83rd Annual Meeting of the American Thyroid Association Meeting Abstracts & Program

Nuclear receptor co-repressor (NCoR) and silencing mediator of retinoid and thyroid hormone receptors (SMRT) are well-recognized co-repressors of the thyroid hormone receptor (TR) isoforms and other nuclear receptors. Defects in their function can lead to alterations in thyroid hormone (TH) signaling and metabolic dysfunction. Indeed, we have shown previously that deletion of NCoR function enhances TH action on TR target genes. However, whether NCoR or SMRT have have specific roles in TH action has never been tested previously in vivo.

To test our hypothesis that NCoR is the specific corepressor for the TR we generated mice that lack functional NCoR (NCoRΔID), SMRT (SMRT−/−) or both (DKO) in the liver only using cre/lox technology and then assessed TH and metabolic signaling in either euthyroid or hypothyroid animals.

Consistent with our hypothesis, the isolated deletion of SMRT in the liver had no effect on enhancing TH action in either the hypothyroid or euthyroid state on all TR target genes tested including fasn, thrsp, dio1, gpd2 and bcl3. In contrast and as seen previously the disruption of NCoR function greatly enhanced TH action on all TR targets. The phenotype of DKO mice in context of TH-signaling was similar to NCoRΔID mice confirming the dominant and necessary role of NCoR in TH action. To discern what role SMRT may be playing in the liver we further analyzed the phenotype of DKO mice. Remarkably, DKO mice have significant hepatic steatosis and decreased serum triglycerides compared to WT, NCoRΔID and SMRT−/− mice. Consistent with this, there was profound upregulation of both lipogeneic and lipid droplet formation gene expression in DKO mice. In contrast to TH-signaling, both NCoR and SMRT appear to be required for this steatotic program. Interestingly, the phenotype and gene expression profile of DKO mice closely parallels that found in mice which lack HDAC3 in the liver.

Taken together these data demonstrate that co-repressor specificity exists in vivo as NCoR plays a specific role in TH signaling that cannot be compensated for by SMRT. In contrast, both NCoR and SMRT control hepatic lipogenesis and lipid droplet formation and are absolutely required for the actions of HDAC3.

Type 2 deiodinase (D2) is expressed in skeletal muscle (SKM) at low levels but it is thought to play a role in SKM biology. However, SKM has ectopic deposits of brown adipose tissue (BAT) that could be the source of local D2.

To test this, we developed two new mice with tissue-specific D2 inactivation, i.e. SKM-D2KO or FAT-D2KO by crossing floxed Dio2 mice with the MLC-Cre or the AP2-Cre mice, respectively. In neonatal mice, all hind limb muscles (HLM) were dissected, pooled and processed for D2 activity. In adult mice the soleus muscle (SOL) was used: 200 ug total protein incubated for 3 h in PE buffer containing 20 mM DTT, 1 mM PTU and 0.1 nM 125I-T4 (100 nM for background); results expressed as fmol T4/mg/min; only littermate controls were used.

HLM D2 activity was 40–50% lower in SKM-D2KO as well as in FAT-D2KO. At the same time, SOL D2 activity was ∼75% lower in SKM-D2KO and ∼70% in FAT-D2KO. SOL D2 mRNA levels were also lower in SKM-D2KO by ∼37% and in FAT-D2KO by ∼40%. BAT D2 activity did not change in SKM-D2KO mice but it was ∼65% lower in FAT-D2KO. Hypothyroidism (6 wks on LID+PTU) increased SOL D2 activity by about 8-fold in all animals. However, D2 mRNA was not affected given the predominant post-translational D2 regulation. We studied MyoD, Myh2, Pgc1a, Glut4 and Serca2 gene expression in SOL, and only the latter was ∼20% reduced in SKM-D2KO. The expression of a larger group of genes was not affected in SOL D2KO, in agreement with the finding of normal exercise running capacity in D2KO. When placed on a high fat diet for 8 wks, SKM-D2KO mice exhibited similar body weight, body composition, VO2 and RER as littermate controls. Serum levels of TSH, T4 and T3 were not different in the SKM-D2KO, but there was a ∼24% elevation in serum T4 in FAT-D2KO mice.

In conclusion, D2 mRNA and activity in SKM reflect the combined expression in skeletal myocytes and adipocytes. D2 inactivation did not affect muscle function or energy homeostasis. Remarkably, D2 inactivation in adipose tissue, but not in SKM, resulted in impaired extrathyroidal conversion of T4 to T3.

Multiple case reports and series suggest that rituximab (RTX), an anti-CD20 monoclonal antibody that induces transient B-cell depletion, might be effective therapy for patients with Graves' ophthalmopathy (GO).

We performed a prospective, randomized, double blind, placebo-controlled trial of RTX in patients with active GO [clinical activity score (CAS)≥4] and moderate to severe disease severity. Enrolled patients were euthyroid and either failed or refused glucocorticoid therapy. Patients received 2 RTX infusions (1000 mg each) or saline 2 weeks apart and were assessed by both endocrinologist and ophthalmologist at weeks 8, 16, 24 and 52. The primary end point at 24 weeks was a reduction in CAS assessed as a continuum. Secondary endpoints included success/failure rate (a composite variable of decrease in CAS ≥2 points and no need for additional eye treatment vs. either CAS decrease of <2 points or need for additional therapy), reduction in CAS of ≥2 points, decrease in NOSPECS by ≥2 classes, proptosis by ≥2 mm, lid aperture width by ≥3 mm, motility of ≥8 degrees, and improvement in a GO-specific quality-of-life scale ≥6 points.

21/25 patients completed the study to the primary outcome point. The treatment groups were similar in age, gender, smoking prevalence and CAS. CAS at 6 months decreased from baseline in most patients with no difference between groups [mean CAS change (standard deviation) was 1.4 (1.6) for placebo vs. 1.6 (1.8) for RTX, p=0.86]. Overall therapy failure rate at 6 months did not differ between groups (75% for placebo vs. 62% for RTX, p=0.67). There were 7 adverse events (AE) in 4 patients in the control group and 12 AE in 8 RTX-treated patients; optic neuropathy developed during the trial in 2 of the RTX-treated patients.

RTX was no more effective than placebo at 24 weeks in our population of patients with active and moderate to severe GO.

In a randomized phase 3 study, cabozantinib extended progression-free survival (PFS) in pts with progressive, metastatic MTC (median 11.2 mo cabozantinib treated arm vs 4.0 mo placebo, p<0.0001; Schöffski, 2012) with a response rate (RR) of 28% in the cabozantinib arm.

Pts in the phase 3 study were evaluated for the presence of somatic and germline RET mutations using Sanger and next generation methods using blood, primary tumor, and metastatic tumor samples. Pts without evidence of RET mutation were evaluated for KRAS, NRAS, and HRAS mutations by next generation sequencing. Impact of tumor mutational status was evaluated with respect to PFS and RR according to RECIST.

Sixty-five percent of study pts had their RET status determined (215 of 330 total pts). Of those, 79% harbored an activating mutation (59% exhibited the poor prognosis mutation M918T) and 21% lacked a RET mutation. Generally only a single tumor sample was provided per pt, either primary tumor (117 of 215) or metastasis (65 of 215). Two of 14 pts who had both primary tumor and metastasis samples evaluated showed a RET mutation in the metastasis but not the primary tumor. Approximately 30% of the pts lacking a RET mutation were subsequently found to harbor a mutation in HRAS, KRAS, or NRAS. The greatest benefit was observed in the following: the subgroup of pts who are RET mutation positive (hazard ratio 0.23), the subset of those pts with RET M918T mutations (hazard ratio 0.15) and the subgroup of pts with RAS mutations (hazard ratio 0.15). Kaplan-Meier analysis of the RET mutation negative subgroup (n=46) indicates a heterogeneous population, with PFS benefit largely attributable to pts with RAS mutations. Pts who were both RET and RAS mutation negative (n=30) showed a 21% RR but little prolongation of PFS on cabozantinib. The common polymorphism RET G691S did not show an effect on PFS in either arm. RRs are highest in the subgroups which show the greatest prolongation of PFS: all RET mutations, RET M918T mutations, and RAS mutations (RRs of 32%, 34%, and 31%, respectively).

Pts with activating RET and RAS mutations show the greatest improvement in PFS and tumor response on cabozantinib although benefit was seen across mutational subgroups.

A genetically engineered mouse model (GEMM) of pancreatic ductal adenocarcinoma (PDAC) is induced by activation of constitutively active Kras^G12D in combination with a deletion of p53, which shows the typical changes of human disease.

In previous proof-of-principle studies using xenograft mouse models the sodium iodide symporter (NIS) as well characterized theranostic gene allowed detailed molecular imaging of transgene expression and highly effective application of therapeutic radionuclides. As a next step towards clinical application, in the current study we investigated tumor specificity and transduction efficiency of tumor-targeted polyplexes as systemic NIS gene delivery vehicles in the advanced GEMM of PDAC. Therefore, we used novel tumor-targeted polyplexes based on linear polyethylenimine (LPEI), polyethylene glycol (PEG), and the synthetic peptide GE11 as an epidermal growth factor receptor (EGFR)-specific ligand (LPEI-PEG-GE11) to target a NIS-expressing plasmid to the high EGFR-expressing PDAC.

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In vitro iodide uptake studies with cell explants derived from murine EGFR-positive and EGFR-knockout PDAC lesions demonstrated high transduction efficiency and EGFR-specificity of LPEI-PEG-GE11/NIS. In vivo ¹²³I γ-camera-imaging and 3-dimensional high-resolution ¹²⁴I-PET-imaging experiments showed significant tumor-specific accumulation of radioiodine. These results were further confirmed by NIS-specific qPCR analysis and immunohistochemistry. A first series of therapy studies indicates that the tumoral accumulation is high enough for a dramatic therapeutic effect of ¹³¹I as demonstrated by significant reduction of tumor volume that was measured by magnetic resonance imaging.

In conclusion, our preclinical data in an advanced GEMM of PDAC clearly demonstrate the enormous potential of EGFR-targeted synthetic polymers for systemic NIS gene delivery allowing for targeted radionuclide therapy of non-thyroidal cancers.

With a median survival of 5 months and lack of curable therapies, Anaplastic thyroid carcinoma (ATC) represents one of the most aggressive forms of cancer. Recently, advances in immunotherapy have resulted in clinical responses in patients with cancer, although against solid tumors, the success has been limited to a few immunogenic cancers such as malignant melanoma. We sought to investigate whether ATC is a suitable target for immunotherapy.

16 ATC and 3 PTC cell lines were established from fine-needle aspirates (FNA) and analyzed for 1) their susceptibility to killing by natural killer (NK) cells in vitro by 51Cr-release cytotoxicity assay; 2) expression of ligands to activating NK cell receptors by flow cytometry for; and 3) their propensity to secrete NK cell attracting chemokines by ELISA. Furthermore, FNA and peripheral blood was obtained from 4 untreated ATC patients and analyzed for infiltration and phenotype of NK cells as well as tumor cells.

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ORAL 6.

Linear regression analysis of NK cell mediated killing and mean flurorescence intensity (MFI) of ULBP2 on thyroid cancer cells.

Our functional analysis revealed that ATC cell lines are extremely sensitive to lysis by ex vivo expanded NK cells, despite a high expression of MHC class I (range NK cell killing=16.1–97.1%, mean=58.9%), while the PTC cell lines were more resistant to NK cell lysis (range NK cell killing=10.6–55.5%, mean=31.5%). NK cell mediated lysis of ATC cells was abrogated upon blockade of the NK cell activating ligand NKG2D. A phenotype analysis revealed that the level of sensitivity to NK cell lysis correlated with surface expression of the NKG2D-ligand UL 16 binding protein 2 (ULBP2) on thyroid cancer cells (p=0.0014). Moreover, silencing or blockade of the ULBP2 receptor on ATC cells resulted in increased resistance to NK cell mediated lysis. In addition, several of the ATC cell lines produced high levels of the chemokine CXCL10 and were able to stimulate migration of NK cells in vitro. In fresh ATC tumor samples NK cells had a reduced expression of the NKG2D receptor compared to NK cells in peripheral blood from the same patient.

Our findings demonstrate that ATC tumor cells are prone to attract and undergo lysis by NK cells. We conclude that ATC is a promising target for treatment strategies involving adoptive transfer of ex vivo expanded NK cells.

MicroRNA-145 (miR-145) has been reported as a tumor suppressor. Ectopic expression of miR-145 in cancer cells leads to decreased proliferation and induces morphological changes. However, the role of miR-145 in thyroid cancer is undefined. The aim of this study was to characterize expression of miR-145, identify its function in thyroid cancer cells, and determine its diagnostic utility in thyroid cancer.

The viability of thyroid cancer cells was determined after transfection by either miR-145 or miR-C. Cell cycle progression and DNA fragmentation was investigated by flow cytometry and western blot. Luciferase expressing 8505C cells were transfected with miR-145 or miR-C for in vivo experiments. Subcutaneous flank injections into nude mice were used to determine whether miR-145 inhibits tumor growth. The role of miR-145 and tumor metastasis was explored by tail vein injection into IL-2 knockout mice. The expression of miR-145 was evaluated by quantitative RT-PCR in training and validation sets FNA samples and in serum samples from patients with PTC, benign lesions, and healthy controls. Exosomes were extracted from the thyroid vein, peripheral circulation, and medium.

Our results show miR-145 is downregulated in thyroid cancer. In vitro miR-145 overexpression resulted in G2/M cell cycle arrest, decreased cellular proliferation, migration, invasion, expression of EMT markers, and VEGF secretion, as well as inhibition of the PI3K/Akt pathway. In vivo miR-145 overexpression decreased tumor growth, metastasis, and VEGF secretion. Furthermore, inhibition of miR-145 in normal thyroid primary culture decreased expression of key regulators of thyroid cell differentiation. Serum miR-145 levels were higher in patients with thyroid cancer, and a gradient based on proximity to the tumor was demonstrated. As a diagnostic biomarker, miR-145 had a negative predictive value of 92% in distinguishing between benign and malignant thyroid nodules in indeterminate FNA.

These data show miRNA-145 to be a master regulator of thyroid cancer growth which is likely mediated through its effect on the PI3K/Akt pathway. Mir-145 is likely secreted by thyroid cancer cells, and may be a helpful adjunct marker for thyroid cancer diagnosis.

Thyroid follicular cells (TFCs) are recognized by their expression of a gene quartet including thyroglobulin (Tg), thyroperoxidase (TPO), thyroid stimulating hormone receptor (TSHR) and the sodium/iodide symporter (NIS) genes. The expression of this gene quartet is dependent on a unique set of transcription factors including NKX2 homeobox 1 (NKX2-1, formerly called TTF-1), forkhead box protein E1 (FOXE1, formerly called TTF-2) and paired box gene 8 (PAX8) which are not expressed simultaneously in any other cell type. NKX2-1 and PAX8 are known to associate biochemically and synergistically in their role as thyroid gene activators. We have successfully used the ectopic expression of PAX8 and NKX2-1 to induce the differentiation of murine embryonic stem (ES) cells into TFCs (Thyroid 23:385, 2013) and following further development toward the endodermal lineage such cells developed into three-dimensional thyroid follicles and expressed abundant thyroglobulin protein in vitro.

To assess the in vivo potential of such ES cells, expressing both PAX8 and NKX2-1, we injected, subcutaneously, increasing numbers (104–106) of embryoid body cells suspended in a soluble basement membrane extract (Matrigel) into nude mice and observed their development.

Histological analysis revealed the formation of thyroid tissue, 4 weeks after injection, forming what we have previously termed a “thyroid organoid”, with fully developed, and developing, follicles and reaching ∼0.8 cm in size. Immunohistochemical analysis of the graft tissue showed intracellular Tg and Tg deposition in the luminal compartments.

This thyroid transplantation model using ES cells furthers the possibility of thyroid gland replacement for patients with congenital hypothyroidism or following total thyroidectomy.

The human syndrome resistance to thyroid hormone (RTH) is characterized by high thyroid hormone (TH) and thyroid stimulating hormone (TSH) levels. Mice with mutations in the thyroid hormone receptor beta (Thrβ) gene that affect its ability to bind the steroid-receptor coactivator 1 (SRC-1) or mice that are null for SRC-1 have a phenotype similar to RTH. In contrast, mice that express a mutant nuclear corepressor 1 (Ncor1) allele that cannot interact with TRβ, termed NCoRΔID, have low TH levels and normal TSH. We hypothesized that RTH present in Src-1^−/− mice is due to unopposed corepressor action blocking appropriate T₃-mediated regulation.

To test our hypothesis we crossed NCoR^ΔID/ΔID and Src-1^−/− mice resulting in mice deficient for both coregulators in all cell types. We measured TH levels in WT, NCoR^ΔID/ΔID, Src-1^−/− and NCoR^ΔID/ΔID Src-1^−/− mice by performing radioimmunoassays. TSH levels were measured in all genotypes with a Multiplex™ assay (Millipore). Using quantitative real time PCR, we evaluated mRNA levels in the pituitary and the liver. Lastly, to test recruitment of coregulators by the TR we performed chromatin immunoprecipitation assay (ChIP) for SRC-2 in the livers of WT and NCoR^ΔID/ΔID Src-1^−/− mice.

Remarkably NCoR^ΔID/ΔID Src-1^−/− mice have normal TH and TSH levels and are T₃ sensitive at the level of the pituitary thyrotroph. Although the absence of SRC-1 prevented T₃-activation of key hepatic gene targets, the expression of NCoRΔID in Src-1^−/− mice allowed these targets to reacquire T₃ sensitivity. We next asked if the removal of both NCoR and SRC-1 allowed other coregulators to be recruited by the TR on the promoters of target genes? Using ChIP, we found enhanced recruitment of SRC-2 to the promoter of T₃-sensitive genes Thrsp14 (Spot14) and Gpd2 in NCoR^ΔID/ΔID Src-1^−/− mice suggesting that SRC-2 is responsible for T₃ sensitivity in NCoR^ΔID/ΔID Src-1^−/− mice and that removal of WT NCoR1 augments SRC-2 binding to the TR.

In conclusion, T₃ targets require a critical balance between NCoR1 and SRC-1 in order to respond appropriately to T₃. Furthermore, expression of the mutant NCoRΔID allele in Src-1^−/− mice corrects their RTH phenotype by allowing increased recruitment of SRC-2 to the TR.

Genetic evidence from patients with mutations of the thyroid hormone receptor α gene (THRA) indicates that the dominant negative activity of mutants underlies pathological manifestations. Using a mouse model expressing a dominant negative TRα1 mutant (PV) and a mutated nuclear receptor corepressor (NCOR1ΔID) (Thra1PV/+Ncor1ΔID/ΔID mice), we recently showed that aberrant release of TRα1 mutants from the NCOR1-histone deacetylase (HDAC) repressor complex mediates the dominant negative actions of TRα1 mutants.

We tested whether HDAC could be a potential molecular target by treating Thra1PV/+ mice with an HDAC inhibitor, SAHA, daily for 2 months and evaluating its effects.

SAHA treatment did not significantly correct the abnormalities in body weight of Thra1PV/+ mice, but it ameliorated the impaired bone development and adipogenesis. A 19% reduction in femur length of vehicle-treated Thra1PV/+ mice was partially corrected to a 15% reduction in SAHA-treated mice. We previously showed that the expression of NCOR1ΔID reverted the 19% reduction in femur length of Thra1PV/+ mice to a 17% reduction in Thra1PV/+Ncor1ΔID/ΔID mice. SAHA treatment further corrected this to a 12% reduction. Moreover, a 69% reduction in white adipocyte tissue (WAT) mass in vehicle-treated Thra1PV/+ mice was partially corrected to a 44% reduction in SAHA-treated Thra1PV/+ mice. The expression of NCOR1ΔID reverted the 69% reduction in WAT mass of Thra1PV/+ mice to a 24% reduction in Thra1PV/+Ncor1ΔID/ΔID mice. Remarkably, SAHA-treated Thra1PV/+Ncor1ΔID/ΔID mice exhibited normal WAT mass and histology. Analysis showed that the expression of PPARγ and C/EBPα, the 2 master regulators of adipogenesis, were markedly higher in WAT of SAHA-treated Thra1PV/+ and Thra1PV/+Ncor1ΔID/ΔID mice than the respective vehicle-treated mutant mice, indicating de-repression of these 2 genes in SAHA-treated mutant mice.

Our studies show that the effectiveness of SAHA treatment is target tissue-dependent. In WAT, together with lack of recruitment of NCOR1 by TRα1PV, an HDAC inhibitor completely corrected the impaired adipogenesis. Thus, the NCOR1-HDAC repressor complex could be considered a potential therapeutic target for treatment.

Presence of thyroid antibodies in pregnancy, even in euthyroid women, has been associated with increased risk of abortion and preterm delivery. We investigated the prevalence of thyroid peroxidase antibodies (TPOAb) in pregnant Danish women before and after the implementation of the national iodine fortification program (IFP), and compared this to the development in preterm deliveries over the same course of time.

The study was a comparative cohort study of 1722 Danish pregnant women. In three cohorts, data was collected before (1998–2000), during (2000–2003), and after (2008) the IFP, respectively. In the first cohort (n=282) TPOAb were measured with the DYNOtest radioimmunoassay (BRAHMS, Hennigsdorf, Germany; functional assay sensitivity 30 mU/l). In cohorts 2 (n=151) and 3 (n=1273), TPOAb-levels were measured with automated Kryptor immunoflourescent assays (BRAHMS, Hennigsdorf, Germany; functional assay sensitivity 28 and 50 mU/l, respectively). Tests for trends were performed with χ2-tests. Risk of preterm delivery (gestational age at delivery <37 weeks) according to TPOAb-positivity (TPOAb>60 mU/l) was tested by binary logistic regression to adjust for the following covariates: cohort origin, gestational age at visit, maternal age, smoking status, pre-pregnancy BMIxBMI, pregnancy achieved by assisted reproductive techniques, and thyroid hormone levels (z-scores of logtransformed TSH, free T3, and free T4).

In the three cohorts, TPOAb-levels above our clinical cut-off of 60 mU/l were found in 5.4, 7.9, and 13.7% (χ2(2, n=1722)=18.65, p<0.001) of the women, respectively. However, there was no significant increase in the proportion of preterm deliveries between cohorts (χ2(2, n=1497)=2.22, p=0.33). Preterm delivery occurred in 68 out of 1496 (4.5%) pregnancies with no significant effect of antibody-status (adjusted OR=1.44, 95%CI [0.56–3.71]).

Prevalence of TPOAb in Danish pregnant women has more than doubled upon the implementation of the IFP. However, this increase has not been accompanied by a rise in the proportion of preterm deliveries. Unlike previous studies, we did not find an increased risk of preterm delivery in thyroid autoantibody-positive women.

IgG4 related disease (IgG4-RD) is a new clinical entity that affects various organs with increased IgG4 positive plasmacytes and progressive fibrosis. While IgG4-RDs in association with Hashimoto thyroiditis or Riedel's thyroiditis have been reported, relation between IgG4-RD and Graves' disease (GD) is yet unknown. To elucidate the relation of GD to IgG4-RD, serum IgG4 levels and their clinical implications in patients with GD were investigated.

A prospective study. One hundred nine patients with GD were subjected to the measurement of serum IgG4 concentrations and classified into two groups based on the comprehensive diagnostic criteria of IgG4-RD: 1) GD with elevated serum IgG4 concentrations (≥135 mg/dL), and 2) GD with non-elevated IgG4 (<135 mg/dL).

Seven out of 109 patients with GD (6.4%) had elevated serum IgG4 levels; mean±SD (range), 175.0±44.5 (136–266) mg/dL and elevated ratios of IgG4/IgG, 12.7±4.5 (7.6–21.2) %. The remaining of patients with GD had serum IgG4 levels and IgG4/IgG ratios of 39.6±27.6 (3–132) mg/dL and 3.2±2.2 (0.3–11.5) %, respectively. Ages of elevated-IgG4 group were significantly higher than those of non-elevated-IgG4 group; 54.7±6.2 vs. 43.4±15.4 yr., respectively. Ultrasound examinations revealed that elevated-IgG4 group had significantly increased low echogenic area in the thyroid in comparison to non-elevated-IgG4 group (low echo scoring; 1.66±0.81 vs. 0.61±0.89, respectively. In the correlation analysis, TSAb (rs=0.385, n=42) titers were significantly correlated with serum IgG4 levels, while they were not significantly different between the two groups. In elevated-IgG4 group (n=7), patients were controllable with a small dosage of anti-thyroidal drug (ATD) (n=4), a combination treatment with ATD and L-T4 (n=1) or L-T4 administration only after 1 year from the first visit (n=2).

A small portion of GD patients harbored elevated serum IgG4 levels. They were older, had manifested lower echoic area in the thyroid, and appeared to be responsive or prone to be hypothyroid after ATD treatment. Thus, the present study suggests the presence of a novel subtype of GD. Measuring serum IgG4 levels may help to distinguish this new entity and provide potential therapeutic options for GD.

Next-generation sequencing (NGS) allows for massively parallel sequencing of the human genome and becomes a powerful tool for the detection of genetic alterations. We report a novel targeted NGS panel (ThyroSeq) for the detection of mutations and chromosomal rearrangements in thyroid cancer.

ThyroSeq NGS panel was designed to sequence 42 regions of 12 thyroid cancer related genes for mutations and for 28 types of gene fusions using next generation sequencing on Ion Torrent PGM (Life Technologies). The panel was validated on 228 DNA and 70 RNA samples from thyroid neoplastic and non-neoplastic samples including 208 tissue and 90 FNA samples.

Small amount of nucleic acids (5–10 ng) was sufficient for successful analysis of 99% of thyroid tissue and FNA samples using ThyroSeq NGS panel. The analytical accuracy for mutation detection was 100% with sensitivity of 3–5% of mutant alleles or fusion transcripts. ThyroSeq DNA assay identified mutations in 70% of PTC, 83% of follicular variant PTC, 78% of conventional and 39% of oncocytic follicular carcinomas, 30% of poorly differentiated carcinomas, 74% of anaplastic, and 73% medullary carcinomas. In contrast, only 6% of histologically benign thyroid nodules were positive for mutations. The most common mutations detected were BRAF and RAS followed by PIK3CA, TP53, TSHR, PTEN, GNAS, CTNNB1 and RET. ThyroSeq NGS analysis identified common gene fusions including RET/PTC1, RET/PTC3, and PAX8/PPARγ, and also rare fusion types involving RET, BRAF, NTRK1 and NTRK3 genes. The method allowed for quantitative assessment of mutant alleles, demonstrating clonal origin of BRAF and most of other mutations.

