATD). There are some data which demonstrates more frequent H pylori infection in ATD patients. However, data regarding the relationship between H pylori infection and thyroid autoimmunity are limited in Korean population, who has extremely high prevalence of H pylori infection. We performed this study to investigate the prevalence of H pylori infection according to the presence of thyroperoxidase antibody (TPO Ab) in healthy adults without history of thyroid disease.

This study was done in adults aged from 30 to 69 years (median 52 years) who had visited the healthy promotion center at Asan Medical Center, Seoul, Korea, from Jan 2009 to Dec 2010. Subjects with previous thyroid disease were excluded. 5,325 subjects (2,286 females, 3,039 males) were analysed. Thyroid assessment was done by free T4, TSH and TPO Ab. Ig G Antibodies to H pylori (H pylori Ab) were determined as diagnosis of H pylori infection. We compared the prevalence of positive TPO Ab between subjects with positive H pylori Ab and negative H pylori Ab.

TPO Ab was positive in 278 women (12.2%) and 154 men (5.1%). H pylori Ab was positive in 2,787 (52.3%), out of 5,323 subjects. Prevalence of TPO Ab was more higher in subjects with positive H pylori Ab (8.9 % vs 7.2%, P=0.024). After adjusting for age and sex, those with H pylori infection were more higher prevalence of TPO Ab (P=0.026).

In our study, prevalence of TPO Ab was more higher in subjects with H pylori infection. Our findings suggest H pylori infection might be a causative factor to autoimmune thyroiditis.

1 Division of Endocrinology and Metabolism, UCSF, San Francisco, CA 2 Department of Biostatistics, University of Washington, Seattle, WA 3 Department of Epidemiology, University of Pittsburgh, Pittsburgh, PA 4 Department of Medicine, University of Pittsburgh, Pittsburgh, PA 5 Department of Medicine, University of California, Davis, CA 6 Division of Diabetes, Endocrinology, and Metabolism, University of Pennsylvania, Philadelphia, PA Poster 111 Longitudinal Changes in Thyroid Function Testing in the Oldest Old and Survival: The Cardiovascular Health Study All-Stars Study

Autoimmunity Friday Poster Clinical

Thyroid function testing abnormalities are common among the elderly; 13% of individuals over age 80 without known thyroid disease have TSH levels above the reference range. The natural history of thyroid function and its relationship to survival is unknown in this population of the oldest old. We sought to examine changes in thyroid function tests over time and to assess the association between thyroid function, thyroid peroxidase antibodies (TPOAbs), and mortality in a cohort of individuals of advanced age.

TSH, free thyroxine, total T3, and TPOAbs were measured from samples obtained at the 1992–1993 and 2005–2006 study visits in 1049 participants enrolled in the Cardiovascular Health Study All Stars Study (mean age 85.6±3.8 years in 2005–2006, 64% women, and 16% African American). The overall and annual change in TSH, free thyroxine, and total T3 was calculated over the 13 year period between visits in 649 individuals not taking thyroid medication. Age, sex, and race-adjusted Cox proportional hazards models were constructed to determine the relationship between TSH levels and TPOAb status at the 2005–2006 visit and incidence of death.

At the 2005–2006 visit, 88% of participants not taking thyroid medications were euthyroid (n=739) and subclinical hypothyroidism was the most common thyroid function abnormality, affecting 10% of the cohort (n=85). We found a small but statistically significant increase in TSH (0.32mU/L, p<0.01) and FT4 (0.02ng/dL, p=0.01), and decrease in TT3 (−0.23 nmol/L, p<0.01) in the 13 years between assessments. The median annual rate of change of TSH in those who reported no thyroid medication use was 0.017 mU/L/y. We found no association between TSH level at the 2005–2006 visit and death (HR=0.95, 95% CI 0.89–1.02), or TPOAb status and death (HR=1.03, 95% CI 0.65–1.61) over a median follow-up time of 4.8 years.