ThyroSeq NGS panel (i) allows testing for multiple mutations and gene fusions with high accuracy and sensitivity; (ii) requires small amount of DNA and RNA and can be performed in tissue and FNA samples, and (iii) provides quantitative assessment of mutant alleles and fused transcripts. ThyroSeq NGS approach detects genetic alterations in a cost effective way and can be potentially used in clinical setting.

Thyroid hormone (TH) is essential for myelination and formation of white matter tracts. In rodents, early TH deficiency leads to significant reductions in white matter tracts, especially the corpus callosum (CC). Traditionally, CC is known to connect regions between hemispheres while recent neuroimaging evidence has identified specific subregions that form distinct fiber tracts with different regions of the cortex. Children with congenital hypothyroidism (CH) are TH deficient during a critical stage of CC development. Therefore, we asked whether they show abnormal CC development and if these are located within specific subregions and related to initial hypothyroidism severity and neuropsychological abilities.

Studied were 83 children (mean age 12.2 yrs), 41 with CH and 42 controls matched for age, sex, and socioeconomic status with CH. CH were diagnosed via newborn screening and in optimal care. All participants underwent extensive neuropsychological testing and MRI scanning. Scans were submitted to ANALYZE and CCs were traced from the midsagittal slice and subdivided into six subregions based on Hofer & Frahm (2006). Determined were areas of subregions, five linear measurements, and five angles reflecting CC shape (see Figure 1). Results were compared between groups and by CH etiology.

CH had significantly smaller genu areas and widths than controls (p<0.007 and p<.02). Children with athyreosis had the smallest genus (p<.05). No effect of CH on CC shape was observed. Mean IQ, which was significantly lower in CH than controls (105.5 vs 115.6, p<.05), was associated with genu size in CH but not controls (p<.05). Genu area was also correlated with visual memory and spatial planning (p<.05).

Lack of TH in late gestation and early infancy leads to a specific abnormality in CC development and this may partially explain some of the specific deficits observed in CH.

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ORAL 14.

CC measurements: (i) and (ii) division of midsagittal callosal slice into 6 regions based on Hofer & Frahm (2006); (iii) linear measurements: A. maximum width, B. height of genu, C. width of genu, D. height of body, E. width of splenium; (iv) angles for CC shape quantification based on Gabrielli et al (1993)

Normal thyroid hormone synthesis is essential for normal mental and physical development and is dependent on adequate iodine intake. During the first few months of life, infants are reliant on breastmilk and/or infant formula as their sole sources of dietary iodine. The iodine status of U.S. newborn infants has not been well-studied.

This was a cross-sectional study of 95 breastfed and/or formula-fed infants less than 3 months of age in the Boston area. Measured iodine content from infants' single spot urine samples was assessed for their associations with maternal demographic data, maternal salt and multivitamin use, maternal smoking, maternal diet, and infant type of feeding.

The overall median infant urine iodine concentration was 197.5 μg/L (range 40–897.5 μg/L). Median infant urine iodine concentrations were similar between infants who were breastfed (203.5 μg/L), formula-fed (182.5 μg/L), and both (197.8 μg/L) (p=0.88). There were no significant correlations between maternal salt use (regularly and in the past 24 hours), multivitamin use (regularly and in the past 24 hours), active and secondhand cigarette smoke exposures, infant weight, infant length, or recent ingestion of common iodine-containing foods.

Both breastfed and formula-fed infants less than 3 months of age in the Boston area are generally iodine sufficient. Larger studies are needed to determine the sources of infant iodine nutrition and confirm these observations among infants nationwide.

Increasingly, patients with thyroid nodule cytology labeled AUS/FLUS, or FN undergo diagnostic analysis with the Afirma gene expression classifier (GEC). No long-term, multi-site analysis of Afirma GEC performance has yet been performed.

We analyzed all patients who had received Afirma GEC testing at 5 academic medical centers between 2010–2013. Nodule and patient characteristics, fine needle aspiration cytology, Afirma GEC results, and subsequent clinical or surgical follow up were obtained for 339 patients. Results were analyzed for pooled test performance, impact on clinical care, and site-to-site variation.

339 patients underwent Afirma GEC testing of cytologically indeterminate nodules (165 AUS/FLUS; 161 FN; 13 SUSP). 174 of 339 (51%) indeterminate nodules were GEC benign, while 148 GEC suspicious (44%). GEC results significantly altered care recommendations, as 4 of 175 GEC benign were recommended for surgery in comparison to 141 of 149 GEC suspicious (p<0.01). Of 121 Cyto Indeterminate/GEC Suspicious nodules surgically removed, 53 (44%) were malignant. Variability in site-to-site GEC performance was confirmed, as the proportion of GEC benign varied up to 29% (p=0.58), while the malignancy rate in nodules cytologically indeterminate/GEC suspicious varied up to 47% (p=0.11). 71 of 174 GEC benign nodules had documented long-term follow-up (mean 8.5 mo), in which 1 of 71 nodules proved cancerous.

These real-world, multicenter data confirm originally published Afirma GEC test performance, and demonstrate its substantial impact upon clinical care recommendations. Though non-significant site-to-site variation exists, such differences should be anticipated by the practicing clinician. Long-term follow-up of GEC benign nodules confirms the clinical utility of this diagnostic test.

BID, a pro-apoptotic Bcl-2 family member, functions as a bridge molecule between death-receptor and mitochondrial related apoptotic pathways to amplify apoptotic signaling. Our previous studies have found a substantial increase in BID expression in the primary normal thyroid epithelia cells treated with the inflammatory cytokines including the combination of IFNγ and IL-1β or IFNγ and TNFα. This increase can sensitize thyroid epithelia cells to death-receptor mediated apoptosis.

A transgenic mouse line that specifically expresses human BID in thyroid cells was established by fusing a rat thyroglobulin (Tg) promoter upstream to human BID (Tg-BID). We tested whether the increased expression of pro-apoptotic BID in thyroid would induce spontaneous autoimmune thyroiditis. In addition, those mice were given iodine water (0.3% of sodium iodide) for eight weeks.

Our data showed that both Tg-BID female and male mice in a CBA/J (H-2k) background, which was established by crossing Tg-BID positive C57BL/6J×CBA/J (H-2k) mice to CBA/J (H-2k) mice, did not spontaneously develop autoimmune thyroiditis for over a year. However, upon ingestion with iodine in drinking water, autoimmune thyroiditis developed in these female transgenic mice, evident by a significant increase in anti-thyroglobulin antibody and 30% of mice having mononuclear cell infiltration into the thyroid glands. But serum T4 levels were similar between iodine-treated and untreated groups.

Collectively, the increased BID expression in thyroids can facilitate the development of autoimmune thyroiditis induced by iodine uptake. Nevertheless, the overexpression of BID itself is not enough to initiate thyroiditis in CBA/J (H-2k) mice, which have a genetic predisposition to develop experimental autoimmune thyroiditis. These findings support the common concept that autoimmune thyroiditis is a multi-factorial disease, resulting from an interplay of genetic, environmental, and endogenous factors.

Surgical, radioiodine and antithyroid drug (ATD) therapy all have their indications in the therapy of Graves' disease (GD). However, current recommendations on surgery (near total) and radioiodine (near ablation) restrict the hope of returning to normal thyroid physiology with no medication to patients that enter remission during a course of ATD. A main obstacle to sustained cure in such patients is the tendency to relapse after stop of ATD.

RISG is a multiphase two center Danish prospective study aiming to promote better targeting of ATD therapy in individual patients. The results of the observational (up to 24 months(m)) protocol RISG1 with titration ATD to GD remission (TRAb negative with normal TSH for 2 m on <5 mg Methimazole (MMI)/d) are reported. In addition an interim status on RISG2, a subsequent 24 m prospective randomized study of no therapy vs continuous low dose MMI, will be given. 208 newly diagnosed GD patients (Aalborg/Copenhagen n=167/41, F/M 176/32, age 45 (35–53) yrs (median (25–75% range)), T3 5.40 (4.22–7.08), T4 210 (175–255) nM were included. TRAb at inclusion was 9.1 (5.2–15.0) IU/L; thyroid volume 20.0 (14.5–31.9) ml; smokers 26.9%, eye signs 29.8%. Initial dose of MMI (20 (15–30) mg/d) was gradually reduced based on standardized thyroid function testing.

173 patients (83.2%) completed the study protocol to remission or for 2 yrs. Frequencies of having entered remission after 12, 18, 24 m of ATD were 24.3/43.4/53.2%. Predictors (p<0.05) at time of diagnosis of NOT being in remission at 24 m in univariate logistic regression analyses were: Age <45 y (OR 2.26); BMI>25 (OR 0.52); eye signs (OR 1.99); T4>240 nM (OR 2.5); TRAb 5–12 IU/L (OR 3.4); TRAb>12 (OR 6.9); thyroid vol >40 ml (OR 3.0); but sex, smoking, previous hyperthyroidism, GD in family, estrogen use, region of living, and TPO-Ab were not. In a multivariate model including the significant predictors, only age <45 y, eye signs, and high TRAb remained significant independent predictors.

Many GD patients are not in remission after recommended standard ATD of 12–18 m duration. A more individual approach with longer therapy of especially patients with young age, orbitopathy, and high TRAb may be warranted.

Previous data demonstrate that thyrocytes (TFC) secrete CXC chemokines, particularly CXCL8 and CXCL10. The physiopathological significance of such secretion and the effects of a combination of proinflammatory stimuli in terms of preferential CXCL8 and CXCL10 release is unclear.

We study the modulation of the secretion of CXCL8 vs. CXCL10 by TFC in Graves' disease (GD), and in primary fibroblasts (OF) or preadipocytes (OP) from Graves' ophtalmopathy (GO).

CXCL8 and CXCL10 were measured in supernatants of TFC, OF or OP cells basally and after 24 h stimulation with IFNg (1000 IU/ml) and/or TNFa (10 ng/ml). CXCL8, not CXCL10, was detected in basal conditions in TFC, OF and OP. CXCL10 secretion was significantly induced by IFNg (P<0.01) but not TNFa, whereas CXCL8 was secreted in response to TNFa (P<0.01), inhibited by IFNg (P<0.01), in TFC, OF and OP. TNFa+IFNg synergistically increased the IFNg-induced CXCL10 secretion (P<0.01) and reversed the TNFa-induced CXCL8 secretion (P<0.01), in TFC, OF and OP.

In conclusion, we first show that TFC, OF and OP secrete CXC chemokines. CXCL8 and CXCL10 secretion is differentially sustained by specific proinflammatory cytokines or their combination, which ultimately determines the nature of the infiltrating lymphocytes in human GD and GO.

Despite early optimal care, children with congenital hypothyroidism (CH) show persisting cognitive impairments. Commonly observed are weak memory functions on tasks of spatial and verbal associative recall that rely on an intact hippocampus. Using MRI, we previously reported children with CH show reduced hippocampal size and atypical functioning for recalling associations and places. Another major critical hippocampal function is the recall of past personal events or autobiographical memory (AM), which is impoverished in children with CH (Willoughby et al, 2013). However, the relation between AM and atypical hippocampal structure and function is not known. Thus the current study sought to evaluate AM relative to hippocampal size and function in children with CH.

Participants were 58 9–14 years olds, 26 with CH diagnosed via newborn screening who received optimal care and 32 age-matched controls. All were assessed with the Children's Autobiographical Interview (CAI) requiring them to describe two past personal events and structural MRI scans from which traced hippocampal volumes were determined. One year later, a subset (7 CH, 19 controls) underwent fMRI with a paradigm requiring them to judge the validity of statements about past personal events (episodic) or personal facts (semantic). Critical contrast was the different signal strength between episodic and semantic statements.

On CAI, CH recalled fewer episodic but not semantic details than controls, suggesting impoverished memories. CH also had smaller left hippocampal volumes than controls. However episodic details and hippocampal size were not correlated (all ps>0.05). On fMRI, both groups indicated bilateral hippocampal activation, which was significantly stronger on the left in CH than controls. CH also activated the entorhinal cortex (ERC) region to a greater degree than controls (p<0.01). Higher TSH at diagnosis predicted increased ERC activity in CH.

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POSTER 22.

Increased Hippocampal Activation for CH versus Controls on Personal Episodic Minus Personal Semantic Contrast

Children with CH show abnormal hippocampal engagement and increased ERC engagement in remembering past personal events, signifying early TH insufficiency leads to functional disorganization of the personal memory system. Thus despite early optimal care, brain development may still be compromised in CH.

Our objective was to compare the performance of liquid chromatography tandem mass spectrometry (MS) versus immunoassay (IA) for measuring thyroid hormones in a diverse group of inpatients and outpatients, some of whose blood samples would provide the types of problems which challenge the performance of IA, such as binding protein abnormalities.

100 patients gave a single blood sample for the study. Their inpatient or outpatient status was documented. The blood samples were assayed for thyroxine (T4), triiodothyronine (T3), free thyroxine (FT4), and free triiodothyronine (FT3) measured by MS. At the same time T4, T3, FT4, and FT3 were measured by IA. IA reference intervals from the manufacturer were confirmed in-house, and MS reference intervals were based on a population of 1700 adults and children.

Although T4 and T3 values measured by the two different assays correlated reasonably with each other, the correlation was best in the mid-range of hormone values and was quite poor at the extremes. This was particularly notable for T3 at the lower end of the range. 13% of T3 values measured by IA were below the 2.5th percentile, which contrasted with 47% of values measured by MS. For T4 measurements 3% of values measured by IA were below the 2.5th percentile, which contrasted with 9% of values measured by MS. FT4 and FT3 values measured by the two assays did not correlate well with each other. In addition, 12% of the FT4 values measured by MS were above the 97.5th percentile, compared with 25% by IA. For FT3 values measured by MS, 1% were above the 97.5th percentile, compared with 6% by IA. FT4 assays also performed differently at the lower end of the range, with 4% of FT4 values measured by IA falling below 2.5th percentile, which contrasted with 29% of values measured by MS.

The greatest discrepancy between these two assays is thus demonstrated at low and high extremes of hormone concentrations, in the concentration ranges where accurate assay performance is most clinically important. Based on the lesser susceptibility of MS to interferences from conditions such as binding protein abnormalities, it is suggested that MS is representative of the clinical situation.

Adequate maternal iodine intake is critical for fetal neurodevelopment. Perchlorate (ClO4) and thiocyanate (SCN) decrease thyroidal iodine uptake by competitively inhibiting the sodium/iodide symporter (NIS). There are conflicting data on whether ClO4 and SCN exposure affects thyroid function. In Thailand, where iodine intake is sufficient, it is unclear whether environmental exposure to ClO4 and/or SCN adversely affects thyroid function during early pregnancy. The present study was carried out to determine the effects of environmental ClO4 and/or SCN exposure on thyroid function in first trimester pregnant Thai women.

Two hundred pregnant Thai women with a gestational age less than 14 weeks were studied. Urinary ClO4, SCN, iodine and serum thyroid function tests were measured. Data are expressed as mean±SD.

The women were aged 28.6±6.1 years and the mean gestational age at the time of sampling was 9.6±2.7 weeks. Median (range) urinary iodine concentrations were 153.5 μg/L (50–1,219 μg/L). Urinary ClO4 and SCN levels were detectable in all women (median 1.9 μg/L, range 0.1–35.5 μg/L and median 510.5 μg/L, range 68–3,525 μg/L, respectively). Using Spearman's rank correlation analyses, there was no association between serum free thyroxine (FT4) and urine ClO4 (r−0.07, p=0.26) or between serum TSH and urine ClO4 (r 0.09, p=0.17). In multivariate analyses adjusted for log urine iodine, log urine SCN, log urine creatinine and gestational age, log urine ClO4 was positively associated with log serum TSH (p=0.006) and inversely associated with log serum FT4 (p=0.003). In the multivariable models, log SCN was not a significant predictor of thyroid function.

Low-level ClO4 and SCN exposure is common in Thailand, where iodine intake is adequate. In adjusted models, low-level ClO4 exposure was significantly associated with increased serum TSH and decreased serum FT4 in first-trimester pregnant Thai women, although serum TSH and FT4 were almost all within the trimester-specific normal range. These data are in conflict with our previous findings in pregnant cohorts. More studies are needed to understand these effects.

The use of Armour Thyroid (desiccated thyroid) in the treatment of hypothyroidism has generated considerable debate. Recent studies have demonstrated both a patient preference for replacement regimes which include T3 as well as providing a scientific basis for potential benefits of combination T4 and T3 treatment in a subgroup of hypothyroid individuals with resistant disease symptoms. Biochemical and clinical data is presented here from a retrospective analysis of 153 consecutive patients with persistent symptoms of hypothyroidism on T4-only treatment who were switched to Armour Thyroid (AT).

450 consecutive patients being treated for hypothyroidism within a single endocrinology practice were screened. Of these, 153 had previously been switched from either generic or brand T4 replacement to AT for treatment of persistent symptoms of hypothyroidism. Total T4, total T3, and TSH levels on T4-only and during AT treatment were analyzed. Patients were asked to compare AT treatment versus T4-only treatment using a 5 point satisfaction rating scale. Results are reported as mean±SD.

On a 5 points scale, with “5” corresponding to AT “definitely superior” to prior T4-only treatment and “1” corresponding to AT “definitely worse” the reported score was 4.3±1.0, P<0.001. 113 patients gave a score of greater than “3”. Two patients reported adverse events on AT, none serious. T4 to T3 ratio on T4-only was 7.9±3.81 while it was 4.7±1.97 (p<0.001) on AT. TSH was 1.30±1.9 μIU/mL and T3 1.21±0.56 ng/mL on T4-only while TSH 1.27±2.2 μIU/mL and T3 1.49±0.87 ng/mL on AT (NS for TSH and p<0.003 for T3). There was no significant correlation between TSH and satisfaction rating.

AT treatment was highly efficacious for improving symptoms of hypothyroidism in a sub-group of patients resistant to T4-only therapy. TSH levels were comparable on T4-only and AT therapies indicative of similar intensities of thyroid hormone replacement between replacement regimes.

Iodine and selenium are essential elements in thyroid hormone synthesis. Iodine is incorporated into thyroid hormones, while selenium is a key component at the catalytic site of several selenoproteins involved in protecting the thyroid gland from free radicals produced during thyroid hormone synthesis, and in peripheral tissue conversion of thyroxine to triiodothyronine. Bromine and arsenic are antagonists of thyroid hormone synthesis: as the former competes with iodine in the thyroid, while the latter forms a tight complex with selenium, preventing its incorporation into selenoproteins. To better understand the interplay of bromine on iodine and arsenic on selenium, we developed a new method to measure these four elements in urine dried on filter paper.

Twenty five volunteers collected four spot urine samples on Ahlstrom grade 226 filter paper (morning, lunch, afternoon and night) during a 24-hour period. Liquid standards, calibrators, blanks and urine samples were dried on filter paper, punched into a 96-well filter block and extracted with ammonium hydroxide containing germanium as an internal standard. The extract was then simultaneously analyzed for iodine, bromine, selenium and arsenic using inductively coupled dynamic reaction cell mass spectrometry (ICP-DRC-MS). Remaining extract was further analyzed for creatinine in a 96-well format using a modified version of Jaffe's reaction to correct for hydration status. After creatinine correction, we compared the average of all four spot urine collections to averaged morning and night spot urine collections.

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Detection limits, recoveries, inter- and intra-assay variations, and linearities were acceptable for each analyte. Accuracy was validated using certified reference materials. Urine dried on filter paper is stable for at least a month at room temperature, allowing for convenient shipment and storage. The average of four spot urine collections correlated well with the average of morning and night spot urine collections.

The method described is ideal for large population studies and clinical testing investigating the role of iodine, selenium and their antagonists, bromine and arsenic, in thyroid hormone synthesis and function.

The purpose of this study was to evaluate the incidence and predisposing factors of postoperative hypothyroidism after hemithyroidectomy

We analyzed 91 patients who underwent hemithyroidectomy between October 2008 and January 2009. The definitions of euthyroid and subclinical hypothyroid (hypothyroidism) were based on TSH laboratory data

Postoperative hypothyroidism was diagnosed in 25 (27.5%) of 91 patients with a mean postoperative TSH level of 8.55 (5.2–18.2) μU/ml. The mean of last follow up duration was 18.94 months. The preoperative TSH had relationship with postoperative hypothyroidism with significant cut-off value at higher than 3.0 μU/ml and (p<0.05). Among 25 patients, 12 (46.0%) had preoperative TSH higher than 3.0 μU/ml. The overall mean TSH of immediate postoperative and the last were 6.34 and 3.99 μU/ml, respectively.

Even though the immediate postoperative TSH seems higher than the normal range, the last showed mean TSH below 5.0 μU/ml. These findings indicate that TSH should be followed for long-tem duration before the diagnosis of postoperative hypothyroidism. Also, within the patients having preoperative TSH higher than 3.0 μU/ml, half of them should be considered to develop postoperative hypothyroidism.

To determine the necessary dose of levothyroxine in different types of hypothyroidism, time since the diagnosis, and the initial level of TSH in primary hypothyroidism.

Retrospective cohort study in patients over 14 yo, normal TSH range for at least 2 consecutive measures 3 months since the primary hypothyroidism diagnosis, and normal free T4 for central hypothyroidism.

518 patients met the inclusion criteria of which 90% were women. Overall, 50.9% had primary hypothyroidism with TPO unknown o negative in clinical history, 15.4% positive TPO, 13.1% total thyroidectomy, 6.1% hemithyroidectomy, 5.9% central hypothyroidism, 5.7% post radioactive iodine, and 2.5%. post thyroiditis. The necessary dose of levothyroxine (μg/kg/d) to get a normal TSH o free t4 in central form was 1,03±0,46, 1,21±0,54, 1,65±0,46, 1,11±0,52, 1,33±0,6, 1,51±0,58 and 1,11±0,72 respectively. In patients with primary hypothyrodism, with initial TSH of less than 10 and less than 2 years since the diagnosis the requirement was 0.65±0,33 μg/kg/d, when the initial TSH was more than 20: 1,34±0,68 μg/kg/d. (p<0,001). There was a progressive increment in the needed dose of levothyroxine proportional to the years since diagnosis: less than 2 years since diagnosis: 0,77±0,38, between 2 to 5: 0,90±0,40, and more than 5 years: 1,07±0,48 μg/kg/d (p<0,001)

The necessary dose of levothyroxine to achieve a normal TSH level is variable and depends of the type of hypothyroidism, initial TSH level, and time lapsed since diagnosis. The initial dose in mild hypothyroidism is less than the usual recommended dose in overt hypothyroidism.

Case of a 29 y/o female patient status post C/S of twins at 38 weeks of gestational age who comes to ER presenting with vaginal bleeding, palpitations, headaches, tremors, shortness of breath and fever of 5 weeks evolution. Further inquiry revealed that she had been bleeding per vagina for more than a month and that she had to be admitted for PRBC's transfusions due to symptomatic anemia secondary to vaginal bleeding that started 3 days after delivery. On that admission dilatation and curettage done due to suspected retained placental tissue and discharged after hemoglobin levels stabilized. She had no other history of note.

At our evaluation patient found with unstable vitals signs. She also presented with respiratory distress, icteric sclera, hyperreflexia, bilateral lung crackles and a palpable hard uterus just below umbilical line.

Pertinent labs included TSH<0.002 mIU/dL, elevated free T4 levels 4.5 ng/dL, Hbg levels 9.3 g/dL (stable), total bilirubin 4.89 mg/dL and tumor marker HCG 161, 412,000 mIU/ml. Pathology report of D/C showed trophoblastic tissue with necrotic material consistent with a choriocarcinoma. CT scan showed large enhancing pelvic mass of 10×14×15 cm representing the suspected choriocarcinoma with extensive pulmonary metastatic burden, no evidence of pleural effusions. Due to her clinical presentation, Thyroid Storm suspected with a Burch and Wartofsky Criteria >55. She was started rapidly on antithyroid medications, B-Blockers, Steroids, IV fluids and Lugol's solution. After a day on this therapy clinical status markedly improved. Hematology-Oncology services consulted and patient started on chemotherapy with EMACO (etoposide, methotrexate, actinomycin D, cyclosphosphamide and vincristine). After few days on chemotherapy patient now with normal thyroid hormones levels and normal HCG levels. Antithyroid meds already discontinued.

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POSTER 29.

Choriocarcinoma www.surgicalpathologyatlas.com

This case represented a rare cause of thyrotoxicosis secondary to a metastatic choriocarcinoma. The malignant choriocarcinoma, occurs in 1 in 70,000 pregnancies and only 2% have clinical hyperthyroidism. It is important to include trophoblastic tumors in the differential diagnosis of thyrotoxicosis to avoid untoward consequences and provide rapid treatment.

Whilst radioiodine ablation is an effective therapy for many patients with thyroid cancer, a subset of patients are incapable of accumulating the amount of iodide-131 required for treatment, due to low sodium iodide symporter (NIS) activity. Previous work has identified that the overexpression of pituitary tumor transforming gene (PTTG) binding factor (PBF) in thyroid cells leads to the redistribution of NIS from the plasma membrane into intracellular vesicles, thereby reducing radioiodine uptake. With radioiodine being proposed as a potential treatment for breast carcinomas, where PBF has been reported to be overexpressed, it is important to discern the relationship between PBF and NIS in breast cancer cell-lines.

Immunofluorescent microscopy was used to image MCF-7 and T47D cells to evaluate subcellular localisation of transfected NIS-MYC and PBF-HA. NIS activity was assessed in MCF-7 and MDA-MB-231 cells by measuring the uptake of Iodine-125.

Immunofluorescent microscopy revealed co-localisation between NIS and PBF in transfected MCF-7 and T47D cells, with increased intracellular staining for NIS compared to cells transfected with NIS alone. We have recently identified PBF as a tyrosine phosphorylated protein, with phosphorylation at residue Y174 critical to NIS regulation in thyroid cells. Importantly, phosphorylated PBF co-localised at the plasma membrane with NIS in T47D breast cells. In preliminary functional studies MCF-7 cells, PBF repressed radioiodine uptake in cells that had been transfected with NIS (Fold change=0.12), as well as those treated with the NIS-inducing reagents all-trans retinoic acid (ATRA) and dexamethasone (Fold Change=0.38). PBF also significantly repressed iodide uptake in MDA-MB-231 cells transfected with NIS (fold change=0.75, p<0.05).

Taken together, these data suggest that PBF can alter the subcellular location of NIS and thereby reduce the ability of breast carcinoma cell-lines to take up iodide, consistent with those findings previously reported in thyroid cells.

To fight obesity, low carbohydrate diets are popular. In the Paleolithic type diet (PD) (stone age diet) two of the largest iodine sources, table salt and dairy products, are excluded and the risk of iodine deficiency (ID) is evident. This study aimed for the first time to evaluate iodine status in subjects on PD compared to subjects on a diet according to the Nordic nutrition recommendations (NNR).

This is a two-year prospective randomised trial in healthy postmenopausal overweight women that were recruited for a dietary weight reduction program and were randomized to either PD (n=35) or NNR (n=35) diets. Median 24-hour urinary iodine concentration (24-UIC), 24-hour urinary iodine excretion (24-UIE) during three days and thyroid hormone levels were evaluated at baseline and after 6- and 24 months. The urine sampling was monitored by para-aminobenzoic acid (PABA), the salt intake by urinary sodium (U-Na) and dietary habits were registered.

From similar baseline levels (24-UIC 72 μg/L, 24-UIE 134 μg/L), the levels decreased after 6 months in PD group to 36 μg/L (p<0.001) and 77 μg (p<0.001) in 24-UIC and 24-UIE, respectively, whereas levels in the NNR group were held constant. The median TSH at 24 months was higher than at baseline in both groups, p<0.05. FT3 decreased in the PD group after 6 months and was lower than on the NNR diet p<0.05.

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POSTER 31.

24-hour urinary iodine excretion (24-UIE) at baseline, 6 and 24 months after intervention with a paleolithic diet (PD) or a diet according to Nordic nutrition recommendations (NNR).

A paleolithic diet for two years resulted in iodine levels in accordance with mild to moderate ID and iodine supplementation is recommended.

Whilst the majority of differentiated thyroid cancers (DTC) have oncogenic mutations, a significant minority may be driven by the over-expression of proto-oncogenes. PTTG and PBF are proto-oncogenes which are induced in DTC, elicit tumours in xenograft models and interact in vitro, where PBF shuttles PTTG into the nucleus. However, the relative contributions of each gene to DTC has not been delineated.

We constructed a bi-transgenic murine model over-expressing both PBF and PTTG specifically in the thyroid gland, and characterised it in comparison to age and sex matched single transgenic (PTTG-Tg, PBF-Tg) and wild-type (WT) mice. A total of 68 WT, 98 PBF-Tg, 25 PTTG-Tg and 23 bi-transgenic mice were assessed.

No significant difference in thyroid weight was observed between male and female mice within each of the 4 genotypes. However, there was a significant 2.7-fold increase in thyroid weight in bi-transgenic mice compared to WT (p<0.001) at 6 weeks of age. PBF-Tg thyroid weight was 1.7-fold higher than WT mice (p<0.001), whereas PTTG thyroid weights were similar to WT (0.95-fold; p=0.18). Interestingly, bi-transgenic thyroids were 1.6-fold heavier than PBF-Tg thyroids (p<0.001). Enlarged thyroid growth in bi-transgenic mice was accompanied by significant hyperplasia and macrofollicular lesions. As oncogenic expression of PTTG is known to induce genetic instability (GI), we determined GI levels through FISSR-PCR in primary thyroid cultures of each genotype. Compared with WT (arbitrary GI Index=0%), PBF-Tg mice had a GI Index of 19.8±1.8%; PTTG-Tg mice of 7.6±1.6%; and bi-transgenic mice of 37.9±2.7%. Examination of a panel of 83 DNA repair genes to understand which genetic changes might underlie these differences showed that expression of 9 genes were significantly down-regulated >1.5-fold in bi-transgenic thyrocytes compared to PBF-Tg, including Gadd45a (2.3-fold, p=0.006), Brca1 (2.1-fold, p=0.003) and Chek1 (2.4-fold, p=0.01).

Together, our data reveal a complex interplay between PTTG and PBF in vivo; the bi-transgenic thyroid phenotype is closer to that of PBF-Tg mice than PTTG-Tg mice, but reveals increased goitre size, and heightened genetic instability than either single transgenic model alone.

The antitumoral activity of two new “pyrazolo[3,4-d]pyrimidine” compounds (CLM29 and CLM24), which inhibit several targets (including EGFR, VEGFR and the RET tyrosine kinase and have an anti-angiogenic effect), have been studied in primary anaplastic thyroid cancer (ATC) cells.

We tested the antiproliferative effect of these new compounds in ATC cells obtained from patients with recurrence of the tumor at the time of reoperation. In the in vitro experiments different concentrations of CLM29 and CLM24 (1, 10, 30, 50 μM) were used.

After treatment with CLM29, proliferation assays in ATC cells showed a significant reduction of proliferation, respect to the control (expressed as 100%), that was by 80% with CLM29 5 μM, 50% with CLM29 10 μM, and 32% with CLM29 50 μM. In ATC cells CLM24 also induced a slight but significant reduction of proliferation that was 97% with 30 μM, and 78% with 50 μM. The percentage of apoptotic cells in in vitro experiments with ATC cells was increased by CLM29 and CLM24, dose-dependently (p<0.001). In 3/9 of ATCs used for in vitro experiments the V600EBRAF mutation was observed. The results obtained about the inhibition of proliferation by CLM29 and CLM24 in ATC from tumors with V600EBRAF were similar to those from tumors without BRAF mutation. CLM29 inhibited migration (p<0.001) and invasion (p<0.001) of ATC cells, while CLM24 had no significant effect.

In conclusion, the antitumoral activity of these two new “pyrazolo[3,4-d]pyrimidine” compounds (CLM29, CLM24) in in vitro experiments in ATC has been shown, independently from the presence of the BRAF mutation, opening the way to a future clinical evaluation.

Metastasis is a multistep process responsible for the vast majority of endocrine cancer cell deaths. The initial stage of metastasis involves the invasion of tumour cells into the adjacent tissue. We have previously identified PBF to be upregulated in differentiated thyroid cancer, and recently PBF expression has been correlated with distant thyroid cancer metastasis at diagnosis. Further, PBF potently induces breast cancer cell invasion in vitro and our recent in vivo data demonstrate that colorectal tumours with higher PBF protein expression demonstrate increased vascular invasion.

Boyden chamber invasion assays were used to determine if PBF regulates thyroid cell invasion. To gain insight into the pathway in which PBF induces cell invasion we used two different approaches. 1) IP-MS was employed to discover PBF binding partners. 2) As epithelial cells undergo an epithelial to mesenchymal transition (EMT) to facilitate invasion we performed focused SABiosciences cDNA arrays housing 84 genes of central importance to EMT.

We now show that PBF significantly promotes thyroid cell invasion in vitro in SW1736 cells (1.3-fold compared to vector only (VO), P<0.01). Further, our IP-MS approach identified the cortical actin binding protein, cortactin, as an interacting partner of PBF. This interaction was confirmed using co-immunoprecipitation assays, which also found that mutation of residue F at position 177 to A within the C-terminal sorting signal of PBF disrupts this interaction. Cortactin has a central role in invasion as it promotes cell migration; we therefore examined whether the interaction between cortactin and PBF controls cell migration. Wound healing assays in MDA-MB-231 cells revealed that GFP-tagged PBF cells migrated significantly further than GFP-VO cells (VO=115.3 μm, PBF=143.0 μm, P<0.01). Finally, cDNA arrays revealed that PBF significantly regulates four genes (DSP, JAG1, PDGFRB and TCF3) of central importance to EMT in SW1736 thyroid cancer cells (P<0.05).

Taken together these data suggest that PBF may promote thyroid cell invasion by 2 independent mechanisms; 1) PBF binds to cortactin and regulates migration, and 2) PBF regulates the expression of genes involved in EMT.

Mutations in BRAF kinase are widely observed in PTC and activate downstream kinases along the MAPK pathway, resulting in functional dependence upon this cascade. While many patients respond to treatment with the BRAF inhibitor vemurafenib, responses are incomplete and patients inevitably progress. The mechanism of acquired resistance is not completely understood, nor is it clear which drug should be started after progression. The 3:1 (female:male) gender disparity and prevalence of PTC in women of childbearing age suggest estrogen receptors, ERα and GPR30, as potential facilitators in this resistance. Moreover, EGFR is a putative target of GPR30 and its increased activation has been correlated with increased BRAF inhibitor resistance in colon cancer. This study begins to investigate whether activated estrogen receptors potentiate/induce acquired resistance to inhibitors of mutated BRAF through adaptations in cell surface receptor tyrosine kinases and the MAPK and PI3-K pathways, as well as the role of estrogen receptors in the observed gender disparity.

Western blots were used to analyze receptor expression in cell lines were treated with 2μM vemurafenib and/or 10 nM Estradiol. Tissue arrays were imaged and analyzed for receptor expression using a Vectra automated multispectral imaging system.

Our data show that ERα and GPR30 are indeed expressed in the PTC cell line BCPAP, which harbors the BRAF V600E mutation, and were both significantly upregulated in PTC lymph node metastasis tissue cores compared to normal thyroid tissue. Although ERα levels were relatively lower in the BCPAP line than the highly aggressive breast cancer cell line MCF7, levels of EGFR and GPR30 were five and fifteen times higher in BCPAP cells, respectively. Estradiol has been shown to increase proliferative and metastatic phenotypes in this PTC line. Our experiments show increased levels of activated AKT and MAPK, as well as EGFR in BCPAP cells following estrogen treatment.

These results indicate the potential for activated estrogen receptors to promote acquired resistance to BRAF inhibitors. Further study of this potential and the molecular mechanism behind the activation of the MAPK and PI3-K via ERα, GPR30, and EGFR is warranted.

Thyroglobulin (Tg), is mandatory to monitor efficacy of thyroid gland surgical and Radio-Iodine ablation in patients with Differentiated Thyroid Cancer (DTC). Successful treatment (by removing the unique source of Tg) is currently assessed by undetectable Tg in the serum. The aim of our study was to evaluate the analytical and clinical performances of the new sensitive Tg seric immuno-assay developed on Kryptor Compact Plus instrument (Thermo Fisher Scientific).

Kryptor hTg sensitive assay is using TRACE methodology (Time-Resolved Amplified Cryptate Emission), with 3 anti-Tg monoclonal antibodies labeled with Lumi4 (cryptate of Terbium) and one anti-Tg polyclonal antibody labeled with Cyanin5.5, allowing the detection of each fluorophore separately or associated in the same antigen-antibody complex.

Analytical performances of Kryptor hTg sensitive assay showed total coefficients of variation (CV) of 8% and 5% for Tg levels of 0.97 μg/L and 54.7 μg/L respectively and a Functional Assay Sensitivity (FAS) of 0.14 μg/L Tg. Kryptor hTg sensitive assay was compared to Access 2nd generation Tg (Beckman) in 131 samples from 97 patients with DTC, either on LT4 treatment (n=69 samples) or under TSH stimulation (n=62 samples). The Tg levels varied from undetectable to 363 μg/L and to 370 μg/L on Kryptor and Access respectively. The regression equation in the direct measuring range was y=0.84x+0.07, where y and x are the Tg levels measured on Kryptor and Access respectively. With a cut-off corresponding to the FAS of each assay for patients under LT4 treatment (i.e. 0.14 μg/L for Kryptor and 0.1 μg/L for Access), and a cut-off of 1μg/L Tg for patients under TSH stimulation, the percentage of concordant results was 87%. To the exception of one patient with an unusual Tg response to TSH stimulation, the discrepant results (n=17), i.e. Tg higher than the cut-off by one method and lower than the cut-off by the other method, showed Tg levels slightly elevated over the cut-off.

In conclusion, Kryptor hTg sensitive assay is suitable for the follow-up of patients with DTC as all the results in DTC patients (except in one) were either correctly classified or slightly above the cut-off value whatever the method.

Smoking is a major risk factor for cancer development and is strongly related to 90% of lung cancers. In contrast, epidemiological studies demonstrate that cigarette smoking is associated with reduced risk of thyroid cancer. It has been demonstrated that cigarette tobacco smoke metabolites cause cell injury and dysfunction by enhancing oxidative stress and inflammation. We hypothesize that thyroid and lung carcinoma cell growth and proliferation are differentially stimulated by metabolites from cigarette smoking.

Primary cell cultures from papillary thyroid cancer, adjacent normal thyroid tissue (from the same patient), lung adenocarcinoma and adjacent normal lung tissue (from the same patient) were incubated in conditioned F-medium with Y compound (ROCK inhibitor) using the “Georgetown Method”. All cells were incubated with 1% human serum obtained from a smoker (SMK), a second hand smoker (SHS), and a non-smoker (non-SMK) for 24, 48, and 96 hours, respectively. Images of cells were taken and cell numbers were counted at each time interval. The study was repeated using different subjects at each round. Smoking levels were detected using serum cotinine as a biomarker for smoke exposure measured by tandem mass spectrometry (LC/MS/MS).

Thyroid cancer cells did not demonstrate a dose response to the different serum, but did grow less in the presence of serum from SMK and SHS relative to non-SMK. Normal thyroid cells had the highest cell proliferation when incubated with serum from non-SMK and the least with serum from SMK. In comparison, a dramatic increase in lung cancer proliferation, of 300%-700% was detected when cells were incubated in the presence of serum from SMK. A dose response pattern was noted in the presence of serum from SHS vs. serum from non-SMK. Further, normal lung cells did not show differential response in the presence of each of the serum types.

This study demonstrates that smoking is not associated with thyroid cancer cell growth and is associated in a dose response manner with lung cancer cell proliferation. The different effects of cigarette smoking on lung and thyroid cells growth imply that smoking metabolites play distinct roles in the development of these two types of cancer.

Detectable circulating tumor cells (CTCs) have been associated with poor prognosis in breast, colon and prostate cancers. We have previously reported that ≥5 CTCs per tube can be detected using the Veridex CellSearch system in blood from a subset of patients with metastatic medullary thyroid carcinoma (metMTC) (Michaelis et al EndoSoc 2010). We now evaluate whether elevated CTCs are associated with worse survival in metMTC.

Two CellSave tubes of whole blood were obtained from 18 subjects (M:F 9:9) with metMTC. CTCs were enumerated by the CellSearch system, which identifies CTCs by immunomagnetic cell selection using EpCAM as a capture antigen, followed by fluorescent immunolabeling for detection of epithelial-derived cells that stain positive for cytokeratin and DAPI and negative for the lymphocyte marker CD45. Captured cells are visually confirmed and counted by microscope.

Mean age at diagnosis was 43 yrs and at sampling was 52 yrs; log mean and median calcitonin were 3918 and 3240 ng/mL, respectively. Metastatic disease was noted in liver, lungs, and bones in 89%, 72% and 67% of patients, respectively. 8 patients were being treated with TKI therapies, and another 7 had undergone previous treatment. 6/18 patients had ≥5 CTCs per tube detected by CellSearch. With a median follow-up of 24.5 months after sampling, 9 patients had died, including 5/6 of those with ≥5 CTCs per tube compared with 4/12 for those with <5 CTCs. Calcitonin doubling times did not significantly differ between those who died and those alive at last follow-up. Median survival was 13 months for those with ≥5 CTCs, and had not been reached for those with <5 CTCs. Kaplan-Meier analysis demonstrated significantly shorter survival for those with ≥5 CTCs (Fig 1; P=0.024). The hazard ratio for mortality of patients with ≥5 CTCs compared with <5 CTCs was 4.05 (P=0.042).

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The presence of ≥5 CTCs per tube detected by CellSearch in a single blood specimen from patients with metMTC is associated with worse survival and may be more predictive than calcitonin doubling time. Larger cohorts are required to validate this observation, and to determine if sequential changes in CTCs are predictive of outcomes with subsequent treatment.

An impact of CTL on PTC outcome has been long advocated but this matter is still controversial. Moreover, there is increasing evidence that the balance between the cytotoxic and the regulatory components of the lymphocytic infiltration (LI) may affect the tumor-specific immune response. The purpose of this study was to evaluate the prognostic value of CTL in a retrospective cohort of PTC patients and to characterize the LI and the lymphocytic subpopulations.

We assessed 375 PTC patients, aged 45.2±16.4 years, treated with thyroidectomy and radioiodine remnant ablation, with a mean follow-up of 6.28±3.86 years. In a subgroup of patients (n=100), tissue sections were reviewed for the presence of CTL and lymphocytes within and/or surrounding tumor (TAL); lymphocytic subsets were characterized by immunohistochemistry.

Seventy-five/375 patients (20%) had a histological diagnosis of CLT and were more frequently women (90.7% vs 69.7, p=<0.001) with a tendency to be low risk (according to ATA criteria) compared to those with no CTL. At the last follow-up, PTC patients with CTL showed a significantly better outcome compared to those with no CTL, even considering only female patients (cure rate: 92.4% vs 79.3%, p=0.009), low (cure rate: 100% vs 89.8%, p=0.039) or high risk patients (cure rate: 82.9% vs 66.3%, p=0.043). Data from LI characterization are available for 43/100 patients: PTC patients with CTL (n=14) compared to those with TAL (n=21) tend to have more often tumors with intra-thyroidal extension and less aggressive histological variant. Foxp3+ lymphocytes progressively increased from outside the tumor to the intra-tumoral LI in PTC patients with TAL while they showed an opposite trend in PTC patients with CTL.

Our data suggest that concurrent CTL has a protective effect on PTC outcome and that the imbalance between cytotoxic and regulatory T lymphocytes in the intra-tumoral TAL may affect the tumor-specific immune response favoring a more aggressive behavior of cancer.

Foxp3+ regulatory T cells (Tregs) are increased in peripheral blood and intra-thyroid lesion of thyroid cancer. These Tregs facilitate the growth and invasion of thyroid cancer. Recently, there are increasing publications showing that Foxp3 can also express in cancer cells but its function remains inconsistent. Very limited information is available on Foxp3 expression in thyroid cancer cells. The activity or/and expression of PPARγ is down-regulated in thyroid cancer and the activation of PPARγ can result in the arrest of thyroid cancer growth. The relationship between Foxp3 and PPARγ has not been reported.

Human thyroid cancer cells and north thyroid cells were cultured to examine the express Fox3 at mRNA and protein level by real-time PCR and Western blot respectively. siRNA was used to inhibit the Fox3 expression. Cell proliferation, migration and apoptosis were examined to determine the cell function. PPARγ expression and activity were determined.

We demonstrated that Foxp3 expression was higher in thyroid cancer cells than in normal thyrocytes. Foxp3 inhibition by its shRNA decreased cell proliferation and migration, but increased cell apoptosis, suggesting a positive role of Foxp3 in thyroid cancer growth. Interestingly, Foxp3 inhibition led to the elevation of PPARγ expression and activity. In addition, Foxp3 inhibition downregulated the expression of NF-κB subunit p65 and cyclin D1 but upregulated caspase-3 levels. These molecular changes are in line with Foxp3 shRNA-mediated alteration of cell functions.

Our study demonstrates that thyroid cancer cells express a high level of functional Foxp3 and that the inhibition of this Foxp3 suppresses the proliferation and migration but promotes apoptosis in thyroid cancer cells likely via inhibiting PPARγ but promoting NF-κB and cyclin D1. The findings suggest that targeting Foxp3 in thyroid cancer cells may offer a novel therapeutic option for human thyroid cancer.

TP53 gene exerts a major role in the negative control of cell proliferation and in controlling signaling cascades important in DNA repair and apoptosis. It has been proposed that functional p53 protein is involved in the induction of anti-tumor CD4+ cytotoxic-T-cell activity against carcinoma cells. We aimed to investigate the clinical pathological role of p53 and immune cell markers in Differentiated Thyroid Cancer (DTC) and their utility as diagnostic and prognostic markers.

We used the ACIS-III system to evaluate p53 and immune cell markers including tumor associated macrophages (TAM); CD68 and tumor infiltrating lymphocytes (TIL) subsets such as CD3, CD4, CD8 and CD20 in 206 thyroid carcinomas, 105 benign nodules and 18 normal tissues. In addition, TP53 was sequenced in 78 out of 164 patients with papillary thyroid carcinoma.

Among the thyroid cancer patients, 85% evolved free of disease after 53.8±41 months of follow-up. P53 expression was observed more frequently in malignant than in benign lesions (p<0.0001) and helped discriminate follicular patterned lesions. In addition, p53 expression was more frequent in smaller tumors (p=0.0015), presenting as solitary nodules (p=0.0286), with thyroiditis (p=0.0486) and without metastasis at diagnosis (p=0.0201). We observed that TAM was present in 89.6% of P53 positive and 71.4% of P53 negative tumors (p=0.002). We did not -find any association between P53 expression and infiltration of CD3+TIL. A marginal association was found between P53 expression and infiltration of CD4+TIL (p=0.051). Interestingly, while 61.7% of P53 positive tumors presented infiltration of CD8+TIL, CD8+TIL was found in only 25.6% of P53 negative tumors (p<0.001). A Kaplan-Meier survival curve did not confirm p53 as an outcome independent determinant and there was no correlation, neither between p53 protein expression and TP53 mutational status, nor between TP53 and features of tumor aggressiveness.

In conclusion, we suggest that p53 and immune cells profile analysis by IHC might be useful in the differential diagnosis of thyroid lesions and may help characterize less aggressive cases that do not need hard-line management.

Thyroid cancer is the fastest growing solid malignancy in the U.S. It is unclear if this is a true increase or reflects improved surveillance and diagnostic techniques. If due to increased surveillance, then incidence should vary with access to healthcare.

County-based thyroid cancer incidence for 2009 was obtained from the NCI state cancer profiles database. County-specific insurance coverage rates and median household income were obtained from the U.S. Census Bureau, Current Population Survey, 2009–2012. Correlation coefficients were calculated to evaluate the relationship between cancer incidence, insurance rates, and median household income.

Data was available on 1282 counties in 48 states. Incidence of thyroid cancer ranged from 3.9 to 39.7. The wealthiest counties with the highest insurance coverage had the highest incidence. There was a positive correlation coefficient between cancer incidence and insurance rates (0.27, p<0.001), as well as median income (0.17, p<0.001). Cancer incidence was more affected by insurance rates than median income. Each unit increase in insurance rate correlated to a 0.2 increase in thyroid cancer incidence (p<0.001). When considered by state, 6/8 states with the highest incidence are contiguous in the Northeast while 7/8 states with the lowest incidence are contiguous in the Southeast.

Thyroid cancer rates are greater in wealthier counties with higher rates of insurance coverage, suggesting that increasing thyroid cancer rates are in part due to increased surveillance. Other environmental factors also may contribute to geographic variance.

The vast majority of patients with well differentiated thyroid cancer (WDTC) will have excellent outcomes, with only a select few at high risk of death from disease. None of the existing staging systems for WDTC however are capable of accurately predicting outcome for an individual patient. There is therefore a great need for an accurate, individualized method for predicting outcome, both for patient counselling and for selection of therapy in the growing number of patients presenting with WDTC. The aim of this study was to produce a nomogram to predict disease specific survival for individual patients with WDTC.

1810 consecutive patients treated surgically for WDTC between 1986–2005 were included in this retrospective analysis. Accurate clinical, histological, therapeutic, and outcomes data were collected for all patients. Multivariable Cox proportional hazards regression was used to model the association between predictors and the outcomes. Model reduction was performed using the stepdown method to eliminate predictors with less predictive ability from the final models with the purpose of simplifying the nomogram for widespread application. Concordance index was calculated for disease specific survival with bootstrap correction of overfit bias.

1298 patients (71%) were female with a mean age of 47 years (s.d.16 y). Mean tumor dimension was 2 cm (s.d. 1.5 cm). 315 (17%) had microscopic and 206 (11%) had macroscopic extra thyroid extension. 625 had no neck dissection (35%), 580 had benign nodes excised (32%) and 605 had positive nodal disease excised (33%). 53 patients (3%) presented with distant metastatic disease (M1). With a median follow up of 78 months (range 0–320 months), 55 patients died of disease. The 10 year DSS was 96%. Age, tumor dimension and M stage were independently predictive of outcome. A nomogram based on these factors was able to predict DSS with very high accuracy (concordance index of 0.96).

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We have designed a nomogram which is highly accurate at predicting the risk of disease specific survival in individual patients with WDTC.

Familial-non-medullary thyroid cancer (FNMTC) is defined as when 2 or more first degree relatives are affected and is thought to have an autosomal dominant pattern of inheritance. However, there has been no study investigating the mode of inheritance in FNMTC by prospectively ascertaining disease status. The aim of this study was to determine the inheritance pattern(s) of FNMTC.

Kindreds with 2 or more first-degree relatives affected with papillary thyroid cancer were prospectively enrolled and screened for thyroid cancer/nodule. The modes of inheritance were deduced from pedigree analysis.

Nineteen kindreds with 204 family members were enrolled in a prospective screening clinical protocol. 63 of the 204 patients had a thyroidectomy for a thyroid nodule: 3 had benign pathology, 84% (48/57) had papillary thyroid cancer, and 16% (9/57) had follicular variant papillary thyroid cancer. 13 of 19 families (68.4%) had a parent-offspring relationship and 60.5% (26/43) of the offspring generation was affected. The prevalence of thyroid cancer in the offspring generation was not different by the total number of affected members per family. Pedigree analysis suggested autosomal dominant inheritance with or without reduced penetrance in 13 families, autosomal recessive inheritance in 4 families and a possible X-linked inheritance in one family. When considering all family members with a thyroid neoplasm (benign/malignant) on screening ultrasound in the parent and offspring generation, the mode of inheritance was consistent with an autosomal dominant pattern in 15 of 19 families.

In FNMTC, the mode of inheritance is variable with most kindred showing an autosomal dominant pattern of inheritance. Our findings demonstrate that a complete pedigree analysis with screening ultrasound of unaffected family members should be performed to ascertain the pattern of inheritance and for counseling at-risk family members.