In this cohort of individuals of advanced age, there was a slight increase in TSH and free thyroxine and decrease in total T3 over a 13 year period. Neither TPOAb status nor TSH levels were associated with mortality. These findings suggest an age-related change in deiodination of T4 that is without clinical significance.

1 Department of Medicine, The University of Chicago, Chicago, IL 2 Department of Pediatrics, The University of Chicago, Chicago, IL 3 Pediatrics Endocrine Unit, Clalit Health Maintenance Organization, Haifa, Israel Poster 112 Common Ancestry for Two Mutant Alleles of Thyrotropin Receptor Gene in the Two Arab Families with Resistance to Thyrotropin

Disorders of Thyroid Function Friday Poster Clinical

Although inactivating thyrotropin receptor (TSHR) gene mutations are not uncommon causes for resistance to TSH they were particularly common in Arab tribes living in Northern Israel. In fact our laboratory has identified 6 distinct TSHR mutations in this population (P68S, L89L, Q90P, P264S, R609X and L653V) and in one tribe the frequency was 4.3%. In a large kindred of 30 individuals (Fam A) 3 nucleotide substitutions were identified in exon 3 producing Q90P and one in exon 9 of the same allele producing P264S. Another family of 9 individuals, reported herein (Fam B), belonging to a different tribe harbors only the 3 nucleotide substitution in exon 3. The aim of this study was to determine if the mutations have common ancestral origin.

Clinical and genetic studies. All coding regions of the TSHR were sequenced and microsatellite markers spanning the TSHR locus (5.19 cM) were used for haplotyping.

Two siblings of Fam B with congenital hypothyroidism were compound heterozygous for TSHR gene mutations. The paternal allele contained 3 nucleotide substitutions in exon 3 producing Q90P. The maternal allele harbored a missense mutation in exon 10 producing L653V. Using genetic markers spanning the TSHR locus, we investigated the possibility of a founder effect with subsequent mutational events for the presence of the same exon 3 mutation in different families. The haplotype of the TSHR allele harboring the mutation in exon 3 in Fam B was identical to the haplotype of the TSHR allele in Fam A, except for the presence of the mutation in exon 9 in Fam A, indicating that this P264S mutation occurred subsequently. Interestingly, wild-type TSHR haplotype was present in Fam B, indicating that the mutation in exon 3 was also a new mutational event in the history of that population.

It is possible that 2 consecutive mutational events occurred on the original wild-type allele generating the allele with both exon 3 and exon 9 mutations, instead of a recombination event that brought exon 3 and exon 9 mutations together on the same allele. We hypothesize that new mutation events contribute to the high prevalence of TSHR mutations in this population in addition to a founder effect and limited gene pool due to inbreeding.

1 Second Division, Department of Internal Medicine, Hamamatsu University School of Medicine, Hamamatsu, Japan 2 Department of Urology, Hamamatsu University School of Medicine, Hamamatsu, Japan Poster 114 Inappropriately Elevated Thyrotropin Levels in Patients Treated with Axitinib: A Case Series

Disorders of Thyroid Function Friday Poster Clinical

Axitinib is a selective inhibitor of vascular endothelial growth factor receptors. Although thyroid dysfunction in axitinib-treated individuals was first reported in 2010, the etiology and clinical features remain elusive.

We describe four consecutive patients treated with axitinib for metastatic renal cell carcinoma and referred to our department because of thyroid dysfunction.

Four patients (4 men; mean age 63 years) were started on 5mg axitinib twice daily. Baseline thyroid function tests were within the normal range and thyroid autoantibodies were negative in all patients. Marked elevation of TSH was observed in every patient, reaching more than 100 μIU/mL, within 1 month of axitinib treatment. Two patients showed a transient thyrotoxic phase about two months after therapy. In spite of very high TSH levels, free T4 remained within normal limits in two patients and decreased only slightly in the other two patients.

Administration of 25–125 μg levothyroxine was started in every patient; however, TSH levels remained relatively high. TSH levels returned to normal or to the upper limit of the normal range at treatment interruption in all patients. Since the patients exhibited inappropriate elevation of TSH, which was resistant to levothyroxine treatment, we compared the serum free T4 and TSH in axitinib-treated patients with those in 140 outpatients with thyroid diseases in our institute. Interestingly, most serum in patients treated with axitinib apparently shifted to the right on the free T4 vs. TSH plot (see figure). Inappropriate elevation of TSH induced by axitinib may be due to attenuated biological activity of circulating TSH or an impaired hypothalamus-pituitary-thyroid axis.

OPEN IN VIEWER

We report here a case series of axitinib-treated patients whose TSH levels were inappropriately elevated.

Black rhombus shows serum TSH and free T4 measurements in axitinib-treated patients. Solid line represents an approximated curve from data of 140 outpatients.

1 Surgery, UCLA, Los Angeles, CA 2 Surgery, UCSF, San Francisco, CA 3 Radiation Oncology, UCSF, San Francisco, CA Poster 116 Quality of Life Assessment in Pediatric Graves' Disease Patients After Treatment with Surgery Versus Radioactive Iodine (A Pilot Study)

Disorders of Thyroid Function Friday Poster Clinical

Due to the high failure rate with antithyroid drugs, the treatment of pediatric Graves' disease relies on the definitive therapies of radioactive iodine (RAI) ablation and surgery (thyroidectomy). The optimal treatment choice between these two options remains controversial. This study compares the quality of life outcomes in children treated for Graves' disease with either RAI or surgery.

Patients who were treated for pediatric Graves' disease from 1988 to 2008 by either surgery (26) or RAI (43) were identified in the operative and radiation oncology databases of an academic medical center. All patients were mailed two quality of life (QOL) surveys. 1) A novel Graves' disease QOL questionnaire created by the authors focused on the changes in Graves' disease symptoms associated with treatment that were related to physical health, mental health, and social welfare. 2) The CHQ PF-28, a validated generic QOL questionnaire, measuring present-time QOL was also used to evaluate patients under 18 years of age.

Of the 69 patients, 55 (80%) were female. There was a 16% response rate to the surveys (6 patients from the surgery arm and 5 patients from the RAI arm). Follow up times ranged from 4 months to 6 years post-treatment. From the Graves' specific QOL survey, there was a statistically significant benefit from surgery in improving sleep habits and for resolution of eye disease as compared to RAI (Mann-Whitney U test, p<= 0.02). None of the RAI patients with eye disease improved (n=3). Even though the surgical arm patients reported more pre-treatment symptoms than the RAI group (p=0.0067), 95% of symptoms (42/44) resolved completely in the surgery arm as compared to 62% (13/21) in the RAI arm (Z test, p<0.001). There were no significant differences in each of the subscales of the CHQ PF-28 between the surgery and RAI groups (n=4 per group).

This study suggests that eye disease and sleep habits improve more with surgery than with RAI for treatment of pediatric Graves' disease. Of those with pre-treatment symptoms, there is a greater resolution rate with surgery than with RAI. Overall quality of life appears similar between the two treatments; however, a distinction may become apparent in a larger cohort.

1 Endocrinology, Hospital Curry Cabral, Lisbon, Portugal 2 Centro de investigação de Patologia Molecular, Instituto Portugues de Oncologia de Lisboa, Lisbon, Portugal Poster 117 Familial Pseudohypoparathyroidism Type IB (PHP-IB): Clinical and Genetic Study of a Portuguese Family

Disorders of Thyroid Function Friday Poster Clinical

Familial PHP-Ib is a rare disease with difficulties in differential diagnosis. There is a resistance to PTH action, through its G-Protein-coupled receptor in the renal tubules, resulting from tissue-specific silencing of the G-protein alpha-subunit (Gsalpha), due to imprinting disruption of its encoding locus—GNAS (chromosome 20q13.3). In familial PHP-IB, maternally inherited deletions at the STX 16 gene are associated to a regional GNAS methylation defect. To study a Portuguese family in view to prevent hypocalcaemia—related complications through an early diagnosis and management of PHP-Ib.