While thyroid and parathyroid surgeries were initially performed using local anesthetic techniques, the advent of safe general anesthesia (GA) resulted in the majority of surgeons performing these procedures under GA. However, recent studies have evaluated the return to locoregional techniques, claiming similar results to resections performed in the traditional manner. The purpose of this study was to evaluate the intra-operative metrics and post-operative outcomes of these two approaches.

ACS-NSQIP data from 2005–2010 were queried for patients undergoing thyroid and parathyroid surgery. Of these, 1,771 patients received locoregional anesthesia (RA) with the remainder receiving GA. After patient demographics and pre-operative risk factors were obtained, data were evaluated for the effect of GA vs RA on outcomes of operative time, anesthesia time, unplanned return to OR, and time to discharge.

Patients who received RA had less EtOH and tobacco use, but were otherwise equivalent. No significant differences were noted in post-operative complications between the two forms of anesthesia. Operative time was significantly shorter with RA vs GA (112 minutes [95%CI 109–116]) vs (162 [95%CI 162–163]). Anesthesia time was also shorter with RA (71 minutes [95%CI 68–74]) vs (111 minutes [95%CI 111–112]). Time to discharge was significantly shorter, with 82.15% of RA patients leaving on day 0 and 15.67% on POD #1 vs 18.27% of GA patients leaving on day 0 and 69.71% on POD #1 (p<.0001). Upon stratification by CPT code, these differences remained statistically significant for the majority of procedures performed under RA, primarily thyroid lobectomy, total thyroidectomy, parathyroid exploration, and parathyroid re-exploration.

It remains for future studies to determine whether or not same-day neck surgeries are safe in regards to post-op hematoma and airway compromise concerns. RA is non-inferior to GA upon evaluation of thyroid and parathyroid complications recorded in the ACS-NSQIP database, and results in shorter OR and anesthesia times as well as earlier discharge. This, in addition to the reduced cost of RA over GA, may result in significant cost savings to healthcare systems.

Thyroid cancer (TC) incidence has increased dramatically over the last decades in most developed countries. There is an ongoing discussion whether this is a result of an increased detection rate or if unknown factors contribute. The aim of this study was to analyze TC-epidemiology over 10 years in a long-time iodine-sufficient, well-defined geographic population of 1,5 million inhabitants in Western Sweden.

The National Cancer Registry (NCR) is mandatory in Sweden and covers over 98% of all malignancies. In a population-based registry for clinically detected TC in Western Sweden, 716 consecutive patients (male 198; female 518) were included 2001–2010. Their median age was 52 years (range 6–95). Compared with the NCR 95,3% of all cases diagnosed in the Western region were reported to the register without selection bias. Changes in age, sex, tumor size, stage and type were analyzed over time. Previous studies have shown that the population has an iodine intake well within the WHO-recommended limits.

The female TC incidence rose from 5 to over 9 cases/100 000 inhabitans during the 10 year period whereas the male incidence was stable around 2,5 cases/100 000. Tumor size, proportion with node metastases and distribution of tumor types did not change over time. 27% of the tumors were <1 cm at diagnosis. 45% had node metastases. 75% of the tumors were papillary.

The female incidence of papillary TC is getting higher in the Western region of Sweden. The distribution of tumor sizes was stable and the proportion of small tumors (<10 mm) was unchanged during the 10 year period. Preliminary data from 2011 and 2012 indicate continuous increase among females. Female dominance and unchanged tumor size indicate that other causative factors, than just better detection, are likely to explain the increasing incidence. This will be further studied in detail.

Basal serum thyroglobulin assessed using an ultrasensitive assay (Basal-Tg) has been proposed as an alternative to TSH-stimulated thyroglobulin (Stim-Tg) measurement in the follow-up of patients with papillary thyroid carcinoma (PTC). We aimed to examine the relationship between Basal-Tg and Stim-Tg in patients treated for PTC, and the optimal Basal-Tg that predicts a Stim-Tg≥1μg/L and ≥5μg/L.

We retrospectively analyzed 166 pairs of Basal-Tg and Stim-Tg measurements, performed within a 6-month interval of one another, among 144 patients with a variety of PTC recurrence risks. All patients underwent total thyroidectomy with therapeutic central neck dissection if clinically indicated. Fifty eight (41%) patients received radioactive iodine therapy. Basal-Tg was measured using a second-generation Beckman ACCESS immuno-chemiluminometric assay. Stim-Tg was assessed during TSH stimulation by one of three methods, all of which achieved a TSH>25 mIU/L. All patients had negative anti-thyroglobulin autoantibodies. Pearson correlation was used to assess the relationship between Basal-Tg and Stim-Tg measurements. Area under the curve (AUC) and optimal thresholds for Basal-Tg were determined by receiver operating characteristic (ROC) analysis.

There was a strong, positive correlation between Basal-Tg and Stim-Tg (r(166)=0.93, p<0.001). The line of best fit was modelled by [Stim-Tg]=11.1[Basal-Tg] - 0.6, both measured in μg/L. A Stim-Tg≥1μg/L and ≥5μg/L was present in 68 (41%) and 12 (7%) observations, respectively. The AUC for Basal-Tg in identifying a Stim-Tg≥1μg/L and ≥5μg/L was 0.87 and 0.90, respectively, suggesting good discrimination. The optimal Basal-Tg value for identifying a Stim-Tg≥1μg/L was 0.20μg/L (sensitivity 77%, specificity 87%) and for a Stim-Tg≥5μg/L was 0.6μg/L (sensitivity 58%, specificity 94%).

Basal-Tg and Stim-Tg have a strong positive correlation. A Basal-Tg of 0.2μg/L and 0.6μg/L were the optimal values for identifying a of Stim-Tg≥1μg/L and ≥5μg/L, respectively. Incremental increase in Basal-Tg between 0.2μg/L and 0.6μg/L may require additional investigation with Stim-Tg and neck ultrasound to assess for PTC recurrence.

Thyroid cancer continues to increase rapidly in incidence, and approximately 5% of non-medullary thyroid carcinomas are familial or hereditary. But, the clinicopathologic features and genetic basis of familial non-medullary thyroid carcinoma (FNMTC) are poorly understood. The Familial And Hereditary Non-medullary Thyroid carcinOMa (FAHNTOM) study is aimed to identify the clinicopathologic features, genetic and environmental factors of FNMTC.

Methods: The FAHNTOM study is designed as a prospective multicenter cohort study. A case of FNMTC was defined as a patient with the following two criteria: a well-differentiated follicular origin thyroid cancer and at least one first-degree relative with a well-differentiated epithelial origin thyroid cancer. After an informed consent is obtained from each subject, patients who are scheduled for thyroid surgery and their family members will be interviewed to get the pedigrees and questionnaires about lifestyle and environmental factors. Medical records, blood and tissue samples will be collected from patients and blood samples will be taken from family members who will be screened on a regular basis with high resolution neck ultrasound. The existing group of a large case-control study will be used as a control group for statistical analysis. The blood and tissue samples will be tested to find genetic predispositions for FNMTC. The results of ultrasound in family members will be analyzed to determine the screening strategy of FNMTC.

From November 2012 to May 2013, a total of 63 subjects (patients: 43, unaffected family members: 19, affected family member: 1) have participated in this study. The clinicopathologic features of patients were analyzed. In comparison with the sporadic cases, there was a significant difference in vascular invasion between the two groups (p=0.038).

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FNMTC is a rare disease entity of thyroid cancer and multi-constitutional long-term studies are needed to comprehend the disease. The FAHNTOM study is focused on this specific group of thyroid cancer patients which are radically increasing in South Korea. The results from this study are expected to be utilized for the clinical practice and research of FNMTC.

Fine needle aspiration biopsy (FNAB) is the gold standard method in the characterization of thyroid nodules We aimed to evaluate the diagnostic efficacy of ultrasound-guided thyroid fine needle aspiration biopsy of larger thyroid nodules.

Thyroid ultrasonography, FNAB and histopathological data of a total of 371 patients subjected to surgery because of nodular thyroid disease between 2006 and 2011 were retrospectively examined.

We evaluated 407 nodules of 371 patients in this study. Mean age was 50,9±13,4 and mean TSH level was 1,6 [1.3–1.9] mIU/L. We grouped nodules by size; group A nodules (n=43) were smaller than 1 cm, group B nodules (n=234) were between 1–2.9 cm and group C nodules (n=130) were 3 cm or greater in diameter. Non-diagnostic cytology was present 23.3% in group A, 5.9% in group B and 7.7% in group C nodules. In group A; sensitivity, specificity, positive predictive value (PPV) of FNAB was 87.9%, 71.4%, and 87.9%, respectively. In group B sensitivity, specificity, PPV of FNAB was 65%, 79.6% and 78.9% respectively. In group C sensitivity was 55.5%, specificity was 80.9% and PPV was 52.6%.

This is the first study which shows that the sensitivity of USG guided FNAB decreases in greater nodules. This finding must be evaluated in larger series.

In the accident of Chernobyl nuclear reactor, the contamination of milk with 131I, for which prompt countermeasures were lacking, resulted in large doses to the thyroids. This led to the increase of childhood thyroid cancer. Although thyroidal 131I measurements and reconstructions were extensively performed, the dose relationship had not been confirmed until 2011. In the accident of Fukushima Nuclear Power Stations on March 11, 2011, the residents within 20 km radius of NPSs were instructed to move before the evening of next day and the instruction of food control (<200 Bq/kg of 131I for drinking water and milk) was issued on the 6th day and of the distribution restrictions of contaminated food on the 10th day.

The measurements of thyroidal 131I were performed from March 26 to March 30, 2011, using a NaI (TI) scintillation survey meter in 1080 children under the age of 15 in evacuation areas. Thyroidal 131I were also measured using NaI scintillation spectrometer or using whole body counter in March, 2011. The program to survey thyroids of all 360,000 children in Fukushima Prefecture by ultrasonography started from 2011 by the requests from psychological and social demands.

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POSTER 50.

Thyroid Radiation Doses in Fukushima, Ukraine and Belarus in Dose-response Relationship between Thyroid Cancer and I-131.

No children showed values greater than 50 mSv (Intervention level). Comparison of thyroidal 131I among Fukushima, Ukraine and Belarus is shown in the figure. However, according to the information on the website (5/6/2013), 174,976 children were examined; nodules were found in 1.15% (0.51%>5 mm), and malignancy was suspected in 29 children. Among them, 13 were operated and 12 (69/million) were confirmed as papillary carcinoma.

The incidence of childhood carcinoma is reported to be one/million in many countries, and the maximum incidence in Chernobyl accident is 40/million in 1995 in Belarus. The countermeasure for thyroid carcinoma is the biggest issue in not only health consequences in the Fukushima accident, but also in the general thyroidology.

The management of medullary thyroid cancer (MTC) after resection remains complex, with multiple variables affecting risk of recurrence. We introduce a dynamic postoperative risk stratification tool for MTC recurrence, based on patient, tumor and treatment characteristics.

After institutional review board approval, 124 MTC patients who were treated entirely at Memorial Sloan-Kettering Cancer Center between 1986–2010 were identified. Immediate postoperative risk groups were defined as low, intermediate, and high based upon extent of extrathyroidal extension, presence of regional or distant metastases and preoperative calcitonin level. Response to therapy categories were then defined as excellent, acceptable and poor based upon 6 month calcitonin level and presence of radiographic structural disease. Overall risk groups based upon the immediate postoperative risk and the response to therapy category were then defined.

The median age was 55 years (range: 6–88). Median follow-up was 66 months (range: 1–229). In the immediate postoperative risk groups, the 5-year risk of structural recurrence for low, intermediate, and high risk groups was 5.9%, 24.9%, and 67.8% respectively (p<0.001). In the overall risk groups, the 5-year risk of structural recurrence for low, intermediate, and high risk groups was 3.2%, 24.0%, and 45.9% (p<0.001). Low risk patients with poor responses to therapy had increased recurrence risk from 5.9% to 24.9%, while high risk patients with excellent responses to therapy reduced their recurrence risk from 67.8% to 24.9%.

A clinically useful dynamic risk stratification tool to predict risk of recurrence in MTC patients over time is introduced. Its prognostic value may augment patient counseling on prognosis, help determine the frequency and extent of follow-up investigations, and aid decision-making for adjuvant treatment.

Cervical ultrasound(US) is a standard part of the preoperative evaluation of patients with thyroid cancer. The ability of US to identify nodal disease in the central neck is debated which has lead to the utilization of prophylactic central dissection in order to prevent early disease recurrence.

Retrospective analysis of a prospective database of all clinically N0 well differentiated cancer patients. Patients undergoing lymph node (LN) dissection at time of thyroidectomy were excluded, as were patients without documented US evaluation of the neck. Patient demographics and out comes were reviewed, and patients were categorized based on who performed the thyroid US (a single thyroid surgeon vs. non-surgeon sonographer). Recurrence was defined as the need for additional radioactive iodine treatments or subsequent positive pathology on biopsy or exploration.

From 2005 to 2012, 177 patients were assessed with US prior surgery. 48 patients had surgeon performed US in clinic, compared to 129 patients with non-surgeon performed US. Groups were equivalent in age, gender, operative procedure, tumor size, and tumor characteristics. Surgeon US group had LN assessment documented more frequently (69% vs. 20%, p<0.01). While equivalent rates of papillary and hurthle cell carcinoma where in both groups, the surgeon performed US group had a higher incidence of follicular carcinoma (p<0.01). Treatment and dosing with radioactive iodine were equivalent. Radioactive iodine uptake following ablation was significantly lower in surgeon performed US (p<0.05). Recurrence rates were significantly higher in the non-surgeon US group in comparison to the surgeon US group (11% vs 0%, p=0.01, Figure 1). Median time to recurrence was 1 year. However, mean follow up was longer in the non-surgeon US group (24±2.3 months vs. 40±2.3, p<0.01).

US examination of the thyroid should include a routine evaluation of the cervical LN stations. Performance of an US by a sonographer specializing in thyroid cancer ensures optimum assessment and correctly identifies patients as N0 which may eliminate the need for prophylactic LN dissection and not increase the risk of early recurrence.

The impact of preoperative neck US on management of the lateral neck in patients with WDTC is unclear. The objective of this study was to assess the impact of preop neck US on the rate of lateral neck dissection and postop Response to Therapy (RTT).

An IRB approved retrospective review of 892 patients from an institutional database of WDTC between Jan 1 2009 to Dec 31 2010 was carried out. Patients with palpable neck disease, distant metastases, less than total thyroidectomy, no postoperative thyroglobulin (Tg), no postoperative US and positive Tg antibodies were excluded leaving 468 patients available for analysis. Patients were divided into those who had preoperative neck US (241 patients) and those that did not (227 patients). Patient and tumor characteristics were compared using the Chi square test. The primary endpoint was RTT as defined by postoperative US and Tg level.

There were no significant difference in age, histology type, T stage, postoperative RAI dose, AJCC stage, ATA risk or duration of follow up between the 2 groups. Patients with preoperative neck US had more Lateral neck dissection (LND) compared to patients without preoperative Neck US (24(10%) vs 9(4%); p=0.006). In patients having neck dissection, there was no significant difference in the positive or total number of lymph nodes resected between the 2 groups. Importantly, those receiving a preoperative neck US had better RTT (more likely to be NED, less likely to have biochemical or structural incomplete response) than those without preoperative neck US (p=0.003).

Preoperative neck US detects more lateral neck disease, facilitates lateral neck dissection resulting in better Response to Therapy.

Fibroblast growth factor receptor 4 (FGFR4) is associated with development and prognosis in some cancers. The FGFR4 Gly388Arg polymorphism is a prognostic factor in many cancers, but this significance in thyroid cancer is unclear. This study investigated the relationship of the FGFR4 Gly388Arg polymorphism with clinical, pathological and molecular parameters including BRAFV600E mutation, and evaluated the prognostic outcome in papillary thyroid cancer (PTC).

FGFR4 Gly388Arg polymorphism was evaluated in 247 consecutive patients with PTC by polymerase chain reaction-restriction fragment length polymorphism, along with examination of clinical, pathological, and molecular parameters including BRAFV600E mutation and expression of biological tumor markers. Clinical outcome indicating cancer recurrence/persistence was also evaluated in a subgroup of study subjects.

Gender and age distribution, cancer characteristics such as tumor size, extrathyroid extension, multiplicity, lymph node metastasis, expression of biological tumor markers, and the frequency of BRAFV600E mutation were not different between three FGFR4 genotypes (Gly/Gly388, Gly/Arg388, and Arg/Arg388). However, the FGFR4 Gly/Gly388 genotype was associated with extrathyroid extension (P=0.045) in patients with PTC-BRAFV600E. Tumor recurrence of PTC was more frequent in the Gly/Gly388 group than in other FGFR4 genotypes (P=0.043). Univariate analysis of disease-free survival using the Kaplan-Meier estimation showed that FGFR4 Gly/Gly388 genotype had more likelihood of tumor recurrence (4/25) than the Gly/Arg388 and Arg/Arg388 groups (1/41), but this is not statistically significant (P=0.12).

The FGFR4 Gly388Arg polymorphism might have no dominant effects on cancer progression and prognosis in PTC.

ATA guidelines recommend measurement of thyroglobulin level (Tg) in the wash out of lymph node FNA for the diagnosis of metastatic thyroid cancer. This series compares aspiration cytology to Tg in the needle wash out for the diagnosis of metastatic thyroid cancer in a community FNA clinic.

Patients with a tissue diagnosis of papillary thyroid carcinoma, and sonographically abnormal lymph nodes with negative cytologic on-site assessment for metastasis were included. Needles were rinsed in 1 ml of normal saline, and Tg measured by the Siemens chemiluminescent method. Tg test is positive if >1.0 ng/mL in athyroid patients and >36 ng/mL with thyroid gland. All biopsies and cytologic evaluations were done by one cytopathologist with 12 years experience in FNA and education in neck ultrasound. Sensitivity, specificity, PPV and NPV were calculated for cytology and Tg using histology as the gold standard for discordant cases.

39 lymph nodes from 31 patients were analyzed. 38 nodes from 30 patients had concordant results in final cytology and Tg (35 negatives and 3 positives). One node had negative cytology but positive Tg (1.6 ng/mL); this node was negative for metastasis on excision. For cytology, sensitivity, specificity, PPV and NPV was 100%. For Tg, sensitivity=100%, specificity=97.2%, PPV=75% and NPV=100%.

An increase in sensitivity for metastatic thyroid carcinoma may not be seen in all settings by adding Tg level measurement to cytology in lymph node FNA. Practice settings such as experience of the aspirator and availability of on site assessment may weigh heavily on the baseline sensitivity of aspiration cytology, and thus in the benefits obtained by adding Tg testing. Sensitivity and NPV was identical for both tests in this series, although the selection bias could reduce Tg false negatives which would have lowered Tg sensitivity. As with any test, Tg false positives have been described before, and thus its effect in the specificity and PPV for detection of metastasis must be considered. The use of a 1.7 ng/mL cutoff proposed by some authors for the chemiluminescent method would result in identical performance for both tests in this series.

Follicular neoplasm (Bethesda IV cytology) requires thyroid lobectomy for diagnosis. Approximately 15–30% of cases are ultimately malignant, often requiring reoperative completion thyroidectomy. The use of intraoperative frozen section in these cases is controversial. We sought to reassess whether intraoperative frozen section (FS) reduces the need for reoperative thyroidectomy.

A retrospective chart review of patients with follicular neoplasm on fine needle aspiration (FNA) from 2003–2012 was performed. It is our practice to offer thyroid lobectomy with FS for these patients; if FS was suspicious, total thyroidectomy was performed instead. FS suspicious for papillary thyroid carcinoma (PTC) was based on nuclear features (nuclear grooves/atypia, pseudonuclear inclusions) and for follicular thyroid carcinoma (FTC) was based on capsular/vascular invasion.

A total of 148 patients with follicular neoplasm on FNA were identified, of which 79 underwent FS. Fifteen had suspicious FS with 12 having malignancy on final pathology, for a positive predictive value of 80%. Nine showed features suspicious for PTC, of which 8 had PTC. Six showed features suspicious for FTC, of which 4 had malignancy on final pathology. Of the 64 patients with unremarkable FS, 49 had benign final pathology, for a negative predictive value of 77%. Twelve (19%) patients required reoperation. Seven of 19 patients (37%) with malignancy avoided reoperation due to FS. Risk of malignancy with follicular neoplasm diagnosis was 34% (51/148), while risk of malignancy with follicular neoplasm and suspicious FS was 80%.

Risk of malignancy with follicular neoplasm and suspicious frozen section is 80%. Frozen section may avoid reoperative completion thyroidectomy in up to a third of patients.

The diagnosis and treatment of differentiated thyroid cancer (DTC) is associated with good prognosis. However, quality of life can be affected by treatments and long term side effects. Our study evaluates the quality of life of Puerto Rican patients with a diagnosis of DTC.

Patients with diagnosis of DTC were identified at the General Endocrinology Clinics at the University Hospital of Puerto Rico. Medical chart was reviewed to obtain demographic and clinical data, thyroid function tests, surgeries and other treatments received. A validated Spanish version of the University Of Washington Quality Of Life Questionnaire (QOL) was administered to each patient. The questionnaire evaluates the domains of pain, appearance, activity, recreation, swallowing, chewing, speech, shoulder, taste, saliva, mood, anxiety and other global questions. The association between QOL scores and variables of interest, such as treatment modalities and age at diagnosis, were evaluated using the Mann-Whitney test.

A total of 75 patients with DTC participated. Mean age of the group was 51.54±13.3 years; 84.0% were female. Papillary thyroid cancer was diagnosed in 96.0% of them, 66.7% underwent total thyroidectomy and 32.0% had total thyroidectomy with lymph node dissection. Of those who underwent treatment with radioiodine, 60.6% received <150 mCi of therapy, while 21.2% received >150 mCi of radioiodine therapy. A total of 82.7% of the patients reported that their health was the same or better than it was before treatment. The mean composite score was 82.3, meaning an overall little effect on QOL. Patients diagnosed with DTC after 45 years of age reported a significantly better score on the pain domain (p<0.05) when compared with those patients diagnosed earlier. Patient who received >150 mCi of radioiodine had a tendency toward a worse score on the same domain (p=0.05).

This group of Puerto Rican patients with DTC reported an overall little change on their QOL. However, patient who received >150 mCi of radioiodine and those diagnosed on or before 45 years of age, showed lower scores on the pain domain than their counterparts. Future treatment strategies must include periodic QOL evaluations and long-term side effect of therapy in order to tailor therapy in this growing population of patients.

There has been controversy of the lobectomy for well differentiated thyroid cancer (WDTC). Current guidelines recommend total thyroidectomy for the cancer over 1 cm, despite previous report suggesting that the lobectomy provides similar excellent outcomes. The purpose of our study is to report our experience of WDTC treated by thyroid lobectomy.

We retrospectively analyzed 284 patients with WDTC treated by thyroid lobectomy at department of Surgery in Chosun University Hospital from January 2002 to December 2010. Overall survival (OS) and disease-free survival (DFS) were determined by the Kaplan-Meier method. Factors predictive of recurrence by univariate and multivariate analysis were determined using the χ2 test and Cox proportional hazard model respectively.

With a mean follow-up of 60.4 months, OS and RFS for all patients were 97.9% and 96.5% respectively. No patient died due to WDTC. Univariate analysis showed statistically significant differences in recurrence by tumor size (p=0.013) and presence of invasion (p=0.039). However, Multivariate analysis showed no significant difference in local recurrence.

Patients with WDTC confined to one lobe can be safely treated by lobectomy.

Pathology subspecialty practice is still in infancy in Kuwait. It started few years back after a group of local pathologists did their training in North America. The aim of this study: 1) describe the most common problems in thyroid pathology experienced by general pathologists. 2) Determine discrepancy in thyroid pathology diagnoses after reviewing by subspecialized pathologist.

The archive materials of the author were reviewed. The cases were divided into two groups. Group I: cases were sent for the author before issuing a report or a provisional report was issued and awaiting the consultation opinion. Group II: cases were the final reports issued and sent for the Cancer Center for review and reviewing pathologist doubting the diagnosis; or a review was requested by a clinician.

Seventy three cases were identified in the archives concerned with thyroid pathology. 48 cases (65.7%) were included in group I and 25 in group II. All cases in group I referred by pathologists being the Cancer Center had the highest number of referral (77%). Twenty three (92%) cases in group II were referred by pathologists and 2 by clinicians. Among all referred cases follicular patterned thyroid nodules was the most common causes of referral seen in 64 (87.6%) followed by undifferentiated carcinoma seen in 3 (4%) of the cases. In group I, 22 cases provided with provisional diagnoses; 12 (54.5%) were changed after revision. In group II, (12/25) the diagnoses were changed after revision of the cases, (50%) had significant implication on management or prognosis.

In conclusion, 1) Follicular patterned thyroid nodules is the most challenging problem in thyroid pathology. 2) High percentage of change in diagnoses after revision mostly due to unawareness of nuclear morphology of papillary carcinoma.

The objective of the present study is to evaluate the rise in TSH levels and the quality of life of patients after Recombinant human thyrotropin (rhTSH) administration for the treatment and follow-up of papillary thyroid cancer, without the presence of hypothyroidism or thyroid hormone withdrawal.

Prospective, longitudinal and comparative study. Two groups were compared; G1: patients without hypothyroidism and administration of rhTSH. G2: patients with 4 weeks hypothyroidism and thyroid hormone withdrawal. Studied variables: levels of TSH before and after the administration of rhTSH and 4 weeks of hypothyroidism, quality of life, as well as the presence of cold intolerance, dry skin, palpebral oedema, lower extremity oedema, constipation, sleep, weight gain, physical activity incapacity, loss of memory and other side effects. The statistical analysis was made by means of chi square and Fisher and Yates exact probability with level of significance of p=0.05.

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POSTER 61.

Elevation in TSH levels above 30U/mL in G1 (72 hours after rhTSH administration) and G2 (after 4 weeks of thyroid hormone withdrawal).

G1 (n=21) and G2 (n=25) in both groups the TSH rose above 30 mU/ml and the average elevation for each group was not statistically different (p=0.098). The evaluation of the quality of life had a statistical difference (p<0.001) in favour of G1. All other variables also had statistically significant differences (p<0.001) again in favour of G1. One G1 patient felt slightly nauseous. The administration of recombinant human thyrotropin offers adequate levels of TSH elevation without altering the quality of life.

We are presenting a case of follicular carcinoma of the thyroid with metastasis to the rib 57 yo woman with past history of mediastinal lymphoma treated with chemotherapy and radiation was referred to Endocrinology clinic for newly diagnosed metastatic follicular thyroid cancer. A left thyroidectomy was done 10 years ago due to a large nodule that displaced the trachea. The lesion was benign and right lobe of thyroid was normal. Pathology reports were not available. 7 years ago an incidental enlarging right paraspinal mass was discovered. Due to pain and discomfort a CT scan of chest was obtained and a left 9th rib mass was discovered incidentally. CT guided core biopsy showed metastatic follicular cancer of the thyroid. Bone scan showed no evidence of metastasis. She underwent completion thyroidectomy and excision of both masses. Pathology showed incidental 1 mm papillary carcinoma of thyroid, the rib mass measured 7 cm and consistent with metastatic follicular carcinoma of thyroid with negative margins, and the paraspinal mass consistent with lipoma with calcification and necrosis. She received 201 mCi of iodine-131 after recombinant human TSH (rh-TSH) stimulation. The total body scan post treatment showed intense activity in the neck but no evidence of distant metastatic disease. Her levothyroxine dose was adjusted accordingly.

The serum thyroglobulin(Tg) trended from 3999 ng/mL to less than 0.2 ng/mL without anti-Tg antibodies after the surgery and RAI therapy. Table above includes lab values.

We are presenting a case of follicular carcinoma of the thyroid with metastasis to the rib. There are few cases reported and it is found to be an unusual presentation. The incidence of follicular carcinoma presenting with metastatic disease of bone is 7–20%. We suspect her initial nodule was not benign thyroid tissue rather follicular carcinoma in addition. This patient had many risk factors associated with thyroid cancer and would have been benefited from aggressive management modalities.

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Currently the main stream practice for postoperative care following a thyroidectomy has been on an inpatient basis. Due to the abundant advancements in surgical techniques, these procedures have shifted from the traditional 23 hour observation setting to same day surgery procedures. The purpose of this study was to compare the outcomes of same day surgery and 23 hour observation thyroidectomies encompassing patients with similar morbidity scores.

We performed a retrospective comparison between 100 consecutive patients that underwent outpatient thyroid surgery from June 2008 to May 2013 and 100 patients that underwent thyroid surgery and held post operatively for 23 hour observation. All patients met predetermined morbidity scores based on the Charlson index score. Clinical variables including patient demographics, body mass index (BMI), and surgical outcomes were obtained and analyzed. Principle outcome measures were thyroid volume, length of operation, length of hospital stay, incidence of complications, and estimated blood loss (EBL). Clinical characteristics of patients and operative data were compared between the groups using Student t-test, and the Chi-square test.

Of the two hundred patients undergoing thyroid surgery; 100 were accomplished on an outpatient basis, and 100 under a 23 hour observation status. The outpatient and observation groups were similar in BMI (29 vs. 30, P=.288), operating room time (180.6 vs. 191.2, P=.152), and thyroid volume (40.3 vs. 40.4, P=.99). The postoperative complications including temporary hoarseness, hematoma, wound cellulitis, seroma, and paresthesia stay did not statistically differ between groups.

In a select patient population with a similar Charlson index score of 3 or less, same day thyroid surgeries has yielded favorable experiences. Same day thyroid surgery can be accomplished in a safe and effective manner in a high volume academic setting with excellent results.

Thyroid disorders compromise the integrity of brain tissues, such as hippocampus and parietal cortex, influencing behavior and process of learning and memory. The deiodinase type III (D3) prevents activation of T4 converting it into reverse T3 which are considered inactive form of the hormone. D3 is increased in critically ill patients, primarily in tissues with hypoxic ischemic injury. During the status epilepticus there is a high release of catecholamines, which can cause several changes, including metabolic acidosis entailed by respiratory failure. Cerebral hypoxia and ischemia also appear to be key to the of self-regulated interruption of seizures. A failure of this inhibition can increase the extension of status epileptics. Following this reasoning we evaluated the effects of epilepsy on D3 expression and the local reduction of T3 in brain tissue. We also evaluated the levels of neuroglobin, an intracellular hemoprotein which has a strong protective role against oxidative stress and is increased during hypoxia.

We studied rats with epilepsy induced by pilocarpine and quantified the expression of D3 in the hippocampal regions, using the method of Immunohistochemistry and Western Blot. A group of rats stayed for 3 hours in status epileticus and then was killed to remove the hippocampus (acute group). Another set of rats was killed two months after the induction of the epilepsy for remove the hippocampus (chronic group).

D3 expression was dramatically increased in acute and chronic epilepsy in hippocampus in CA3, CA1, Dentate Gyrus and Hilo. Also, the neuroglobin levels were significant higher in the epileptic animals, showing that during epilepsy the brain is in a hipoxic state.

Our data shows that epilepsy leds to a hipoxia and an increased expression of D3 in the hippocampus in both acute and in chronic state. The higher D3 activity could be a neuroprotective effect. Also, it is possible to correlate the consequences of epilepsy to a local reduction of the of thyroid hormone in this disease.

Adult-onset hypothyroidism causes emotional and cognitive alterations. These are paralleled by alterations in the cell population dynamics of the hippocampus, which involve an increase in the expression of markers of DNA damage and apoptosis. It has been recently shown that some fatty acids are able to modify the cell population dynamics in different regions of the nervous system. Particularly, the dietary supplementation with n-3 polyunsaturated fatty acids (ω-3 PUFAs) attenuates certain symptoms of neuropathological disorders such as autism, depression, anxiety, and Alzheimer disease, by an effect that involves the stimulation of cell proliferation and glutamatergic synapse formation in regions such as the hippocampus.

In this study we evaluated the ability of the dietary supplementation with ω-3 PUFAs to prevent the effects of hypothyroidism on the hippocampal cell population. We induced hypothyroidism to a group of rats by treating them with methimazole for 4 weeks. A second group received supplementation with ω-3 PUFAs (350±0.75 mg/kg/day) along with the antithyroid treatment.

Open-field behavior tests showed that hypothyroid rats have reduced motivation for exploration and a reduced ability to modify their behavior by experience (i.e., learning), and that both traits are prevented by supplementation with PUFAs. Immunodetection of marker proteins showed that PUFAs do not change the population dynamics of hippocampal cells in normal conditions, but reduce the expression of p53, associated with DNA damage, in hypothyroid animals. The expression of markers of cell arrest (p21) or apoptosis (Bax/Bcl-2) was not modified.

These results suggest that the administration of ω-3 PUFAs exerts partial neuroprotection against the effects of hypothyroidism in cell populations of the hippocampus. Work supported by SIP-20131071. A. B.-C. is fellow of PIFI-IPN.

Subclinical hypothyroidism is a common diagnosis in children as well as in adults. Subclinical hypothyroidism is known to be a risk factor for arteriosclerosis. Alterations of blood lipids as well as markers for inflammation and hemostasis were shown in adult patients. In children data on this topic are rare. Calibrated automated thrombography visualizes the entire process of thrombin generation, and is the only overall function test of coagulation that is sensitive to hypercoagulable states. Lagtime, time to peak, peak, endogenous thrombin potential, start tail and velocity index are parameters of thrombin generation. Aim of this study was to analyze the correlation between thyroid function and thrombin generation.

31 children (16 females) with a median age of 8.2 years (range 1.4–17.9) and a suspected subclinical hypothyroidism underwent a thyroid function test (TRH-stimulation test) and had simultaneously determined factor II and thrombin generation.

Median basal TSH was 4.7 U/ml (range 1.0–22.9). We found a significant correlation between TSH and factor II (p<0.05). Moreover, we found a significant correlation between lagtime and fT3 (p<0.05) and between velocity index and fT3 (p<0.05). We found no correlation between thyroid function and other parameters of thrombin generation.

Our data show that there is a correlation between thyroid function and thrombin generation in children with subclinical hypothyroidism and that impaired thyoid function could lead to a hypercoagulable state in children.

Developmental hip dysplasia is a significant musculoskeletal pathology with health and cost implications at both the individual and societal level. There are several well-known risk factors associated with developmental hip dysplasia, however, the potential role of thyroid hormones is unclear. Graves' disease is the most common cause of autoimmune hyperthyroidism in pregnancy, and uncontrolled Graves' disease is associated with miscarriages, pregnancy-induced hypertension, prematurity, low birth weight, intrauterine growth restriction, stillbirth, thyroid storm, and maternal congestive heart failure. Triiodothyronine and thyroxine have been shown to be important regulators of early bone and muscular development. It has been hypothesized that excess amounts of thyroid hormone early in pregnancy is a risk factor for developmental hip dysplasia. Data is limited to a single retrospective cohort study by Ishikawa in 2008 which concluded that there was an association between developmental dysplasia of the hip and first-trimester maternal hyperthyroidism. Since Ishikawa's initial report, there have been no other studies evaluating the relationship between maternal hyperthyroidism and developmental dysplasia of the hip.

In this case report, we describe the complication of developmental dysplasia of the hip in the child of a pregnant woman who presents in the second trimester with new onset uncontrolled Graves' disease.

As thyroid hormones are important regulators of early bone and muscular development, we postulate that untreated maternal Graves' disease may be a risk factor for development of neonatal hip dysplasia.

Children of mothers with untreated hyperthyroidism during pregnancy should be monitored for developmental hip dysplasia to prevent long-term complications requiring costly corrective measures. Further studies should be performed to assess whether the incidence of developmental hip dysplasia is increased in the infants of mothers with uncontrolled Graves' disease during pregnancy.

POSTER 68. Table Shows the Chronological Relationship Between Gestational Age, TSH, FT4, FT3, TSI, and TPA Though the Duration of the Patient's Pregnancy and Post-Partum in the Context of Treatment. Methimazole Therapy was Initiated after 16.6 weeks, Discontinued after 33 weeks Gestation, and Tapazole was Started after Delivery

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Iodine is essential for thyroid hormones (THs) synthesis and an important regulator of thyroid function. Maternal THs are important in promoting normal placental and fetal development. Adequate maternal iodine intake is required for the THs synthesis. The drastic consequences of iodine deficiency during pregnancy are well described; however, the effects of iodide excess during this period are still controversy. Therefore, this study aimed to investigate the consequences of iodide excess exposure during pregnancy (P) and lactation (L) periods on thyroid function of rat dams.

Female Wistar rats were treated with iodide excess (5X, 50X and 500X the physiological dose) in drinking water throughout P+L. After these treatments, body weight, heart weight and the number of pups were evaluated. Thyroid genes expression was evaluated by Real-Time PCR and Western Blotting. D1 activity was evaluated in the kidney and liver.

All treatment doses reduced body and heart weight of rat dams in comparison to control group. Iodine treatment decreased the number of pups, and the most striking result was observed in the higher dose of treatment, that led to an increased number of stillbirth. Iodine excess reduced the expression of NIS, Tg, TPO and TSHR in a dose-dependent manner. D1 activity was also reduced after iodine treatment.

Our study strongly suggests that THs production is impaired in rat dams exposed to iodine excess during P+L, since the expression of proteins involved in THs synthesis were reduced after iodine treatment. Moreover, the reduced activity of D1 suggests that THs peripheral metabolism was also impaired by the treatment. Thus, iodine excess seems to lead to central and peripheral hypothyroidism in rat dams, which may have serious consequences in the development of their offspring, as shown by the increased number of stillbirth in the higher dose of iodine treatment. Finally, iodine excess may be as harmful as iodine deficiency to intrauterine and neonatal development.

Hypothyroidism and obesity are prevalent conditions in the U.S. The use of bariatric surgery to treat obesity has increased substantially in recent years and weight loss can be dramatic. It is unknown what effect various methods of bariatric surgery have on thyroid hormone replacement in the setting of primary hypothyroidism. This is particularly true of gastric bypass (Roux-en-Y) procedures which may alter intestinal absorption of LT4. This study utilizes data from one academic medical center to determine whether bariatric surgery for weight loss impacts thyroid hormone requirements in adults with primary hypothyroidism.

The University of Texas Southwestern Research Data Warehouse was utilized to identify individuals who had undergone bariatric surgery at the institution between 4/1/05 and 12/1/12 and had a diagnosis of hypothyroidism at the time of surgery. Individuals were included if they were taking LT4 for thyroid hormone supplementation and had serum TSH value within the reference range prior to surgery. Roux-en-Y, gastric sleeve and gastric banding procedures performed either openly or laparoscopically were included. Exclusion criteria were central (secondary) hypothyroidism, use of medications known to cause disturbances in thyroid function, and use of any thyroid hormone replacement other than LT4 during the study period. Doses of LT4 preoperatively were compared to doses 0–6, 6–12, 12–24 and 24–36 months postoperatively.

We included 40 patients (24 with gastric banding, 12 with Roux-en-Y and 4 with sleeve gastrectomy surgery). Of the 12 patients with Roux-en-Y procedures, 3 (25%) required a reduction in LT4 within the first 6 months of surgery and 4 (36.4%) within the first year. No significant dose changes were observed in the gastric banding and sleeve gastrectomy groups.

Our data suggests that a significant proportion of individuals undergoing bariatric surgery with Roux-en-Y procedures may require a reduction in dose of LT4 soon after surgery. Clinicians should be aware of this possibility and measurement of thyroid function tests with appropriate dose adjustment should occur within the first 6 months of gastric bypass surgery.

It has been reported that the presence of thyroid antibodies or TSH above 2.5 μU/mL in the first trimester affects outcomes of pregnancy.

Objective: To assess the effects of autoantibodies and TSH levels on pregnancy outcomes.

Methods: We measured TSH and antithyroid antibodies in 967 consecutive singleton pregnant women at their first visits to Seibo Catholic Hospital in 2011. Pregnancy outcomes in relation to TSH or antibody levels were examined.

Mean gestational age at the examination was 10.6 weeks. TSH levels were above 2.5 μU/mL in 53 women (5.5%), and 64 women (6.6%) were positive for antithyroid antibodies. In 20.3% of the antibody-positive and 4.4% of the antibody-negative women had TSH levels above 2.5 μU/mL (p<0.01). The frequencies of miscarriage in women with antibody-positive versus antibody- negative and women with TSH above 2.5 μU/mL versus women with 2.5 μU/mL or below were 5.9% versus 3.4% (p=0.42), and 4.9% versus 3.6% (p=0.67), respectively. However, there was a positive correlation between the frequencies of miscarriage and TSH levels (r=0.72), and the frequency in women with TSH 3.0 or above was 13.6%. The frequencies of previous miscarriage were not affected the presence of antibodies nor TSH levels. Forty-three percent of antibody-positive women had previous successful delivery, which was not inferior to antibody-negative women (43%). The frequencies of preterm birth in antibody-positive and -negative women were 2.3% and 3.1%, respectively. No preterm birth was found in women with TSH above 2.5 μU/mL.

No positive association exists between the presence of thyroid antibody and miscarriage or premature delivery. TSH above 2.5 μU/mL not always indicates adverse outcomes of pregnancy. The reason that our data are conflicting to others may be due to the methods to measure TSH and thyroid antibodies, or the small sample size. Furtherr investigations with larger sample size will be necessary.

Serum thyrotropin (TSH) levels of the elderly are often above the upper normal range even when the patients show no clinical symptoms of hypothyroidism. Over the past two decades, the upper TSH reference limit has declined from 10 mIU/L to 2.5–3.5 mIU/L. This decrease is due to several factors, namely improved sensitivity and specificity of monoclonal antibody-based immunometric TSH assays, exclusion of individuals with subclinical autoimmune thyroid disease from the reference population, and the elimination of high values that are due to cross-reactivity problems with other glycoproteins. The controversy surrounding the lowering of the TSH upper reference limit is that it may lead to the unnecessary treatment of healthy individuals. Indeed, serum TSH 3.0–4.5 may be an early indicator of hypothyroidism; however, an upper reference interval of 2.5–3.0 mIU/L would yield a 300–400% increase in the number of patients who are clinically not in need of LT4 treatment; overtreatment may cause serious health problems, including adverse cardiovascular effects. Objective: To determine if higher TSH with increased age is due to the increased presence of biologically inactive isoforms of TSH.

In order to selectively control for elevated TSH, we obtained 148 serum samples of patients from 6/2012-1/2013 at the Georgetown University Hospital. Inclusion criteria were only serum samples with TSH concentrations greater than 5 uIU/mL. Patient ages ranged between 21–99 y. TPOAb and TgAb were measure by ELISA. Thyrotropin receptor (TSHR) antibodies were measured using the TSH-Binding Inhibiting Immunoglobulin (TBII) immunoassay.

72% of the subjects were females; 80% older than 70 years. 17/148 (11.5%) subjects were positive for TPOAb. 7/148 (0.5%) subjects were TgAb positive. 21/148 (0.14%) were positive for TSHRAb and 19/148 (12.8%) were positive for TSI.

Since most of the subjects were not positive for the antibodies the high TSH will be tested for inactive TSH isoforms that are measured in the laboratory test but may not be representative of a clinical condition such as hypothyroidism. We are currently comparing these TSH forms with other TSH types known to be less biologically active.

After the Fukushima Daiichi Nuclear Power Plant accident (nuclear plant accident) following the Great East Japan Earthquake on March 11, 2011, there has been concern about an increase in the incidence of childhood thyroid cancer because of internal exposure to radioactive iodine. In Fukushima prefecture, thyroid ultrasonography(US) has been performed as a screening test for thyroid cancer, and there have been many clinical findings and concern about the influence of the accident. Herein, we report the findings in 2753 children screened by thyroid US at Ito hospital in Tokyo over the last 10 years using a screening method similar to that now used in Fukushima prefecture.

A total of 2753 children aged 15 years or younger visited ito hospital from Jan 2003 to Aug 2012, (boys: 518; girls: 2235; average age:12.0 years). These children were screened by thyroidal US and the incidence of nodules was evaluated.

The findings were as follows; 1) no obvious nodules: 1471 (53.4%); 2) cysts: 994 (36.1%); 3) solid nodules: 227 (8.2%); 4) neoplastic lesions (confirmed by pathological examination): 43 (1.6%); 5) aberrant thymus: 13 (0.5%); 6) suppurative thyroiditis: 5 (1.8%). In addition, we compared the results obtained with the use of the 12 MHz digital linear probe(DLP) introduced in our hospital in 2010 and those obtained with the previously findings. The corresponding results before/after the introduction of this probe were as follows: any US findings 671 (40.7%)/651 (54.2%). These findings demonstrate the significant advantage, in terms of the detection ability, of the 12 MHz DLP (p<0.0001: χ2 test). In a study where 670 subjects without any palpable goiter or nodules were examined using the 12 MHz DLP, we obtained the following results: 1) 200; 2) 435; 3) 30; 5) 5. The corresponding results by age (2–5 years/6–10/11–15): 63/185/422 subjects were as follows: 1) 42/60/98; 2) 19/111/205; 3) 1/10/19. Furthermore, our study revealed no significant difference in the incidence of nodules between before and after the nuclear plant accident.

Our study indicated that thyroid US revealed many clinical findings in the child cohort that could not be detected by blood tests or palpation. This could probably be attributable to the improved precision of the test instrument.

Ultrasound is essential for the management of thyroid and parathyroid diseases. We sought to determine the level of training in ultrasound technique and the utilization of surgeon-performed ultrasound (SPUS) among endocrine surgeons.

American Association of Endocrine Surgeons members and recent endocrine surgery fellows were sent a survey requesting information on current practice profile, training background, SPUS utilization and practice impact.

The survey was completed by 36% (173/481) of recipients. Half of respondents have been in practice <10 yrs. 73% reported that thyroid and parathyroid surgery comprised the majority of their practice, and 75% practice at academic teaching hospitals. 60% have completed an endocrine surgery fellowship, and 58% performed ultrasound during fellowship. Only 18% had ultrasound exposure during residency. Of fellowship trained respondents, 31% did not learn biopsy techniques, and 60% did not practice SPUS in the operating room. Currently, 65% of respondents employ SPUS. 66% complete SPUS in more than half of initial patient consults, 70% perform US-guided thyroid and lymph node biopsies, and 39% perform their own lymph node mapping prior to neck dissection. Only 22% use SPUS for long-term surveillance of their thyroid cancer patients. Of the surgeons performing adrenal/pancreatic surgery, 50% employ intra-op SPUS. Over 50% felt that SPUS altered surgical decision making “sometimes” and 31% “most of the time”. The following were cited as primary sources of ultrasound education: an endocrine surgeon (34%), formal ultrasound course (35%), radiologist (9%), and self (7%). Support for “rich ultrasound exposure” was nearly universal, and 64% of respondents support mandatory SPUS training during fellowship. Although 76% felt “very” or “extremely” comfortable with SPUS interpretation, 43% would still obtain a radiology-performed ultrasound. The majority (53%) rated SPUS as “indispensable”.

Ultrasound is employed by a growing number of endocrine surgeons, and most deem it necessary for clinical practice. The level of training and versatility of usage are disparate. The incorporation of formal SPUS education into endocrine surgery fellowship training would be advantageous.

Although the BRAF V600E mutation has low sensitivity for cancer in cytologically indeterminate thyroid nodules, its high specificity may help guide a decision to perform a total thyroidectomy instead of lobectomy as the initial operation. Currently, microarray-based molecular evaluation of thyroid nodules provides accurate detection of benign nodule signatures in cytologically ambiguous nodules, but could also address additional clinical questions, such as gene mutation status, in a single combined analysis. Here we present a molecular test for the identification of the V600E mutation in thyroid fine needle aspirates (FNAs) using mRNA to detect downstream gene expression perturbations resulting from the BRAF V600E mutation.

FNAs were obtained from over 200 cytologically indeterminate (across all three Bethesda sub-categories) and malignant nodules. The gene expression of more than 3,000 transcripts was measured by custom microarray for each FNA, and BRAF V600E-positive or negative labels for training and test samples were established using castPCR (Life Technologies). We specified a minimum detection of 5% mutant allele frequency to designate a sample V600E-positive.

These data were then used to select discriminative transcripts and to train a support vector machine classifier. The performance of the classifier was evaluated using both 10-fold cross-validation as well as an independent test set. The overall false positive rate is less than 1% (99.4% specificity, 95% confidence interval (CI) 96.9%-99.9%) while maintaining sensitivity comparable to that of most DNA-based tests (93.3%, 95% CI 77.9%-99.2%).

The classifier was able to accurately determine the presence or absence of the BRAF V600E mutation in FNAs using changes in gene expression. By capturing the downstream transcriptional effects of that mutation this test is more likely to be robust to potential rescue mutation. Pre-operative knowledge of BRAF gene mutation may reduce the necessity for completion thyroidectomy, intraoperative frozen section review, and in the future, consideration of mutation-targeted chemotherapeutics.

The aim of this study is to identify the most common methods in which thyroid nodules are detected and to determine whether or not there is a correlation between the mode of discovery and the rate of malignancy.

The study comprised of a retrospective medical record review of 495 consecutive patients referred to our clinic for thyroid nodule evaluation during the year 2012. Patients were evaluated by one of two ECNU-certified thyroidologists and ATA nodule guidelines were followed in determining the need for FNA.

Of the 495 patients,122 (24.6%) had their nodules discovered on physical exam, 75 (15.2%) were noted by the patients themselves and 298 (60.2%) were found on incidental imaging (see Table 1). Subsequently, 292 patients required FNA and a total of 395 nodules were biopsied. 25 nodules, in 25 patients, were found to be malignant after surgical resection. This represents an overall cancer rate of 5.1%. Of these, 7 (28%) were discovered by patient detection, 3 (12%) were found on physical exam and the remainder, 15 (60%), were discovered on incidental imaging (see Table 2). Accordingly, malignant nodules found on patient detection had a malignancy rate of 9.3%, with those found on incidental imaging of 5.1% and physical exam of 2.5% (see Table 3).

The majority of nodules discovered were via incidental imaging, most frequently on US for abnormal TFTs/symptoms and to a lesser extent, CT. Physical exam remains a common mode of detection, second to incidental imaging but more frequent than patient discovery. The nodules discovered by patient detection had the highest rate of malignancy, followed by those found on incidental imaging and then physical exam. Upon a closer look at the rate of malignancy by mode of detection, the nodules found on PET scan had the highest rate of malignancy, trailed by carotid Doppler and then patient detection. In our study, nodules detected on physical exam were least likely to be malignant. To further solidify our findings, we plan to combine our data with two other sites in order to determine if there is a consistent trend in the method of detection and rate of malignancy.

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The malignancy rate of nodules categorized as FLUS (Bethesda III) has traditionally been estimated at 5–15%, lower than the 15–30% rate for follicular neoplasm (FN; Bethesda IV). Therefore, a repeated fine needle aspiration (FNA) has been recommended for FLUS; in contrast, surgical resection has been recommended for FN. We hypothesize that the probabilities of malignancy in FLUS and FN are similar.

Of 2106 patients undergoing FNA at a tertiary care center between 2010–2013, 203 (9.6%) had Bethesda III cytopathology; 125 (5.9%), Bethesda IV. The risk of malignancy was determined from 127 nodules with available surgical pathology. A multivariable regression model was used to identify clinical and nodule factors associated with malignancy: age, gender, nodule size, and suspicious sonographic features.

The malignancy rate in FLUS nodules was 21% (12/56); in FN, 32% (23/71) (p=.24). There were 4/108 (3.7%) patients with incidental microcarcinomas. Nodules were more likely to be malignant in patients <45 (OR 2.4, p=.04) or if ultrasound revealed microcalcifications (OR 3.6, p=.007). An indeterminate nodule with microcalcifications in a patient <45 was at 7.4-fold escalated risk of malignancy. Patient gender, nodule size, and other ultrasound features (irregularity, vascularity, echogenicity) were not significantly associated with malignancy.