We studied 14 elements of a family, including clinical presentation, hormone assays (calcium, phosphorus, Thyroid function tests, parathormone) and genetic study. Genomic DNA of each element was screened for 3 kb STX16 deletion, by amplification of a segment 4.3 kb of the gene for long range PCR.

The cohort was characterized: 4 elements symptomatic for PHP-Ib with the del 3 kb STX16 (2 females and 2 males, one of which with hypothyroidism), 4 elements asymptomatic with the del 3 kb STX16 (4 males) and 6 elements asymptomatic without the del 3 kb STX16 (4 females and 2 males).

The epigenetic study of this family permitted the identification of 8 elements with GNAS methylation defect (DMR 1A), responsible for the tissue-specific silencing of the Gs alpha and resistance to PTH in renal tubules. The deletion 3 kb STX16 was maternally inherited. Females can transmit the mutant allele to next generation, which present the disease independently of their sex. Males can transmit the mutant allele to next generation but the methylation defect and disease will not occur, independently of their sex. Although, if descendents have the genetic defect, they can transmit it to future generations. The genetic identification of hereditary form of PHP-Ib contributes to an early diagnosis and management of families with this disease.

1 Endocrinology, University of Wisconsin, Madison, WI 2 Endocrine Surgery, University of Wisconsin, Madison, WI Poster 118 Surgical Management of Pediatric Graves' Disease

Disorders of Thyroid Function Friday Poster Clinical

The management of Graves' disease (GD) in childhood remains controversial as no treatment option is without risk. Thyroidectomy in children is typically associated with higher risk than in adults, and thyroidectomy for Graves' disease can be very challenging. Therefore our goal was to determine if the outcomes of thyroidectomy for Graves' disease were worse in children than they are in adults.

We retrospectively reviewed a prospective database of patients undergoing thyroidectomy for Graves' disease between May 1994 and December 2010. We evaluated the presentation and clinical outcomes in children and adolescents and compared this to adults also undergoing thyroidectomy.

14 children and 40 adults underwent thyroidectomy for GD during this period. The median age in these two groups was 15 years and 38 years respectively. The majority of patients were female in both groups. The presenting symptoms were similar in both groups however the time between diagnosis of disease was longer in the children vs. the adults (14.4 vs 13.7 months, p=0.02). Children were more likely to get a total thyroidectomy than adults (p<0.001). Mean hospital length of stay was 1.4 days in children vs. 1.2 days in adults (p=0.28). Transient hypoparathyroidism was significantly higher in children (31% vs 5%, p=0.04), but there was no difference in the occurrence of permanent hypoparathyroidism (p=0.55). No patients in either group had laryngeal nerve damage, infection or death. One child (7%) and three adults (8%) had recurrence of their disease (p=0.73), all of which had undergone subtotal thyroidectomy.

Signs and symptoms of GD in children were similar to those in adults; however adults had surgery closer to the onset of their disease than children. There was no difference in the length of hospital stay between the two groups. There was a higher incidence in only temporary hypoparathyroidism in children compared to adults. Surgical management of GD in children should therefore still be considered safe and effective when performed by experienced surgeons.

1 Internal Medicine, Marshfield Clinic, Marshfield, WI 2 Endocrinology, Marshfield Clinic, Marshfield, WI Poster 119 Amiodarone Induced Thyrotoxicosis: A Challenging Clinical Situation

Disorders of Thyroid Function Friday Poster Clinical

Amiodarone is a commonly used anti-arrhythmic drug that can lead to both hypothyroidism and hyperthyroidism. Amiodarone induced thyrotoxicosis (AIT) is a disease which poses a diagnostic and therapeutic challenge.