This study supports emerging literature that the rate of malignancy in Bethesda III nodules is higher than initially estimated, and is comparable to Bethesda IV nodules. The risk of malignancy in indeterminate nodules was highest in younger patients with microcalcifications, but was not associated with nodule size. Because malignancy rates are similar in Bethesda category III and IV nodules, we advocate managing these lesions similarly. These findings may have relevance in the era of emerging molecular assays for indeterminate thyroid nodules.

The Afirma® Gene Expression Classifier (AGEC) has been shown to identify benign thyroid nodules among those classified as cytologically indeterminate with a negative predictive value of 94%-95%. This test therefore has the potential of avoiding unnecessary surgery on cytologically indeterminate nodules that ultimately are found to be benign. A recent report suggests that the rate of surgery on indeterminate nodules can be decreased from 74% to 7.6% by the use of the AGEC. This study was undertaken to determine if this observation is reproducible.

The medical records of all patients evaluated by the authors for a thyroid nodule from 9/1/2012 to 6/15/2013 were reviewed. 32 patients were identified in whom an FNA was performed by the authors and submitted for AGEC analysis (FNA Group). 9 patients in this group and 7 additional patients with a suspicious AGEC prior to referral underwent thyroidectomy (Surgery Group). In all patients in both groups, FNA cytology was interpreted as indeterminate (Bethesda Category 3 or 4) by cytopathologists within our institution

In the FNA Group AGEC was interpreted as benign in 13 patients (41%) and suspicious in 19 patients (59%). 9 of these 19 patients have undergone surgery and 6 were found to have papillary thyroid cancer (PTC). Of the additional 7 patients in the Surgery Group, 3 had PTC. A total of 9 patients (56%) in the Surgery Group had PTC. (Figure 1)

This study confirms that patients with a suspicious AGEC have a high likelihood of having PTC and should undergo surgery. Because patients with benign AGEC did not undergo surgery, we cannot draw any conclusions about its negative predictive value. However, the number of patients with a benign AGEC (41%) is substantially less than reported elsewhere. This may be due to inter-institutional differences in the risk of malignancy in each of the Bethesda cytological categories. There may also be a referral bias in patients referred to a surgical group. The potential benefit of the AGEC in avoiding surgery on benign nodules may be less than anticipated.

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The definition of cervical mediastinal goiter (CMG) is based on variable criteria leading to a considerable variation in the reported incidence (from 0.2 to 45%). The incidence of peri- and post-operative complications when it is present is higher than that in thyroidectomy for cervical goiter. The aim of this study was to evaluate the preoperative risk factors associated with post-operative complications.

From 2000 to 2012, 142 (8.5%; 98 women and 44 men; mean age of 58 years; range: 35–78) of the 1690 patients who underwent total thyroidectomy had a CMG, defined as a goiter that was totally or partially located in the mediastinum when the patient was in the operating position, with an edge at least 3 cm below the sternal manubrium. We retrospectively evaluated the following parameters; sex, age, histology, pre- and retro-vascular position, recurrence, extension beyond the carena compared to surgical time, and the number of post-operative complications.

All but two procedures were terminated via cervicotomy, where partial sternotomies were required. No perioperative mortality was observed. Results of the statistical analysis (Student t test, Fisher's exact test) indicated an association between recurrence, extension beyond the carena with surgical time and post-operative complications.

Total thyroidectomy is the procedure to perform in CMG even if the incidence of complications is higher than for cervical goiters. The major risk factors associated with post-operative complications are recurrence and extension beyond the carena. In the presence of these factors, greater care should be used.

Parathyroid cysts are rare, and less than 300 cases have been reported in literature. They are often confused with thyroid nodules and goiter both during physical examination and during ultrasound imaging of the neck. Most parathyroid cysts have sizes ranging from 3–5 cm in size with few measuring over 10 cm in size. Even though parathyroid cysts have been reported with size over 10–15 cm, we found no reports of drainage of over 100 ml of fluid from the parathyroid cyst. We report a case of giant non-functioning right inferior parathyroid cyst measuring over 9 cm in size with retrosternal extension which drained 195 ml of fluid on 2 aspirations.

A 50 year old lady was referred for goiter with progressive dysphagia. She had noticed a swelling in the front of her neck for 6 years which gradually increased in size. Ultrasound examination revealed a 9 cm cyst in the region of the right lobe of the thyroid replacing the rest of the thyroid gland to the left.

Fine needle aspiration revealed clear fluid of 180 ml in the first aspiration and 15 ml of hemorrhagic fluid in the subsequent aspiration. Parathormone assay showed a level of 153 picogram/ml in the cystic fluid with normal serum parathormone level. Cytopathology reports of the fluid showed macrophages with no epithelial cells.

1. Parathyroid cysts are most often located in the neck. Most are non-functional and present as a neck mass or are found incidentally during imaging or neck surgeries. 2. A parathyroid cyst should be suspected in a patient who has a cystic mass that usually yields water-clear fluid on aspiration. 3. Aspiration of the cyst fluid and confirmation of elevated parathormone concentrations in the cyst fluid is diagnostic. 4. Aspiration of cyst fluid may be curative for non-functioning parathyroid cyts in most patients.

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Introduction: Graves' disease, characterized by autoantibodies to the thyroid stimulating hormone receptor, accounts for the majority of cases of hyperthyroidism. Pretibial myxedema, known as Graves' dermopathy, occurs in less than 5% of patients with Graves' and almost always takes place within the first year of diagnosis or treatment of hyperthyroidism.

Methods: A 52 year-old African American woman, with a 20 pack-year smoking history, developed Pretibial myxedema 28 years after Graves' hyperthyroidism was treated, initially with Methimazole, followed by thyroidectomy and finally successfully with radioactive Iodine.

Physical examination revealed non-pitting scaly thickening, induration, hyperpigmentation, tingling and numbness of the skin on her legs. In addition, prominent bilateral exophthalmos and acropachy were present. Patient laboratory values were: TSH 0.94 mlU/L (reference range 0.4–4.5 mlU/L and TSI 578% (<140%). T3 uptake, total T4 and free T4 were within normal limits. Treatment with topical steroids under occlusive dressings was unsuccessful.

Discussion: Pretibial myxedema, as a result of the accumulation of glycosaminoglycan (GAGs) such as hyaluronic acid and chondroitin sulfate secreted by fibroblasts in the dermis, happens in up to 4.3% of patients with history of thyrotoxicosis and usually develops within one year of diagnosis of hyperthyroidism. Ophthalmopathy almost always precedes dermopathy and acropachy. Topical steroids are the first line treatment of pretibial myxedema. Other options include high potency clobetasol ointment with oral pentoxifylline, intralesional steroid injections, octreotide, systemic steroids and cytotoxic therapy with various degrees of success.

Conclusions: This appears to be the only documented case of the development of thyroid dermopathy outside of the commonly reported time frame following the diagnosis and treatment of Graves' hyperthyroidism.

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POSTER 81.

Graves' dermopathy

Hyperthyroidism can occur in 0.1–0.2% of pregnant women, with Graves' disease as the most common cause. Rarely, gestational trophoblastic disease can cause hyperthyroidism and even result to thyroid storm. We report here a case of multiparous woman admitted due to vaginal bleeding from partial molar pregnancy, and who later developed thyroid storm after total abdominal hysterectomy with bilateral salphingo-oophorectomy (TAHBSO).

A 40-year old Filipina, G15P9 (9059), admitted due to vaginal bleeding, nausea and vomiting. The pregnancy test was positive and the ultrasound of the pelvis revealed an enlarged uterus with multiple grape-like masses within, no fetal echo or gestation sac. She underwent emergency TAHBSO due to sudden profuse vaginal bleeding. Post-operatively, she developed fever, tachycardia, shortness of breath and hypertension. There was no palpable thyroid mass on examination. Her FT4 and B-HCG were elevated and her TSH was suppressed. Thyroid storm was considered with a Burch and Wartofsky score of 55. High dose propylthiouracil, propranolol and hydrocortisone were started.

Thyroid storm resolved after 2–3 days of medications. The PTU was shifted to methimazole which was discontinued after 2 weeks. B-HCG decreased to near normal 2 weeks after the surgery. Methotrexate therapy was given to prevent gestational trophoblastic neoplasia.

Thyroid storm arising from partial molar pregnancy is a very rare event. Treatment is, however, similar with hyperthyroidism arising from primary thyroid diseases. On the other hand, definite treatment of molar pregnancy is surgical removal of the mass and prophylactic chemotherapy to prevent the development of neoplasia.

The ultimobranchial bodies contribute to thyroid development. The majority of this contribution consists of calcitonin-producing C-cells, however, embryologic remnants known as solid cell nests, consist of cells that display nuclear membrane irregularities mimicking nuclear features of papillary carcinoma. While ultimobranchial body remnants may have some link to the histogenesis of rare thyroid tumors including mucoepidermoid carcinoma, primary neoplasms of these structures have not been described.

A 64-year-old woman with a history of colon carcinoma was found to have an elevated CEA level. A PET/CT scan localized a nodule in the right thyroid. There was no previous exposure to ionizing radiation or family history of thyroid cancer. Laboratory testing showed a normal TSH and free T4. Fine needle biopsy was reported as suspicious for papillary carcinoma. The patient underwent total thyroidectomy.

The thyroid contained a 1.0×0.9×0.6 cm nodule in the right lobe. On histological examination, this lesion consisted of polygonal-to-elongated cells with centrally located, oval nuclei; they displayed variable nuclear membrane irregularities with squamoid features lacking intercellular bridges. The lesion was positive for p63, mCEA (focal), TTF-1 (SPT-24), CK7 and CK19, and was negative for HBME-1, thyroglobulin, chromogranin-A and calcitonin. These features are consistent with an ultimobranchial body remnant tumor and are not characteristic of other known thyroid neoplasms. The remainder of the thyroid exhibited fibrosing thyroiditis with multiple smaller solid cell nest proliferations consistent with ultimobranchial body rest hyperplasia.

To our knowledge, neoplastic proliferations of ultimobranchial body remnants have not been described. This index case suggests that ultimobranchial body remnant tumors do occur and should be added to the spectrum of proliferative lesions of thyroid that can mimic papillary carcinoma.

A 47 y/o Caucasian female presented for initial care for thyroid cancer without any family history of any malignancy or personal history of head & neck radiation exposure. Her thyroid cancer history is as follows: 1996: Papillary thyroid cancer (PTC) after FNA of self-palpable nodule. Underwent total thyroidectomy at outside facility. Pathology reported 2.5 cm PTC in R thyroid lobe & an additional 0.3 cm focus on the same side. Focus of adenocarcinoma was noted outside the thyroid in an area suspicious for vascular invasion but did not involve the inked margin of resection. A 1 cm focus of PTC was in the L thyroid lobe 1999: Underwent excision of a palpable neck nodule. Pathology showed a 2.4 cm paratracheal granulation & hypertrophic scar in the R thyroid bed 2008: Negative PET scan with no suspicious area in the neck, chest, abdomen, & pelvis Patient recalled having medullary thyroid cancer but no available records indicated such. Starting in 2009, calcitonin serologies were checked. TG, TG antibody, calcitonin, & CEA have been undetectable & negative Additional past medical history was significant for: 2002: Underwent colectomy, cholecystectomy, and partial hepatectomy for metastatic rectal cancer & multiple polyps due to familial adenomatous polyposis (FAP) 2004: Diagnosed with CML, on Imatinib & recent BCR/ABL PCR quantitative fusion transcripts undetectable 2008: Desmoid tumor of the abdomen resected We reviewed original slides from 1996 which demonstrated grooved nuclei & intranuclear cytoplasmic inclusions without psamomma bodies with extension to the desmoplastic stroma with areas of cribriform pattern.

Association between PTC and FAP has been noted since 1949 when Crail reported its first case. FAP associated PTC did not become a distinct type of PTC until Harach et. al first described its histopathology in 1994. Genetic disruption in APC gene and gain in RET proto-oncogene with activation of RET/PTC1 isoform lead to development of FAP associated thyroid neoplasm. While there is a 1–2% lifetime risk of FAP-associated thyroid cancer, there should be low index of suspicion and dedicated annual thyroid exam by experienced thyroidologist is recommended in appropriate clinical context.

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POSTER 85.

Low power photomicrograph of cribriform morular pattern.

No effective systemic chemotherapy exists for radio resistant aggressive metastatic thyroid cancer and patients are still treated with surgery and suppressive levothyroxine therapy. Molecular targeted therapies have shown promising response in phase 2 trials. We report a case where combination therapy with Sorafenib and Valproic acid for two weeks resulted in stable disease and progression free survival of 25 months.

85 year old male diagnosed with Stage IV papillary thyroid cancer, T4a, N1, M1 disease in Sep 2010 is status post total thyroidectomy and RAI ablation therapy in Nov 2010. Post therapy scan showed extensive activity in the remnant thyroid bed. His thyroglobulin levels were 137 with negative antibodies. A PET/CT scan in Jan 2011 revealed FDG avid tumor in the thyroid bed invading tracheal lumen with metastasis in the paratracheal, mediastinal and bilateral hilar lymph nodes. He went to M.D. Anderson Cancer Center, Houston in January 2011 where he underwent valproic acid and Sorafenib treatment. Unfortunately, after 2 weeks of treatment, he developed hand/foot syndrome and stopped chemotherapy. In March 2011, unstimulated thyroglobulin was 52. In May 2012, thyroglobulin was 8.8 and repeat CT scan of the thorax revealed stable mediastinal and bilateral hilar lymph nodes. Most recent thyroglobulin in May 2013 was 15. He is currently on levothyroxine 150 mcg daily.

In our patient progression free survival was 25 months with stabilization of the disease process. Thyroglobulin levels improved significantly and continue to remain low even 2 years after therapy.

Combination of Valproic acid which is a class 1 selective histone deacetylase inhibitor and Sorafenib which blocks the B-Raf pathway for treating aggressive thyroid cancer is still experimental. Also, does this combination therapy improve the radioiodine avidity of the tumor and can patients be treated with RAI therapy subsequently remains to be seen.

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Objective: Report the case of a 39 y/o woman who presented with recurrence of a papillary thyroid microcarcinoma (PTMC); and to review current management recommendations and treatment dilemmas.

Case Presentation: 39 y/o female on therapy for hypothyroidism, referred for evaluation of multinodular goiter. Thyroid nodules were suspicious for papillary thyroid carcinoma (PTC) on FNA biopsy. Patient underwent total thyroidectomy and pathology report of specimen confirmed the diagnosis of PTC, multifocal, with the largest tumor measuring 0.8 cm without capsular invasion, margins free of tumor and lymph nodes (LN) negative for metastasis. I131 radioiodine ablation (RAI) therapy was given and TSH suppression therapy was started. WBS post therapy and one year after therapy were negative for residual tumor or metastases. Neck ultrasound (US) performed 8 months after surgery was unremarkable. A follow up US (16 months post-surgery) showed hypoechoic nodular regions at thyroid bed. Patient underwent surgical resection with central neck dissection after FNA of the 3 mm nodule at right thyroid bed showed recurrent PTC. Final pathology report was positive for LN metastases bilaterally. Follow up WBS was negative for residual neck thyroid tissue or metastatic disease. Multiple LN were found once more in a follow up US. This patient has consistent positive anti-thyroglobulin antibodies titers; quantitative thyroglobulin levels are not reliable.

Discussion: Recurrence is an unusual complication of PTMC. It is unusual to find cancer in FNA biopsy of LN not identified on WBS. Currently there is controversy about the use of RAI therapy in low-risk patients with PTMC, with recent recommendations favoring observation. However, some of these cancers, such as this one, present with aggressive behavior. At this moment risk factors associated with aggressive behavior have not been well defined and a consensus about post-surgical management has not been established.

Conclusion: Recurrence is a rare complication of PTMC. Accurate US imaging for long-term follow up is essential especially in patients with metastasis not identified on WBS studies. It is important to identify risk factors associated with aggressive behavior in PTMC.

Resistance to thyroid hormone (RTH) is an inherited condition characterized by decreased but variable target tissue responsiveness to thyroid hormone. More than hundred different mutations of the thyroid hormone receptor β (THRβ) gene that can cause RTH have been reported to date. Typical hormone findings in RTH are elevated serum free T4 and free T3 levels with normal or slightly increased serum thyrotropin concentrations. The majority of patients are euthyroid with a generalized form of RTH and a minority of them have thyrotoxic features consistent with a less pronounced resistance at the peripheral tissue level. RTH is also associated with increased risk for autoimmune thyroid disease.

We report a new family with RTH and symptoms of hyperthyroidism. The proposita, a 23-year-old female presented with palpitations, anxiety, heat intolerance and difficulty gaining weight. Her thyroid tests showed freeT4 of 2.6 ng/dL (0.8–1.6), freeT3 of 539 pg/dL (249–405), and unsuppressed TSH of 1.6 mcIU/mL (0.3–4.7). Her mother reports having the same symptoms in the past when she was diagnosed with Graves disease and treated with propylthiouracil and then total thyroidectomy. The mother is now asymptomatic and maintained with high dose thyroid hormone. Maternal grandfather and uncle was also diagnosed with Graves disease and the uncle was treated for Graves disease with radioactive iodine ablation. The patient and her mother insist on radioactive iodine treatment for her condition. The patient has negative antibodies for autoimmune thyroid disease.

The patient and her mother were found to have a known mutation in the THRβ gene that is a nonsynonymous single nucleotide polymorphism where adenosine 1025 is replaced by thymidine. This results in the substitution of the normal Proline 247 with a Leucine. Being in the T3-binding domain of the THRβ gene, it reduces its affinity to 30% that of the normal receptor.

The patient was reassured and treated with beta blocker and they were counseled against RAI or surgery. RTH was frequently misdiagnosed and treated as Graves Disease. However, these disorders can coexist, and the concurrent presence of both disorders in a patient can present diagnostic challenge.

Cervical schwannomas are common but rarely present as a thyroid nodule. We report here a lesion in a multinodular goiter yielding spindle cells on fine needle aspiration (FNA).

A 60 year old woman with history of a goiter for 13 years noticed a significant increase in size of the goiter over a 3 years period and dysphagia for 1 year. She denied symptoms of hypo or hyperthyroidism. Thyroid was nodular and enlarged with retro-sternal extension. TSH=0.31 IU/dl (n: 0.34–5.6 IU/dl), TT4=10.4 mcg/dl (n: 6.1–12.2 mcg/dl).

Ultrasound guided FNA of a 4 cm hypoechoic left lobe nodule yielded cohesive spindle cells in a background of lymphocytes. On computed tomography, the thyroid was diffusely enlarged and heterogeneous. The left lobe extended to the retropharyngeal space and appeared to extend to the anterior mediastinum. The trachea was deviated to right side but remained patent. Differential diagnoses on FNA included schwannoma, melanoma, medullary (MTC) and anaplastic thyroid cancer. Immunohistochemistry was positive for S - 100 suggesting neural crest origin of the lesion. Negative staining for calcitonin, CEA, thyroglobulin, TTF1, melan A and HMB45 excluded melanoma, MTC and well differentiated thyroid cancer. Core biopsy of left lobe mass was consistent with a schwannoma. On MRI the left lobe mass was hyperintense on T2 weighted images and distinct from the thyroid. The mass extended from the skull base to the mediastinum. Intraoperatively the mass was found to be adherent to pharynx and esophagus but resectable. A subtotal thyroidectomy for multinodular goiter was performed. Resection of the intrathoracic component of the mass was deferred for future VATS. Based on operative findings, the most likely origin of the schwannoma was the pharyngeal nerve plexus. On histopathology, the schwannoma displayed spindle cells in whorls with Antoni A and B areas. The thyroid gland was diagnosed as a benign multinodular goiter.

In the evaluation of a nodular goiter with an atypical presentation, pathology arising from other structures in neck, including nerve structures should be considered in the differential diagnosis. In addition to cytology and pathology, multimodal imaging may yield helpful clues.

The TSH receptor (TSHR) has 7 transmembrane (TM) helices responsible for G protein activation. It has become clear that TM3 and TM6 form an “ionic lock” which is known to stabilize receptors in an inactive state and thus prevent major signaling initiation. Four mutations within TM3 have been reported to induce hyperthyroidism at residues 485, 501, 505 and 512 and are presumed to break the “ionic lock” releasing a signaling cascade.

Our high throughput screening (HTS) of 50,000 small molecules revealed 2 highly active compounds (437 and 438) which initiate TSHR signaling in nanomolar concentrations as evidenced by cyclic AMP generation. Molecular docking studies of these compounds revealed their binding to residues 505 (438) and 501 (437) in TM3 further confirming the concept of TM3 “hot spots” for receptor activation acting in an allosteric manner. We also know that TSHR activation follows engagement of all classes of G protein leading to thyrocyte growth and development.

To further examine the ability of these small molecules to activate G proteins we used CHO-TSHR cells transfected with bioluminescent reporter vectors with a cAMP response element (CRE-RE), a serum response element (SRE-RE), a nuclear factor of activated T-cell response element (NFAT-RE) or a mutant form of serum response factor (SRF-RE) incorporated upstream of a destabilized luciferase construct that can quantitatively measure activation of Gsα, Gβγ, Gαq and Gα12 (see Figure above). The ability of these constructs to engage the different G proteins was confirmed using TSH ligand which initiated luciferase activity tagged to activation of Gsα, Gα12 and Gαq in a dose-dependent manner. We saw no control activation of Gβγ with TSH. The small molecule agonists, which bind to the intra-helical region of TM3, when tested at 10 uM, showed activation of Gsα, Gαq and Gα12 and Gβγ with engagement of residue 501 more than with engagement of residue 505.

Differential activation of these different signaling pathways of the TSHR indicates that the TSHR response to ionic lock release may be highly variable.

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ORAL 90.

Schematic diagram showing major GPCR signaling pathways (adapted from Current Chemical Genomics, 2010, 484–91).

Graves' ophthalmopathy (GO) is an autoimmune disease of the orbital adipose tissue and extraocular muscles in which circulating thyrotropin receptor (TSHR) autoantibodies activate the receptor on orbital fibroblasts. Recent evidence suggests that ligation of the insulin-like growth factor-1 receptor (IGF-1R), perhaps by locally produced IGF-1, might also activate signaling in these cells leading to the development of GO orbital pathology. In order to better understand how these receptors might interact in this process, we silenced IGF-1R and studied signaling induced by M22, a monoclonal TSHR antibody, TSH or IGF-1 and also investigated the impact of these ligands on receptor expression.

Orbital fibroblasts from patients with GO (n=9) were subjected to IGF-1R silencing using Qiagen GeneSolution siRNA method. Untreated, control siRNA-treated and silenced cells were incubated for 30 minutes with M22 (100 ng/mL), bovine TSH (10 U/L), IGF-1 (10 nM) or IL-6 (10 ng/mL). TSHR and IGF-1R mRNA were measured using RT-PCR. pAkt and cAMP production were assessed using ELISA kits.

IGF-1R was silenced in cultures by 26.5% on average while TSHR expression was not impacted. Silencing decreased M22, TSH and IGF-1-stimulated cAMP production (34.6%; p=0.014, 26.8%; p=0.003 and 28.8%; p=0.004, respectively) relative to control siRNA cultures. Similarly, M22 and IGF-1-stimulated Akt phosphorylation was reduced (28%; p=0.008 and 45.2%; p=0.004, respectively) in IGF-1R silenced cultures. Treatment of cells with M22, TSH or IGF-1 increased both IGF-1R mRNA (1.4 fold; p=0.03, 1.7 fold; p<0.001 and 1.3 fold; p=0.003, respectively) and TSHR mRNA expression (2.6 fold; p=0.005, 2.3 fold; p=0.008 and 2.2 fold; p=0.001, respectively). IL-6 treatment increased only TSHR expression (1.8 fold; p=0.047).

These results suggest that TSHR and IGF-1R cross-communication may play a role in GO pathogenesis. Whether the receptors are transactivated and/or their signaling networks integrated awaits further study.

Persons with positive thyroid peroxidase antibodies (TPOAbs) have an increased risk of developing autoimmune thyroid disease (AITD), including Hashimoto's hypothyroidism and Graves' hyperthyroidism. The genetic basis of TPOAbs and AITD remains largely unknown and neither is it known why only part of the TPOAb-positive persons develops AITD. We therefore performed a genome wide association study for TPOAbs.

The effects of 2.5 million polymorphisms on the risk of TPOAb-positivity and TPOAb levels were studied in 18,300 persons from 11 populations, and replicated in 9,000 persons from 5 independent populations (significance threshold: P<5×10⁻⁸). We subsequently studied the effects of these significant polymorphisms on the risk of hypo- and hyperthyroidism. These effects were also studied in 859 pregnant women, as thyroid hormone metabolism significantly changes during pregnancy.

Significant associations were detected at TPO, ATXN2, and BACH2 for TPOAb-positivity, and at TPO, MAGI3, and KALRN for TPOAb levels (all P<5×10⁻⁸). The MAGI3 and BACH2 polymorphisms were associated with an increased risk of hypothyroidism (OR=1.57, P=1.9×10⁻³ and OR=1.37, P=0.05), and Graves' hyperthyroidism (OR=1.37, P=1.2×10⁻⁷ and OR=1.25, P=6.2×10⁻⁵). A lower risk of suppressed TSH levels (OR=0.82, P=0.01) was found for the KALRN polymorphism. No associations with hypo- or hyperthyroidism were found for the TPO and ATXN2 polymorphisms. In pregnant women, carriage of multiple risk alleles was associated with an increased risk of TPOAb-positivity, but none were associated with hypo- or hyperthyroidism.

We identified five novel genetic loci associated with TPOAbs, and found that in non-pregnant populations the MAGI3, BACH2 and KALRN polymorphisms were also associated with thyroid disease. In contrast, the TPO and ATXN2 polymorphisms were not associated with thyroid disease. These data provide insight into the genetic basis of AITD and as to why only part of the TPOAb-positive persons develops clinical thyroid disease.

The global D2 KO mouse (D2KO) exhibits increased tolerance to glucose and, when on a high fat diet, exhibits liver steatosis and resistance to diet-induced obesity. D2KO animals also exhibit a lower exchange respiratory ratio (RQ) reflecting accelerated fatty acid oxidation, a difference that is dissipated by acclimatization to thermoneutrality.

To define the specific role played by D2 in brown adipose tissue (BAT), we created a mouse with adipose-specific disruption of D2 (FAT-D2KO) by crossing the flox-D2 mouse with the AP2-Cre mouse.

FAT-D2KO animals are grossly normal and systemically euthyroid, but exhibit a ∼65% decrease only in BAT D2 activity. FAT-D2KO have normal BAT UCP1 mRNA (1±0.23 vs. 0.87±0.28; n=12) and defend core temperature normally when at 4°C for 12 h. Despite similar VO2 (5.2±0.7 vs. 5.1±0.4 mlO2/h•g BW), FAT-D2KO have elevated RQ (0.77±0.02 vs. 0.82±0.02; n=4–6; p<0.01; experiment repeated 3x), reflecting accelerated rate of glucose oxidation. In fact, FAT-D2KO animals have increased expression of GLUT4 in BAT (1±0.16 vs. 1.27±0.38; n=12; p<0.05) and in clearance of plasma glucose (34.7±5.7 vs. 25.9±0.84 mg/dl•min, n=12–15; p<0.05) after insulin injection. FAT-D2KO animals have similar body composition by DEXA but are more susceptible to diet-induced obesity caused by high fat diet, gaining more body weight (44.7±0.56 vs. 51.1±1.7 g/day; n=6; p<0.05) and body fat (13.2±3.5 vs. 19.2±5.0% fat) when compared to littermate controls; FAT-D2KO animals never developed liver steatosis. Notably, the metabolic phenotype of the FAT-D2KO mouse was dissipated by acclimatization at thermoneutrality, a condition that minimizes BAT activity.

In conclusion, the metabolic phenotype attributable to a selective D2 inactivation in BAT includes accelerated rate of glucose oxidation (and decrease fat oxidation), what probably explains the greater susceptibility to diet induced obesity.

TSH activates the TSH receptor (TSHR), a member of the family of seven-transmembrane spanning receptors (7TMRs), thereby stimulating the function of thyroid follicular cells leading to biosynthesis of thyroid hormones. Recent studies have demonstrated that the metabolic effects induced by 7TMRs are not entirely a consequence of signaling mediated through G-proteins. β-Arrestins, in addition to their 7TMR desensitizing actions, also serve as multifunctional scaffolding proteins for activation of several, G-protein-independent signal transduction pathways. There are two isoforms, β-arrestin 1 and 2, that have some overlapping and some distinct functions. TSHR has been found to activate/phosphorylate the mitogen-activated protein kinases, ERK1/2, p38α, and Akt. To our knowledge, this is the first report describing β-arrestin mediation of these pathways in TSHR signaling.

TSHR binding to β-arrestins was measured with the PathHunter™ β-Arrestin Assay (DiscoveRx). Phosphorylation of protein kinases was detected with ELISAs. To determine the role of β-arrestin 1 and 2 in TSHR signaling, we knocked down both β-arrestins individually with siRNA.

We showed that the activated human TSHR can bind to and translocate both β-arrestin 1 and 2. We confirmed that TSHR activation leads to phosphorylation of ERK1/2, p38α and Akt in HEK cells that stably express the TSHR, but also in primary cultures of human thyrocytes, suggesting that these pathways are important in thyroid physiology. We showed that phosphorylation of ERK1/2, p38α and Akt is mediated in part by β-arrestins. For TSHR activation of ERK1/2 and Akt, β-arrestin 1 activates and β-arrestin 2 inhibits phosphorylation whereas for p38α, β-arrestin 1 activates but β-arrestin 2 appears to have no effect.

We have shown that β-arrestin 1 is required for TSHR-mediated phosphorylation of Akt, p38α and ERK1/2 and, therefore, β-arrestin 1 in part mediates TSHR-signaling. β-arrestin 2 inhibits TSHR signaling consistent with its role in desensitization of TSHR. Future studies will address the physiological role of β-arrestin 1-mediated pathways in thyrocytes, but also in extrathyroidal tissue, e.g. in orbital fibroblasts from patients with Graves' disease and in bone cells.

It has been shown previously that triiodothyronine (T3) acts on posttranscriptional steps of beta TSH synthesis and reduces the TSH secretion when acutely administered to thyroidectomized rats. In this study we investigated whether these effects on posttranscriptional steps of beta TSH also occur in TalphaT1 cells, a tumor thyrotrophic cell line, independently of gene transcription, as well as, the possible repercussions of T3 on TSH secretion in primary culture of anterior pituitary cells.

TalphaT1 cells were seeded on matrigel-coated plates in two groups: Control (C), cultured in medium containing 10% FBS and Hypothyroid (H), cultured in medium containing 10% FBS depleted of thyroid hormones by treatment with AG1X-8 resin for 48 h. After this, 5,6-dichloro-1-β-D-ribobenzimidazole (DRB - 50 mM) was administered for 2 h to inhibit the gene transcription, followed by the T3-treatment in the doses of 10 nM or 0.1 nM for 30 min or 0.1 μM for 4 h. Total RNA and the polysomes fraction were extracted for the investigation of Tshb and Cga mRNA by RT/qPCR and the degree of adenylation by RACE-PAT assay, respectively. Primary anterior pituitary cells were isolated and cultured with FBS treated with charcoal (Basal) in the presence or absence of T3 (10 nM) for 30 min.

The results obtained with TalphaT1 cells showed that T3 rapidly reduced the total content of Tshb and Cga mRNAs, and the reduction was maintained only for Tshb mRNA after DRB treatment. Moreover, it was shown that the T3 (0.1 nM) specifically decreased the poly(A) tail length of Tshb mRNA and the content of mRNA of both subunits associated with ribosome, which indicates that the translational rate of TSH synthesis was reduced. In parallel, T3 increased the content of TSHB and CGA (alpha subunit) in intracellular extracts of primary anterior pituitary cells while the amount of TSH in extracellular media was reduced.

These results led us to the conclusion that T3 down-regulates TSH synthesis and secretion in several posttranscriptional steps, characterizing novel actions of T3 on its own regulatory axis.

The limited efficacy of cytotoxic chemotherapy (chemo) has led to a paradigm shift in the treatment of advanced differentiated thyroid cancer (DTC). Practice guidelines recommend sorafenib (SOR) as one potential treatment of progressive DTC. The rare subpopulation of patients with poorly differentiated thyroid carcinoma (PDC) has not been independently studied. Thus, we sought to describe the outcomes of PDC patients treated with SOR.

After IRB approval, pathologically confirmed adult PDC patients treated with 1st line SOR were reviewed retrospectively. We used patients on 1st line cytotoxic chemo as a comparator arm. All cases were reviewed and diagnosed by a head and neck pathologist as PDC. Overall survival (OS) after starting systemic therapy, progression free survival (PFS) and overall best response data (as determined by RECIST 1.1) were gathered. The radiologist was blinded to treatment assignment.

From 1994 to 2012, 48 patients were treated with either SOR (n=23) or cytotoxic chemo (n=25). Five patients were excluded (2 SOR and 3 chemo) due to missing data (2), neoadjuvant chemo (1), anaplastic cancer at metastatic site (1) and concomitant unrelated cancer (1). Baseline demographics were similar between the SOR and chemo groups, including time from diagnosis to treatment and sites of metastatic disease. Median OS in SOR treated patients was 34 months vs. 9 months in chemo treated (p=0.026, figure 1a). Best response in SOR: 3/13 (23%) partial responses (PR), 8/13 (62%) stable disease (SD) and 2/13 (15%) progressive disease (PD). Best response in chemo: 1/8 (12.5%) PR, 4/8 (50%) SD, 3/8 (37.5%) PD (figure 1b). PFS to 1st line treatment was significantly longer in the SOR cohort (median 9 vs.3 months, p<0.01).

This is the first study to describe the efficacy of SOR in the subpopulation of PDC patients. Although this is a small cohort, 85% of patients derived clinical benefit (PR+SD) from SOR, similar to the published data in DTC. Acknowledging that a selection bias may be present, we conclude that PDC patients should receive 1st line SOR as it does not appear inferior to chemo.

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SOR is a common 1st line therapy in advanced DTC. Phase 3 results showed a progression free survival (PFS) advantage of 5 months in TKI naive patients. However, responses are not durable and toxicity remains a problem. Median overall survival (mOS) has not been reached. Furthermore, there is no data on OS and efficacy of salvage TKIs after 1st line SOR failure.

This is a retrospective review of DTC patients who received 1st line SOR only (group 1) or with subsequent salvage TKI treatment (group 2). The end points were to assess mOS in all patients treated with 1st line SOR, to compare mOS in group 1 and group 2, and to assess PFS and response rate with 1st line SOR and 2nd TKI. RECIST v1.1 was used to determine best response.

We included 60 metastatic, RAI refractory DTC patients: median age at diagnosis 54, 52% male, 63% papillary, 30% follicular, 7% poorly differentiated carcinoma; 97% lung and 35% bone metastases at the time of SOR start. Group 1 and group 2 included 35 and 25 patients, respectively and were well balanced. 2nd TKI included sunitinib (10), pazopanib (4), cabozantinib (4), lenvantinib (4), vemurafenib (3). The mOS of all 60 SOR-treated patients was 41 months. The mOS was significantly longer with salvage TKI compared to SOR alone (63 vs 24 months, p=0.013) (Figure 1). In group 2, 17 patients were evaluable for response. Two patients had toxicity with SOR leading to drug discontinuation before restaging. Best response with 1st line SOR: partial response (PR) 1/15 (7%), stable disease (SD) 11/15 (73%), progressive disease (PD) 3/15 (20%) and 2nd TKI: PR 7/17 (41%), SD 10/17 (59%). All 3 patients with PD on SOR achieved PR on 2nd TKI (>55% reduction). 2 patients who stopped SOR due to toxicity tolerated and responded to a 2nd TKI (1 SD, 1 PR). The median PFS was 10 months with 1st line SOR and 12 months with 2nd TKI.

The mOS of TKI naive DTC patients treated with SOR is 3.5 years. Although not directly comparable, patients able to receive salvage TKIs following SOR failure appear to extend their mOS from 2 to 5 years. Importantly, SOR failure did not predict response to salvage TKIs despite similar mechanisms of action. The current standard should be to offer salvage targeted therapy to these patients.

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ATA guidelines advise against routine use of postoperative radioactive iodine (RAI) for very low-risk papillary thyroid cancer (PTC), defined as subcentimeter intrathyroidal tumors. Patterns of RAI administration for low-risk PTC vary dramatically across the US, for unclear reasons. We analyzed the association between regional access to healthcare and the pattern of RAI use for very low risk PTC.

We analyzed 13,401 cases of very low risk (defined as ≤1 cm intrathyroidal N0 M0) classical PTC undergoing total thyroidectomy in 337 US counties (1983–2009), in the SEER 18 cancer registry. Aggressive variants of PTC were excluded. County-level access to healthcare was estimated from 8 socioeconomic factors: percentage of county population uninsured, poor, unemployed, white collar employed, non-English speaking, high school educated, college educated, and mean family income. The association between access to care and the probability of RAI use for very low risk PTC was examined using weighted-least squares regression.

During the study period, 32.9% of very low risk PTC patients received postoperative RAI. This proportion was stable between 1990 and 2009, hovering between 30–36%. The proportion was similar (27.9%) when limited to unifocal very low risk PTC. Counties were ranked by socioeconomic factors, and RAI use was more common in the lowest decile, compared to the highest decile (42.0% vs 29.8%, p=.04). The 8 socioeconomic factors together explained 16.7% of the variability in county-level use of RAI for very low risk PTC (r=.41, p<.001). Counties with higher use of RAI had significantly lower levels of income, education and white collar employment, and higher levels of uninsured, non-English speaking, and poor persons.

In the US, RAI is overutilized in very low risk PTC patients, with over 30% of these patients receiving RAI. Levels of access to healthcare are strongly associated with the probability of RAI treatment. Overuse is most frequent in counties with poorer access to healthcare. This association is likely to be multifactorial, possibly attributable to diminished access to experienced specialists resulting in more widespread use of RAI in very low risk patients.

Cystic papillary thyroid cancer (cPTC) is a type of well-differentiated PTC exhibiting classical histopathological features, but different morphological properties due to its common presentation as mural nodule in thyroid cystic mass. The diagnosis of cPTC is challenged, because the fine needle aspiration biopsy usually reveals sufficient volume of cystic fluid, but insufficient amount of representative follicular cells resulting in low-informative cytological reports. The aim of this study was to identify potential diagnostic markers for discrimination between cPTC and benign cystic thyroid neoplasms.

We identified 121 patients who were surgically treated for cystic thyroid neoplasms and the cystic fluid from these cases was collected from post-operative specimens. A 14 cases (7 cPTC, 7 cystic benign thyroid lesions) were selected for proteomics profiling by liquid chromatography tandem mass spectrometry (LC MS/MS). The depletion was performed to remove highly-abundant proteins. The depleted samples were digested, labeled by iTRAQ reagents and pooled into one tube, underwent isoelectric focusing. LC MS /MS was performed on a hybrid LTQ-Orbitrap Velos mass spectrometer. The obtained data was searched by Sequest under the software platform Proteome Discoverer, followed by uni- and multivariate statistical analyses. Immunohistochemistry (IHC) was performed to evaluate the immunoexpression of selected proteins.

Out of all 1581 identified proteins, 841 contained labels in both iTRAQ pools. Of these, 87 proteins were differently expressed in cPTC as compared to control samples by Student's t-test, whereas multivariate OPLS model revealed 41 proteins (p<0.05). Of these, annexin A3 (ANXA3), S100A13, carboxymethylenebutenolidase (CMBL), cytokeratin 19 (CK-19) were selected for evaluation by IHC. ANXA3, S100A13, CMBL showed overexpression in both controls and cPTCs, whereas CK-19 was up-regulated in cPTC only (p<0.05).

To our knowledge this is the first extensive catalogue of the protein content in fluid from the thyroid cystic neoplasms. An overexpression of CK-19 in cPTC fluid supports its possible role as a preoperative diagnostic marker. Additional experiments are needed to validate LC MS/MS and IHC findings.

The DECISION trial (NCT 00895674) was the first placebo-controlled phase III study of RAI-refractory DTC patients. While sorafenib significantly improved progression-free survival, here we sought to better understand the impact of disease burden and sorafenib therapy on the health-related quality of life (HRQoL) in RAI-refractory DTC patients using validated questionnaires.

A total of 417 patients with RAI-refractory DTC who progressed in the preceding 14 months were randomized 1:1 to sorafenib or placebo; n=207 and 210, respectively. HRQoL was measured using the FACT-G questionnaire, a validated tool tracking the physical, social/family, emotional and functional well-being of cancer patients. General health status was measured using the EQ-5D index questionnaire and visual analogue scale (VAS). Questionnaires were self-administered at baseline and day 1 of every 28-day cycle.

Questionnaire completion during study was 96%. Patients had FACT-G scores at baseline comparable to a normative adult cancer population: placebo 82±14 (mean±SD) and sorafenib 81±15 (with 108 being the maximal score possible). The sorafenib group had a lower score at first assessment (cycle 2, day 1; 76±15), possibly related to side effects of treatment, but remained relatively constant thereafter, while the placebo group remained near baseline. A mixed linear model estimated that the FACT-G score was 3.45 points lower in the sorafenib group (p=0.0006). For the EQ-5D tool (both index and VAS), the pattern was very similar to that seen with the FACT-G. Although statistically significant (p<0.0001 for both), the treatment effect (−0.07 and −6.75, respectively) was of a small magnitude.

Compared to placebo patients, patients in the sorafenib treatment arm had lower on-treatment scores for the FACT-G, EQ-5D Index and EQ-5D VAS. All three group differences were small, suggesting a mild but detectable impact of sorafenib therapy on HRQoL in favor of the placebo arm.

The assessment of thyroid nodules is still a common clinical problem. Thyroid fine needle aspiration (FNA) is the standard preoperative tool for diagnosis of thyroid nodules. However, the limitation of this procedure consist in the high rate of indeterminate or suspicious cytological diagnosis which lead to unnecessary surgical intervention. A number of studies have shown that molecular testing of FNA specimens can significantly improve the accuracy of the preoperative FNA diagnosis and the use of molecular marker is now recommended in the American Thyroid Association Management Guidelines for Patients with Thyroid Nodules and Differentiated Thyroid Cancer. However, there are many molecular markers to test, which can require a large amount of DNA, is time consuming, and expensive.

In this study we evaluated the benefits of next generation sequencing (NGS) for helping diagnosis of FNA samples. We retrospectively analyzed 30 indeterminate or suspicious FNA samples for which surgical resection was performed; histological diagnosis being considered as gold standard. DNA from these 30 samples was obtained either from cell block of from Diff-Quick stained smear and subjected to targeted NGS with the Ampliseq Cancer Hotspot Panel, which allowed us to analyze 2850 known cancer-related mutations.

Mutations in BRAF, NRAS and KRAS that are known to be involved in thyroid cancer biology were detected in malignant FNA samples. None of these mutations were detected in the benign samples. Moreover NGS allowed us to detected in the same experiment other rare and low frequency mutations in p53, AKT1 and STK11.

This study demonstrate that thyroid FNA specimens can be successfully analyzed by NGS. The detection in these specimens of different mutations known to be involved in thyroid carcinoma biology can improve sensitivity of the diagnosis in thyroid FNA samples.

Graves disease (GD) is rare in children and is seldom accompanied with extrathyroidal manifestations. Scarce data are available regarding the role of TSH receptor (TSHR) stimulating autoantibodies (TSAb) in pediatric GD. Thus, in this large multicenter trial, the clinical relevance of TSAb is evaluated in GD children with and without orbitopathy (GO).

TSAb levels were measured with a bioassay that uses a chimeric TSH-R and a CRE-dependent luciferase. TSAb results were expressed as percentage of specimen-to-reference ratio (SRR %). Values ≥140% were considered positive. All samples were also measured for TSHR binding inhibiting immunoglobulins (TBII, automated ECLIA assay). Clinical severity of GO was defined according to the consensus statement and recommendations of the European group on Graves' orbitopathy (EUGOGO).

A total of 372 sera samples were obtained from 156 GD children (124 female, mean age±SD 13.6±4.4 years, 66 children with GD/GO showing proptosis, lid retraction, lid swelling, lid erythema and conjunctivitis), 50 with type 1 diabetes (T1D, 13.69±3.7 yrs.), seven with non-autoimmune hyperthyroidism (NAH, 12±8.2 yrs), five with juvenile arthritis (JA, 14.3±3.4 yrs) and from 50 euthyroid healthy controls (12.4±4.3 yrs.). TSAb and TBII were detected in 240/255 (94%) and 226 (89%) samples, respectively (p<0.001). In 97 untreated children, TSAb and TBII were present in 97 (100%) and 91 (94%) samples, respectively (p<0.001). In line with this, TSAb and TBII were present in 100% and 93% samples of treated children with GD/GO (p<0.001). Also, median TSAb levels were markedly higher in untreated children with GD/GO vs. those with GD, only (SRR% 482 vs. 404, p=0.001). During antithyroid drug treatment, children with GD/GO who became euthyroid still had very high median TSAb levels compared with children with GD, only (SRR% 465 vs. 291, p<0.001). Neither age nor gender had an impact on TSAb values. All controls and children with NAH (SRR% 37±3.8), T1D (46±2.1) and JA (39±1.8) were TSAb and TBII negative.

Serum TSAb levels are a biomarker of disease severity and extrathyroidal manifestations in pediatric GD.

Over the past decade several clinical studies have suggested that selenium supplementation may influence the natural course of autoimmune thyroiditis (AIT). The aim of this randomized, placebo-controlled, prospective study was to evaluate the effect of 2 different doses (80 or 160 μg) of selenomethionine (semet) versus placebo in euthyroid female patients with AIT, in terms of anti-thyroid antibody reduction and thyroid hypoechogenicity improvement, over a period of 12 months.

Sixty patients, aged 21–65 years, were randomly divided in 3 groups according to the treatment modality: 80 μg of semet (80-semet), 160 μg of semet (160-semet) or placebo. AbTPO/AbTg and thyroid hypoechogenicity, by grayscale method, were measured basally and every 3 months. Serum selenium, CXCL9 and CXCL11 levels were evaluated basally and every 6 months.

Preliminary data are available at 3 month-follow-up and in a subgroup of patients at 6 months. Compared to basal values: AbTPO levels were slightly increased in the placebo group, while they were unchanged in the 2 semet groups; AbTg levels decreased in the 160-semet group (from a median of 181.5 U/ml to 102.5 U/ml, p=0.02) at 3 months and showed a further decrease (−9.75%) at 6 months while they did not show any change in the placebo and 80-semet groups; there was no change in thyroid function and grayscale value in any of the 3 groups. No side effects were reported.

Both 80 and 160 μg semet supplementations are well tolerated and may prevent as soon as 3 months, an increase of AbTPO levels in euthyroid AIT patients; 160 μg dose was also able to reduce AbTg values compared to basal levels at 3 months and even more at 6 months. On the other side thyroid function and hypoechogenicity were not affected by 6 month-semet supplementation. The optimal semet dose and duration of supplementation needs to be ascertained over the remaining study follow-up.

The aim of this study was to evaluate the relationships between lipid-carbohydrate metabolism parameters and thyroid hormones and autoantibodies and carotid intima-media thickness (CIMT) in children and adolescents with autoimmun thyroiditis (AIT) during the follow up.

We examined 60 patients with the diagnosis of AIT aged range between 9–19 years (10 male, 50 female), based on examination of autoantibodies (anti-TPO and anti-Thyroglobulin) and thyroid ultrasonography (USG). Oral glucose tolerance test (OGTT) was performed to all patients. Hepatic steatosis and CIMT using B-Mode USG, and lipid profile were evaluated in all patients. All procedures were performed to patients during the follow-up. Body mass index (BMI) was calculated as a kg/m2. Insulin sensitivity was evaluated by homeostasis model assessment (HOMA-IR).

Mean duration of diagnosis was 24.76±22.38 months. Frequency of overweight and obesity were 22.4%. Hepatic steatosis is only present in 3.2% of the patients. BMISDS at the diagnosis, insulin levels at 30th minute and totally insulin levels in OGTT were higher in overweight and obese children and adolescents with AIT compared with non-obese subjects with AIT (p=0.003, 0.026 and 0.04, respectively). In these patients, anti-TPO levels was lower in overweight and obese subjects compared with non-obese subjects (p=0.031). Thyroid stimulating hormone (TSH) and FT4 levels were significantly changed during follow-up (p<0.05, paired sample test). The Pearson correlation coefficient indicated that anti-TPO level at the time diagnosis was positively correlated with HOMA-IR (r=0,37 p=0.008).

Overweight and obesity are common among children and adolescents with AIT. Elevated insulin levels are highly prevalent in overweight and obese children and adolescents with AIT. Insulin sensitivity may be related with anti-TPO levels at time of diagnosis.

To analyze the pregnancy outcomes among women with Graves' disease after radioactive iodine therapy and evaluate the influence on the fertility as well as the health status of their births.

We followed a total of 102 female patients who suffered from Graves' disease and kept on the treatment, recorded their pregnancy outcomes during 2009∼2012. Among the pregnant women were classified into two groups: receiving 131I therapy before pregnancy and receiving ATD treatment. During the pregnant period, we monitored closely about the thyroid function to adjust the drug dose and then recorded the health condition of the newborns also the cases about termination of pregnancy. Medication compliance, delivery mode, baby gender and weight were statistically analyzed.

Among the 102 cases, there were 86 women with drug pregnancy and the other 16 without medication during pregnancy; 97 normal deliveries and 5 abortions; 90 term deliveries and 7 premature births; 50 baby boys and 47 baby girls; 86 normal weight babies and 11 abnormal weight babies. The 131I treatment group compared with the ATD treatment group, medication compliance, delivery mode, baby gender and weight were similarity and the difference was not significant.

Women of reproductive age with Graves' disease can choose to pregnant after 131I therapy for at least 6 months later. People can achieve the purpose of giving a good birth as long as their thyroid function kept checking routinely before and during pregnancy period and at the same time rational drugs used to control or maintain the thyroid function normally.

Hypoparathyroidism is a rare endocrine disorder caused by insufficient or absent parathyroid hormone, leading to hypocalcemia and hyperphosphatemia. The PARADOX study aimed to quantify clinical, social, and economic impacts of hypoparathyroidism from the affected patients' (pts) perspective.

Pts aged ≥18 y and diagnosed with hypoparathyroidism ≥6 months ago completed a 30 min self-reported, web-based survey.

374 US adults (mean age, 49 y; women, 85%; mean disease duration, 13 y; severe disease, 31%) completed the study. Pts reported visiting a mean of 6 physicians before and after diagnosis. Nearly half of the pts (48%) strongly agreed to feeling mismanaged at diagnosis, and 79% strongly agreed that most physicians do not understand hypoparathyroidism. Pts visited their current managing physician (endocrinologist, 72%; primary care physician, 21%) a mean of 4 times/y. The majority strongly agreed that they felt unprepared to manage the condition at diagnosis (56%), that controlling their hypoparathyroidism is harder than expected (60%), and that they were concerned about long-term complications of their current medications (75%). Despite current management regimens, 72% experienced >10 symptoms in the preceding 12 months, for a mean of 13 hours/d. Physical symptoms reported by >75% of pts were fatigue (82%), muscle pain/cramping (78%), and paresthesia (76%). Comorbidities were experienced by 259 pts (69%), the most frequent being cardiac arrhythmias (66%) and kidney stones (36%). Hospital or emergency room visits because of hypoparathyroidism were reported by 79% of pts. In addition, 45% reported significant interference with daily life, 85% reported an inability to perform some household activities, and 20% experienced a disease-associated change in employment status.

To our knowledge, this is the largest and most comprehensive study conducted to assess the impact of disease in pts with hypoparathyroidism. Despite the current standard of treatment (oral calcium and active vitamin D), pts with hypoparathyroidism have a high burden of illness and experience a broad spectrum of symptoms, with multifaceted effects on their lives.

Thyroid hypofunction may adversely affect pregnancy outcomes. Recommendations for thyroid function testing and management of subclinical hypothyroidism and hypothyroxinemia in pregnancy are not in agreement. We aimed to determine current practice patterns among thyroidologists who care for pregnant women to understand how guidelines are being implemented.

An anonymous multiple-choice survey was distributed at the 2012 ATA meeting. Respondents were asked whether or not to test for thyroid dysfunction or treat hypothyroidism/hypothyroxinemia given different clinical scenarios. Responses were compared across different provider demographics using ANOVA.