We report a 79 year old male who had been on Amiodarone 200mg daily for 2 years for atrial fibrillation. He presented with excessive sweating and feeling warm. Evaluation revealed low TSH 0.02 (normal 0.35–4.5 uIU/ml) and high free T4 of 4.8 (normal 0.6–1.2 ng/dL). Amiodarone was switched to Dronedarone, a noniodinated agent.

TPO antibody and Thyroid Stimulating Immunoglobulin were negative. The neck ultrasound showed no nodules and color doppler showed no increase in vascularity. The radioiodine uptake was low at 0.8% at 24 hrs. A diagnosis of AIT, most likely type 2 was established and treatment with methimazole and prednisone was initiated. Patient started feeling better and TSH and free T4 returned to normal in 6 weeks.

Amiodarone has significant adverse effects due to the high amount of iodine content. AIT poses a challenge to the clinician in both diagnosis and treatment. AIT type 1 occurs in pre-existing thyroid disease and is triggered by iodine overload. It is treated with antithyroid drugs. AIT type 2 is a form of destructive thyroiditis that occurs in an apparently normal thyroid and is treated with glucocorticoids. Although investigations such as radioactive iodine uptake scan and ultrasound with doppler are useful tools to distinguish one type from another, there is a mixed variant commonly encountered in clinical practice, in which both forms coexist. The decision to treat with one drug rather than both prednisone and methimazole carries the risk of inadequate treatment with higher mortality and morbidity. A safe approach would be to treat AIT with both antithyroid drugs and glucocorticoids initially, and subsequently alter therapy once patient is better.

1 Medical Biochemistry, Acibadem University, Istanbul, Turkey 2 Endocrinology, Erciyes University, Kayseri, Turkey 3 Endocrinology, Suleyman Demirel University, Isparta, Turkey 4 Endocrinology, Acibadem Hospitals, Istanbul, Turkey 5 Public Health, Acibadem University, Istanbul, Turkey 6 Perchlorate Biomonitoring Laboratory, National Center for Environmental Health, CDC, Atlanta, GA Poster 121 Environmental NIS Inhibitors in Urine from Different Locations in Turkey

Iodine Uptake and Metabolism Friday Poster Basic

Perchlorate is an inorganic anion that can disrupt thyroid function by competitively inhibiting iodide uptake at the sodium-iodide symporter (NIS). NIS-mediated iodide uptake can also be inhibited by thiocyanate and nitrate. Prolonged inhibition of iodide uptake can lead to decreased thyroid hormone production and ultimately could result in hypothyroidism.The main objective of this pilot study is to characterize exposure to thiocyanate, nitrate and perchlorate in areas with differing iodine intakes in non-pregnant and non-lactating women.

Health volunteer participants were randomly selected from non-pregnant and non-lactating women 18 years of age or older women. Iodide, thiocyanate, nitrate and perchlorate levels measured in 24 hours collected urine samples from different city in Turkey. NIS inhibitors were analyzed by triple-stage quadrupole ion chromatography-mass spectrometry (IC-MS/MS) using an Applied Biosystems 4000 IC-MS/MS system slightly modified version of the method by Valentin-Blasini et al., 2007 at the Perchlorate Lab of the CDC in Atlanta, USA.

Iodide levels were found to be lower than the required levels suggested by the World Health Organization. All three study populations had median urinary iodide levels lower than 80 μg/L, and thus none of these populations meets the WHO guideline for adequate iodine intake. Iodide levels were lower than urinary iodine levels found in NHANES study. Perchlorate concentrations are higher in the study population compared with NHANES. There are significant differences between Isparta's and Istanbul's perchlorate levels. Nitrate levels in all cities are well exceeding the drinking water standards of World Health Organization. Similarly, thiocyanate levels are not only significantly different from each other but also higher than the suggested drinking water standards published by World Health Organization.

This study provides crucial information about thiocyanate, perchlorate and nitrate exposure in Turkey and gives information about iodide status relationship of non-pregnant and non-lactating adult population with a median urinary thiocyanate, nitrate and perchlorate levels from different locations in Turkey.

1 Pediatrics, The Hospital for Sick Children, Toronto, ON, Canada 2 Psychology, University of Toronto, Toronto, ON, Canada 3 Psychology, Rotman Research Institute, Toronto, ON, Canada Poster 124 Neuroplastic Effects of Musical Training on Hippocampal Structure in Children with Congenital Hypothyroidism

Thyroid and Development Friday Poster Clinical

Animal evidence indicates hippocampal vulnerability to thyroid hormone (TH) loss reflecting cell reductions and disrupted synaptic functioning in TH-deficient rodents. The hippocampus is not only critical for memory, spatial learning, and novelty detection, it is also highly susceptible to training-induced neuroplasticity. For example, musicians exhibit greater hippocampal activity than non-musicians during novelty detection tasks. However, no study has as yet explored hippocampal neuroplasticity in TH-deficient populations. Children with congenital hypothyroidism (CH) experience TH insufficiency occurred during late gestation and early life and show abnormal hippocampal development. To determine whether they show neuroplasticity in hippocampal development following specialized training, we stratified and compared CH and control groups according to whether children received previous musical training.

Participants were 64 10–15 year old children of whom 28 had musical training (14 CH/14 control) and 36 did not (19 CH/14 control). All underwent a 1-hour MRI session in a 1.5 T scanner; volumetric measurements of their hippocampi were later determined by manual tracing. Past musical training was ascertained by questionnaire or telephone interview.

A significant group by musical training interaction was observed for right hipppocampal volumes (p<.05), after controlling for total intracranial volume, age, and gender. On post-hoc testing, CH without training had significantly smaller right hippocampal volumes than CH with training (p<.01), controls with training (p<.05), and controls without training (p<.05) and hippocampi of CH with training did not differ from controls with training (see Figure 1). Findings were not associated with differences in IQ or family socioeconomic status.

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FIG. 1.

Mean Hippocampal Volumes in CH and Controls With and Without Musical Training.

In CH, musical training may help ameliorate abnormal hippocampal development by later inducing structural neuroplasticity of their hippocampi.

1 Otorhinolaryngology, Yonsei University College of Medicine, Seoul, Republic of Korea 2 Otolaryngology-Head and Neck Surgery, Soonchunhyang University College of Medicine,, Seoul, Republic of Korea Poster 127 Efficacy of Honokiol in Thyroid Cancer and New Study of Combination Therapy with Honokiol and Molecular Targeted Agents in Thyroid Cancer

Thyroid Cancer Friday Poster Basic

Systemic chemotherapies for advanced or metastatic thyroid carcinomas have been of only limited effectiveness. For patients with differentiated or anaplastic carcinomas unresponsive to conventional treatments, novel therapies are needed to improve disease outcomes. As the understanding of the molecular biology of thyroid cancer is better understood, new means of targeting these pathways for intervention in thyroid cancer cells is occurring. Honokiol has anti-tumor effect against several human cancer cell lines.However, its antitumor effect in thyroid cancer has not been demonstrated.Clinical trial using kinase inhibitors have demonstrated transient partial responses and prolonged disease control in patients with progressive thyroid cancer. The goal of the present study was to identify the potential value of honokiol as a candicate for the treatment of thyroid cancer and to investigate of anti-tumor effect of honokiol in combination with molecular targeted agents in thyroid cancer cell lines.

Three human thyroid cancer cell lines, TPC-1, FTC133, and FRO, respectively, were exposed to honokiol alone and in combination with sorafenib, sunitinib, RAD001, and AZD6244. Cell proliferation was assessed by MTT assay. Apoptosis was measured by TUNEL assay and FACscan analysis. Western blot analysis was performed to identify that honokiolalone and combination therapy may inhibit the MAPK pathway and PI3K/AKT/mTOR pathway.

Honokiol exhibited significantly anti-proliferative activity in all three thyroid cancer cell lines in vitro. TUNEL assay and FACscan analysis revealed the significant induction of apoptosis after using honokiol in vitro. Western blot analysis showed preferential inhibition of phosphorylation of ERK, AKT or S6K, depending on cell lines. Combination of honokiolwithother molecular targeted agents presented synergistic effects on induction of apoptosis of thyroid cancer cells.

Honokiol, either alone or in combination with other therapeutics, could serve as a new, promising approach for thyroid cancer treatment.

1 Surgical Oncology, UT MD Anderson Cancer Center, Houston, TX 2 Endocrine Neoplasia, UT MD Anderson Cancer Center, Houston, TX 3 Systems Biology, UT MD Anderson Cancer Center, Houston, TX 4 Pathology, UT MD Anderson Cancer Center, Houston, TX Poster 128 Molecular Analysis of Brain Metastases from Thyroid Carcinomas

Thyroid Cancer Friday Poster Basic

Distant metastatic disease occurs in ∼15% of patients with thyroid carcinomas. Although brain metastases are rare, they signify aggressive disease and short survival. The rarity of tissue from distant metastatic sites has limited their evaluation for molecular alterations which may contribute to tumorigenesis and point to therapeutic targets.

Twelve patients with formalin-fixed paraffin embedded tissue available from biopsy or resections of metastatic thyroid carcinomas to the brain from 1995 to 2010 were included in this study. Tumors analyzed included 8 papillary thyroid carcinomas (PTC), 1 follicular carcinoma (FC), 1 Hurthle cell carcinoma (HCC), and 2 medullary thyroid carcinomas (MTC). Extracted DNA was analyzed for 145 mutations/alterations in 30 genes by mass spectrometry based DNA analysis (Sequenom Inc, San Diego, CA).

Brain metastases occurred in 6 men and 6 women, 3 of whom were <45 yrs of age at primary diagnosis. Time to onset of brain metastases from initial diagnosis differed based on age at primary diagnosis <45 or ≥45 yrs, median 15 vs 2.9 yrs (range 1.6 to 24 yrs versus present at initial presentation to 8.8 yrs respectively). At last follow-up 4 patients were alive (12–101 months after brain metastasis diagnosis); 8 were dead (3.7–209 months). Median survival was similar (28.3 vs 30 months) for both age cohorts. 8 of the 12 tumors (75%) showed gene mutations in 5 of the genes tested (Table 1). Six tumors showed one gene mutation. Two PTCs had 2 and 3 different gene mutations respectively (NRAS+PIK3CA and MET+NRAS+PIK3CA). Both MTCs showed sporadic 918 RET mutations. Four tumors were negative for all molecular alterations tested for in this analysis.

Brain metastases may occur secondary to thyroid carcinomas regardless of age at diagnosis however a more rapid occurrence was noted in patients >45 years of age at diagnosis. Survival remained poor regardless of age. Thyroid cancers with brain metastases are molecularly heterogeneous favoring personalized molecular analysis for targeted therapy. Mutations may be activating allowing targeted inhibitor therapy however, certain loci may signify resistance. Further molecular analyses in larger cohorts and in other metastatic sites are warranted.

1 Pathology, University of Texas Medical School at Houston, Houston, TX 2 Endocrinology, University of Texas Medical School at Houston, Houston, TX 3 Public Health, University of Texas Medical School at Houston, Houston, TX 4 Endocrinology, Mobile Diagnostic Center at Providence Park, Mobile, AL 5 Internal Medicine, University of Arkansas, Little Rock, AR 6 Surgery, University of South Alabama College of Medicine, Mobile, AL Poster 133 Effect of Insurance Status on Presentation of Differentiated Thyroid Cancer

Thyroid Cancer Friday Poster Clinical

Black Americans with differentiated thyroid cancer (DTC) often present with larger tumors and at advanced age. This difference has been attributed to unequal access to health insurance. The aim of this study was to compare the DTC histology and age at presentation between different racial groups in two metropolitan hospitals; one serves a medically-indigent population and the other a largely insured population.

Retrospective case-control study of patients with DTC who underwent thyroidectomy at a tax-supported versus a private hospital between 1999 and 2009. The effect of insurance status and race on age at presentation, advanced disease, and tumor size was analyzed. Advanced disease was defined as a tumor with extra-thyroidal extension, local, or distant metastasis.

Two-hundred and sixty three patients with DTC who underwent thyroidectomy at a tax-supported hospital (N=185) and a private hospital (N=78) met inclusion criteria. Neither insurance status nor race affected the age at presentation (p=0.38 and p=0.31, respectively). The mean tumor size was larger in the uninsured population versus the insured (2.7 cm vs. 2.1 cm, p=0.04). When compared to Caucasians, Blacks and Hispanics presented with a trend towards larger tumors (OR 1.20, p=0.08 and OR 1.25, p=0.018, respectively). However, this relationship may be accounted for by the observation that Blacks and Hispanics were less likely to be insured when compared to Caucasians (OR 0.27, p=0.004 and OR 0.03, p<0.001 respectively). Patients with larger tumors were more likely to present with advanced disease (OR 2.70, p<0.001), which was independent of race and insurance status.

In this study the uninsured patients were more likely have larger tumors; this population was mainly represented by Black and Hispanic patients. We found no difference in age at presentation, advanced disease, or tumor size based on race.

1 Radiology, Division of Nuclear Medicine, Memorial Sloan-Kettering Cancer Center, NewYork, NY 2 Medicine, Division of Endocrinology, Memorial Sloan-Kettering Cancer Center, New York, NY 3 Nuclear Medicine and Endocrine Oncology, Institut Gustave Roussy, Villejuif, France 4 Medicine, The Methodist Hospital Research Institute, Houston, TX 5 Medical Physics, Memorial Sloan-Kettering Cancer Center, New York, NY Poster 134 Role of 124I Pet in Predicting the Response to Radioiodine Treatment in Patient with Metastatic Thyroid Cancer

Thyroid Cancer Friday Poster Clinical

The aim of this study is to determine if lesional dosimetry determined by 124I PET imaging would correlate with response to RAI therapy in differentiated thyroid cancer patients with metastatic disease.

Sixteen patients (7F, 9 M, 55±16 years) with metastatic thyroid cancer were studied by FDG PET/CT (Mean activity: 15±1 mCi), three time point (24, 48, 72 hours) I124 PET/CT (Mean activity: 6.4±03.7 mCi) and diagnostic CT scan (n=12/16) prior to administration of I131 therapy (guided by whole body and blood RAI clearance studies). Size, FDG avidity and I124 maximal standard uptake value (SUV Max) was determined for each metastatic focus. Objective response was assessed by RECIST 1.1 criteria for CT scan (n=13) and/or by EORTC criteria for FDG/I124 PET (n=9) 1 year after I131 therapy. The median lesion estimated absorbed dose (Gy) was calculated in responder and non responder lesions.

A total of 271 lesions were evaluated (147 pulmonary metastases, 60 bone metastases, 39 loco-regional lymph node metastases, and 25 other metastatic sites). The majority of the lesions were detected only by FDG PET (n=164, 60%), while 55 lesions (21%) were detected only by I124 PET, and 52 (19%) were visualized on both FDG and I124 PET. Mean lesion size was 13.1±10.9 mm. The median I131 activity administrated was 304 mCi (range 122–398). Objective response was detected in 54/227 (24%) evaluable lesions 1 year after I131 therapy. Lesions that demonstrated an objective response to RAI therapy were smaller (9.9±5.2 mm vs 13.9±11.8 mm, P=0.03), more likely to be in the lungs (P=0.003), and had significantly higher I124 SUV max (12.3 vs 1.5, P=0.008) and demonstrated to a first approximation a significantly higher median estimated absorbed dose (2.4 Gy vs 0.37 Gy without partial volume correction; 8.6 Gy vs 0.9 Gy with partial volume correction).

Pre-treatment evaluation by FDG and I124 PET can identify patients with metastatic disease most likely to benefit from additional RAI therapy.