There were 151 survey respondents. 91% were endocrinologists and 40% had been in practice ≥20 yr. 40% of respondents saw 1–10 pregnant women annually, 34% saw 11–40, and 16% saw >40. 75% had read the 2011 ATA thyroid in pregnancy guidelines and 68% had read the 2012 Endocrine Society guidelines. 74% advocated for and 18% against universal TSH screening in pregnancy; 8% were unsure. 100% advocated thyroid testing in pregnant women with hypothyroid symptoms or family history of Graves' disease and 99% advocated testing in those with goiter. 46% recommended thyroid hormone treatment for a TPOAb negative pregnant woman with TSH 3.5 mU/L; 86% would treat this patient if she were TPOAb positive. 97% would treat for a TSH of ≥8.0 mU/L in pregnancy. 26% would treat isolated maternal hypothyroxinemia in a TPOAb negative woman, and 51% would treat if the woman were TPOAb positive. Provider demographics did not predict survey responses.

Most thyroidologists surveyed favored universal thyroid function testing in pregnancy. Thresholds for treatment of mild maternal hypothyroidism were variable. There was no correlation between provider demographics and survey responses.

We sought to determine the prevalence of post-surgical hypothyroidism in patients undergoing thyroid lobectomy for benign disease, and to identify the appropriate time interval in TSH surveillance.

Patients who underwent lobectomy between 01/2005 and 12/2011 were identified; pertinent data were obtained through a retrospective review of the electronic medical record system.

Three hundred and seventeen patients underwent thyroid lobectomy for benign disease. As per surgeon preference, 131 patients (41%) were placed on prophylactic levothyroxine (LT4) immediately after surgery. The remaining 186 patients were followed for a median of three years and were placed on LT4 when their TSH levels were elevated beyond the normal range. Using Kaplan Meier analysis, the prevalence of new onset hypothyroidism was 14% by 6 weeks, 32% by six months, and 40% by one year. Fifty-nine patients were on LT4 at one year postoperatively, only an additional 6% (n=6) developed hypothyroidism after that. Neither preoperative TSH levels (p=0.09) nor evidence of chronic lymphocytic thyroiditis (p=0.2) were significant predictors for development of hypothyroidism. For patients not placed on LT4 (n=54) during the study period, 45% had final postoperative TSH levels that were at least one point above their preoperative levels, and 18% had final TSH levels that were >3.5 (normal 0.45–5.5 mIU/L). In comparison, only 15% of the patients who were placed on LT4 prophylactically had final TSH levels that were one point above their preoperative levels, and only 9% had levels that were >3.5 mIU/L.

With longer follow up, the prevalence of post-surgical hypothyroidism may be higher than previously reported. This is especially true when taken into account the patients who exhibited “relative hypothyroidism” but were never placed on LT4 because their TSH levels were within the “normal range”. This study suggests that patients with “relative hypothyroidism” may have benefited from LT4 therapy. Furthermore, we recommend checking TSH levels at more frequent intervals within the first year after surgery to ensure that hypothyroidism can be treated promptly.

Thyroid hormones are well known to regulate metabolic parameters in the physiologic state. We were interested in exploring the relationship that the hypothyroid state has on the occurrence of the metabolic syndrome and on the metabolic parameters of the metabolic syndrome.

Methods: This is a retrospective case control study to compare the prevalence of the metabolic syndrome between euthyroid and hypothyroid subjects. We analyzed 149 subjects in total, 39 euthyroid and 110 hypothyroid subjects. Metabolic Syndrome was defined as per ATPIII criteria. All data were collected through chart review. Statistical analysis was performed by the Chi-square test and logistic regression analysis.

Results: The euthyroid and hypothyroid groups were found to be similar in terms of demographic variables including age, gender, smoking status, alcohol consumption. We found that 28.2% of the euthyroid and 51.8% of hypothyroid subjects had the metabolic syndrome. Statistical analysis revealed an Odd's ratio of 2.6 (CI 1.5 to 5.7) with a P-Value of 0.01. The groups did not significantly differ in the prevalence of any single component of the metabolic syndrome, namely glucose tolerance, blood pressure, body mass index, HDL cholesterol or triglyceride levels, though a uniform trend of increased prevalence among the hypothyroid group was seen. Subset analysis revealed a higher mean TSH among those with the metabolic syndrome as compared to those without, in both the euthyroid and hypothyroid groups.

Conclusion: Our study suggests that hypothyroid subjects are at about 2 to 5 fold increased risk for metabolic syndrome independent of age, gender, smoking status and alcohol intake. This may contribute to the association of ischemic heart disease and hypothyroidism. Further research is needed to evaluate the timing and the cost-effectiveness of routine screening of hypothyroid patients for the metabolic syndrome, the effect of thyroid hormone replacement on the metabolic parameters and the target TSH level in hypothyroid individuals with metabolic syndrome.

The key role of an intact gastric acid secretion for subsequent intestinal T4 absorption is supported by biochemical and clinical evidence. Characteristic of several gastric disorders is an increased gastric pH. To note, softgel thyroxine preparation showed a better dissolution profile than T4 tablets under increased medium pH, in vitro. Thus, in patients with gastric disorders, softgel capsules of T4 may help to improve the therapeutic efficacy. Our study was aimed at comparing softgel and tablet T4 requirement in these patients.

Patients enrolled had gastric-related T4 malabsorption, were in long-lasting T4 tablets treatment (same brand) and showed a stable serum TSH (>2 yrs). All patients had been advised and agreed to take oral thyroxine under fasting conditions, waiting at least one hour before eating. Patients bearing additional conditions known to interfere with thyroxine treatment were excluded from the study. A total of 36 patients met these criteria, but only 30 of them (28 F/2 M; median age=51 years; median T4 dose=2.05 μg/kg/day) completed the study. In these patients T4 treatment was switched from the tablet to a lower dose of the softgel T4 capsules (median T4 dose=1.77 μg /kg/day; −16%; p=0.0082). Assessment of FT4 and serum TSH was carried out before (0 time) and after 3,6,12 and 18 months from the treatment switch.

In the whole sample, a slight increase in mean serum TSH has been observed after 3 months of treatment, with no change in FT4 levels. However, once subdivided according with a tertile distribution, two clearly different groups appeared. In more than 2/3 of patients (responders n=21), despite the reduced dose of T4, mean TSH values after 3 months were similar and so remained until the end of the study (p=0.6491). In the remaining patients (non responders n=9), TSH levels were significantly higher than baseline values after 3 months (0.47 vs 4.05 mU/l) and at each time point (ANOVA p<0.0001). To note, in 4 of them we have detected additional intestinal disorders. Again, no significant FT4 variations were observed throughout the study.

The use of softgel capsules, as compared with T4 tablet preparation, helps in optimizing the dose of T4 in most of patients with gastric disorders.

William Ord coined the term Myxoedema in 1878 following Sir William Gull, who in 1873, described the cretinoid state presenting in adult women. George Murray treated hypothyroidism with extracts of sheep thyroid extract in 1891, and for the next 80+ years, treatment with natural desiccated thyroid (NDT) was standard of care therapy for hypothyroidism. However, by 1978, leading British endocrinologists felt compelled to warn against its use, leading to a dramatic decline in the amount of prescriptions of NDT. What prompted this paradigm shift away from NDT to alternative medications such as levothyroxine? This presentation proposes that NDT is a victim of the 'Tomato Effect' (as coined by James S. Goodwin), in which a highly efficacious therapy is ignored or rejected “because it does not make sense” in the light of accepted theories of disease mechanism and drug action.

Through an extensive literature review, the case will be made that three seminal events caused a paradigm shift away from glandular therapy to synthetic thyroxine. These events are: special patent protection (and profit-making potential) lasting over 50 years for synthetic thyroid; the introduction and acceptance of thyrotropin (TSH) as the criteria to diagnose hypothyroidism (as opposed to history and physical exam findings); and the misuse of NDT in combination with digitalis, diuretics, amphetamines, and other unclearly labeled pills (but brightly colored with various food dyes) as part of weight-reduction treatment plans for patients, many of them who were not overweight nor obese, merely because the physicians were able to dispense these pills at great profit. The use of these “Rainbow Pills” caused dozens of deaths in otherwise healthy persons, led to the labeling changes on all thyroid medications, and relegated the use of NDT to rogue physicians outside the mainstream.

Data will be presented showing the benefits and risks of NDT in the treatment of selected patients with hypothyroidism on symptom improvement and patient satisfaction, as well as protocols of how to mitigate potential adverse effects.

NDT is an underutilized therapy with a favorable benefit-to-risk ratio. A reappraisal of the use of NDT is warranted.

A 49-YO F was admitted because of 2 months Hx of diarrhea, and 30-kg weight loss. On exam, she had SVT with HR 190.

We started her on methimazole, propranolol. Initial work up showed significant PTH-independent Hypercalcemia. Her corrected calcium was 12.6 (8.2–10.4 mg/dl). PTH was <5 (10 to 65 pg/mL). TFT showed Free T4 of 3.94 (0.8–1.9 NG/Dl), Free T3 9.0 (2.3–4.20 PG/ML), and TSH of 0.01. In addition, she had severe prolonged hypomagnesemia, her lowest magnesium was 0.8 (1.1–1.3 mEq/L). Work up for hypercalcemia showed suppressed PTH, low 25 OH vit D 12 (30.0–74.0 ng/mL), normal PTH- related peptide (<4.0 pmol/L), negative CXR for lung masses; CT chest, abdomen and pelvis were negative for cancer. Serum and urine PEP were negative. urinary calcium and magnesium were high suggesting renal loss.

While mild hypercalcemia has been reported with thyrotoxicosis, severe hypercalcemia is usually due malignancy. In situations in which thyrotoxicosis is the cause of hypercalcemia, the serum calcium level rarely exceeds 12 mg/dL and is usually asymptomatic. Hypercalcemia in thyrotoxicosis is presumably because of increased bone turnover. Our patient had severe hypomagnesemia, which were mainly due to GI loss; however, coexisting hypercalcemia can exacerbate hypomagnesemia since calcium and magnesium seem to compete for transport in the thick ascending limb of the loop of Henle. The increased filtered calcium load in hypercalcemic states will deliver more calcium to the loop of Henle; the ensuing rise in calcium re-absorption will diminish that of magnesium. Of note, our patient had microcytic anemia, which is a rare finding in thyrotoxicosis. Previous studies showed hypercellular marrow may indicate that erythropoiesis is enhanced due to hyperthyroidism, but in the same time it is ineffective, hence the finding of anemia with low MCV.

This report highlights the need for physicians to be alert regarding these rare manifestations of thyrotoxicosis including severe hypercalcemia, severe hypomagnesemia and microcytic hypochromic anemia.

Recent studies have demonstrated the presence of the chloride channel 5 (ClCN5), a voltage-gated chloride channel protein abundantly expressed in the kidney, at the apical membrane of mouse thyrocytes. The Clcn5-knockout mice display a phenotype reminiscent of Pendred's syndrome. These mice develop a goiter under conditions of normal dietary iodine intake and show decreased iodide organification when compared to wild-type mice. Another study has shown an increase in ClCN5 mRNA expression in the thyroid of a patient with Pendred syndrome. Currently, the role of ClCN5 in apical iodide efflux and iodide organification remains unclear.

In order to address the question whether ClCN5 mediates iodide efflux, we have performed functional analyses in non-polarized TSA-201 cells (a clone of human embryonic kidney 293 cells). TSA cells were transiently transfected with the human wild type sodium-iodide symporter (NIS), pendrin (PDS/SLC26A4), and ClCN5 cDNAs independently or simultaneously. In addition, we determined ClCN5 mRNA expression in rat thyroid (PCCl3) cells in the absence and the presence of iodide by extracting total RNA from the cells and subsequently analyzing it by real-time PCR.

Functional analyses demonstrate that cells co-transfected with NIS and PDS/SLC26A4, as well as NIS and ClCN5 show a decrease (2.8-fold and 1.6-fold, respectively) in the intracellular iodide content compared to transfection with NIS alone. Co-transfection of NIS with PDS/SLC26A4 and ClCN5 result in a decrease of intracellular iodide (3.2-fold), indicating a partially additive effect of PDS and ClCN5 on iodide efflux. Real-time PCR results show that ClCN5 mRNA expression significantly increases following a 30-minute treatment with 1 mM sodium iodide.

In conclusion, these results suggest that ClCN5 can mediate iodide efflux either by acting as an alternative iodide channel or by regulating pendrin's expression and/or function in vitro. Whether ClCN5 has a physiological role in mediating iodide efflux in thyrocytes remains uncertain.

Marine algae (seaweeds) provide the bulk of atmospheric gaseous iodine. This can influence cloud formation but is also available for human ingestion by respiration. Conventional wisdom suggests that iodine intake in coastal regions exceeds that in inland areas. This study aimed to establish if living near the sea in a seaweed abundant environment, and therefore exposed to gaseous I2 ingestion by respiration, may confer advantages in terms of iodine intake. This may have relevance in countries such as Ireland and the UK where only 5% (approximately) of table salt sold is iodine supplemented and where urinary iodine excretion (UI) measurements continue to suggest borderline iodine deficiency.

Atmospheric I2 was measured by gas chromatography-mass spectrometry (GC-MS). Iodine intake was assessed by measuring (UI) using Sandell Kolthoff colorimetry. Urine samples were obtained from populations (N=192) living in coastal areas, including those residing beside a seaweed hot spot, and inland areas of Ireland.

Atmospheric I2 was greatest over the seaweed mass (Median 186: range 110–301PPT) compared to inland values of 15–18PPT. The median UI of 133 μg /L in the seaweed rich coastal area was significantly greater than in the coastal area lesser seaweed abundance (71 μg /L) or in the inland area (58 μg /L). The most striking differences were in the proportion of higher (>150 μg /L) individual UI values which reached 39.4% in the seaweed rich coastal area compared to 3.6% and 2.3% in the other study areas.

Thus the abundance of seaweed rather simply living near the sea may influence iodine intake. It is postulated that the relative absence of iodine deficiency recorded near seaweed hotspots may be the result of atmospheric iodine compensation for inadequate dietary intake in areas such as Ireland where iodine intake is traditionally low.

10% to 25% of fine needle aspiration biopsies (FNAs) of thyroid nodules are either suspicious for follicular neoplasm or atypical (indeterminate cytology) requiring surgical resection for definitive diagnosis. The novel Gene Expression Classifier (GEC) performed on FNAs of thyroid nodules, preoperatively reclassifies these nodules as high probability of being benign (GEC-B) or suspicious for malignancy (GEC-S). We aimed to assess the clinical validity and utility of GEC testing in our institution.

We conducted a 12-month retrospective study involving 1,238 FNAs from thyroid nodules. 94 nodules were sent for GEC analysis. FNAs suspicious for follicular neoplasm or atypical (indeterminate cytology) were named indeterminate. Information regarding demographic characteristics, nodule size and final recommendations by one of our endocrinologists was retrospectively collected. We reviewed surgical and pathology reports from patients who underwent surgery. Ultrasound follow up was recommended in those with GEC-B, whereas surgery was recommended in those with GEC-S.

94 GEC reports were reviewed. 10 were unsatisfactory and 4 were excluded due to questionable indications. Of the remainder 80 nodules that were indeterminate by FNA: 33 (41%) were GEC-B and ultrasound follow up was recommended. 47 (59%) were GEC-S and surgery was recommended. Of the GEC-S, 36 (76%) underwent surgical resection. Malignancy was confirmed in 55% (n=20) of patients (16 papillary thyroid cancers, 2 follicular carcinomas, 1 both papillary and follicular carcinoma and 1 poorly differentiated carcinoma). 44% (n=16) of the GEC-S nodules were benign by final pathology.

This is the largest single center report assessing the clinical utility of GEC testing for suspicious for follicular neoplasm and atypical FNA biopsies of thyroid nodules. Our experience with GEC finds a slightly lower than previously reported rate of GEC-B samples (41% vs. 53%; p<0.01) and a higher rate of GEC-S samples (59% vs. 38%; p<0.01). GEC testing correctly identified a malignancy in just 55% of the GEC-S nodules.

Thyroid cancer is the most common endocrine malignancy, and many patients with metastatic differentiated thyroid cancer (DTC), poorly differentiated thyroid cancer, and anaplastic thyroid cancer (ATC) fail to respond to conventional therapies, resulting in morbidity and mortality. Further therapeutic targets are needed for these patients. We recently reported that peroxisome proliferator-activated receptor gamma (PPARγ) is highly expressed in ATC and confers an aggressive phenotype when overexpressed in DTC cells.

shRNA-mediated gene silencing, microarray, Western blot (WB) analysis, immunohistochemistry (IHC), genetic overexpression, proliferation and glucose uptake assays, orthotopic thyroid cancer mouse model.

Using microarray analysis, we show that TXNIP, which encodes thioredoxin interacting protein, is highly upregulated when PPARγ is depleted from ATC HTh74 cells using specific shRNA. TXNIP is a tumor suppressor in other cell types which, in addition to its role in modulation of cellular redox state, also functions to inhibit glucose uptake, restrict cell cycle progression, and promote a pro-apoptotic environment. TXNIP and PPARγ exhibit reciprocal expression patterns in DTC and ATC cell lines. DTC cell lines and patient tumors exhibit high TXNIP expression in contrast to low or absent expression in ATC cell lines and tumors as assessed by WB and IHC. Overexpression of TXNIP using a genetic approach decreases the growth of HTh74 cells by 37% compared to vector controls (p<0.01) and inhibits glucose uptake in the ATC cell lines HTh74 and T238 (by 28% and 35%, with p=0.0010 and <0.0001, respectively). Importantly, TXNIP overexpression in T238 cells results in attenuated tumor growth in an orthotopic thyroid cancer mouse model (mean tumor volumes±SD: 97 mm³±68 and 27 mm³±26 for vector and TXNIP overexpression, respectively, p=0.0117).

TXNIP is highly expressed in DTC, however, its expression is downregulated in ATC. Exogenous overexpression of TXNIP in ATC cells slows cell growth, inhibits glucose uptake, and attenuates in vivo tumor growth. These studies underscore the potential of TXNIP as an important tumor suppressor in the transition from differentiated to advanced thyroid cancer.

Molecular testing of routinely available thyroid nodule fine needle aspiration (FNA) material has many advantages. Although it can be performed with air dried smears, this material results in highly fragmented RNA. In contrast, liquid based FNA material allows efficient and easy RNA extraction. We therefore analyzed the remaining CytoLyt FNA material for BRAF and RAS point mutations and RET/PTC and PAX8/PPARG rearrangements.

Thyroid FNAs were classified according to TBS after routine cytologic examination, typically of a single ThinPrep slide. The remaining material (suspended in CytoLyt) from all available cases was used for blinded analysis of BRAF, NRAS, HRAS, KRAS point mutations and RET/PTC and PAX8/PPARG rearrangements by high resolution melting PCR and pyrosequencing.

A total of 597 consecutive cases were collected and stored at 8°C for up to 6 months. Molecular analysis of the remaining material was possible for 391 cases (65%). Higher volumes of remaining material (>2 ml) were associated with higher diagnostic success rates (23% vs. 79%, p<0.001, chi-squared test). Mutations and rearrangements were detected in 10 of 87 cases (11.5%) of atypia of undetermined significance (AUS), 11 of 33 (33%) suspicious cases, 24 of 51 (47.1%) malignant cases, 2 of 28 (7.1%) follicular neoplasms, 20 of 216 (9.3%) benign cases, and 4 of 163 (2.5%) non-diagnostic (molecular analysis possible for 103 of 163 (63.2%)) samples. Compared to histology (available for 211 samples), cytology and molecular analysis increased sensitivity, specificity, PPV, and NPV compared to cytology alone to 86.7% versus 73.6%, 98.1% versus 95.7%, 98.7% versus 94.4%, and 81.5% versus 78.8%, respectively, considering 13 mutation-positive but histologically benign cases as true positives.

Mutational analysis is feasible on residual ThinPrep material and has the advantage of not requiring additional FNA procedures or dedicated passes, special preservation, or storage. Its reflex use can be valuable in the pre-operative determination of the extent of surgery for mutation-positive cases, help to clarify 12% of AUS cases, decrease the rate of false negatives for benign cases, and allow molecular diagnostics for 63.2% of the non-diagnostic samples.

Our aim was to examine the mutational profile of non-anaplastic thyroid carcinoma that died of disease (NTCD) and correlate with clinical characteristics and outcome.

39 patients with NTCD were treated with primary surgery at MSKCC from 1986 to 2009. Formalin fixed paraffin-embedded tissue was available on 33 patients; 25 had poorly differentiated, 7 differentiated thyroid carcinoma and 1 Hurthle cell carcinoma. Mass spectrometry-based genotyping was used to interrogate hot spot point mutations in the most common thyroid oncogenes: BRAF, RET, NRAS, HRAS, KRAS, PIK3CA, AKT1. In addition, common fusions of RET and PAX8/PPARγ were assessed by RT-PCR. Mutational profile was correlated with clinical characteristics by χ2test and outcome by the Kaplan Meier method.

Of 33 patients, 17(52%) were female and 31(91%) over 45 years of age. All patients had surgery with adjuvant RAI in 26(79%), adjuvant RAI+radiotherapy in 2(6%) and adjuvant RAI+chemoradiotherapy in 1(3%). 30(91%) patients had pT3/4 tumors, 28(85%) had extrathyroidal extension (ETE) and 19(58%) pN+. 85% of patients had driver mutations: 15 BRAF (46%), 9 RAS (27%), 2 BRAF/PIK3CA (6%), 1 PIK3CA (3%) and 1 had RET/PTC rearrangement (3%). 15% were wild type (wt) with no identifiable driver mutation or gene rearrangement. All patients developed distant metastases, 19(58%) at presentation and 14(42%) during follow up. Distant metastases were pulmonary alone in 11(33%), extrapulmonary in 2(6%) and mixed in 20(61%). Distant disease caused death in 26 (79%) patients: 11 BRAF+, 9 RAS+, 1 PIK3CA, 1 RET/PTC and 4 wt. Locoregional disease caused death in 4 (12%) patients (3 BRAF and 1 PIK3CA) while combined locoregional and distant disease caused death in 3 (9%) patients (1 BRAF, 1 BRAF/PIK3CA and 1 wt).

Majority of NTCD patients die of distant metastases. BRAF and RAS are the main driver mutations in these tumors. BRAF is the main driver mutation in NTCD tumors where locoregional disease is the cause of death.

Thyroid cancer appears as papillary thyroid carcinoma (PTC) in about 80–90% cases and resulted by RET fusion with 12 other genes leading to 13 different oncofusions. Amongst; RET/PTC3 (RET fusion with ELE1) is the most metastatic type occurring in 20–30% PTC cases.

Initially a stable cell line was established of mouse fibroblasts by plasmid containing RET/PTC3 junction oncogene; named as RP3 cells. An efficient siRNA RET/PTC3 and an effective dose were selected on significant gene (RT-qPCR) and protein (Western blot) inhibitions. In vitro siRNA RET/PTC3 effects were tested on RP3 cell viability (MTT), proliferation (CFSE), invasion/migration in matrigel (IncuCyte), apoptosis (FACS, IncuCyte, WB), RET/PTC3 gene (RT-qPCR) and protein (WB) expressions. siRNA RET/PTC3-SQ bio-conjugate was synthesized, corresponding nanoparticles were prepared and tested for their effects on in vitro gene (RT-qPCR) and protein (Western blot) silencing. In vivo tumour growth inhibition and gene and protein silencing efficiency were later assessed as well, on administration in nude mice via intravenous route (cumulative dose=2.5 mg/kg).

In vitro siRNA RET/PTC3 was found to significantly inhibit cell viability, proliferation, invasion/migration, RET/PTC3 gene and protein expressions compared to siRNA control and siRNA RET/PTC1 at 24 h, 48 h and 72 h post-transfection incubations. Although it was not found to increase apoptosis in RP3 cells (Annexin/PI, IncuCyte) but an increased caspase-3 expression was found by Western blot at 24 h and 48 h post-transfection. In vivo, the RP3 cells were found to be tumorigenic in nude mice compared to mother NIH/3T3 cells. In vivo NPs were found efficient in significant (p<0.001) tumour growth, gene and protein inhibitions.

Although these NPs were not found efficient in gene and protein inhibitions in vitro but could be accepted as an efficient in vivo cancer therapy and hence guide towards further pharmacological studies intended for in vivo applications. This work was supported by ANR “P2N Nanosqualonc”.

Cancer-associated fibroblast (CAF) plays an important role in the progression of multiple cancers, but its roles in thyroid cancer have not been investigated.

We first treated fibroblasts isolated from normal thyroid with K1 cell derived conditioned media (CM) to identify papillary thyroid cancer (PTC) CAF specific marker. Furthermore, we performed α-SMA immunostaining in 108 consecutive thyroid nodule patients, including 54 PTC, 21 follicular thyroid cancer, 6 anaplastic thyroid cancer, 11 follicular adenoma (FA) and 15 multinodular goiter. Subsequently we compared the tumor promoting effects of fibroblast derived from PTC (CAF and normal adjacent fibroblast (NAF)) and benign thyroid lesion by co-culture model and a co-implantation xenograft model mixing k1 cell with PTC derived CAF or NAF. Finally, we profiled the cytokines mediating the tumor promoting effects of fibroblast.

We found α-SMA as the only elevated marker for papillary thyroid cancer (PTC). Immunostaining showed significantly higher density of α-SMA+ fibroblasts in all follicular thyroid lesions comparing with normal thyroid. Interestingly, α-SMA+ staining was positively correlated with tumor size (P=0.046), local invasive behavior (P=0.0008) and higher TNM stage of PTC patients (P=0.0006). By in vitro co-culture model, we found that although all fibroblasts promoted K1/TPC1 proliferation and inhibited apoptosis, fibroblast from benign lesion inhibited tumor cell invasion. Surprisingly, while PTC derived fibroblasts all promoted invasion, NAF showed stronger effects. In a co-implantation xenograft model mixing k1 cell line with primary PTC derived CAF or NAF, we found mice bearing NAF had earlier tumorigenesis (P=0.0002) and larger tumor volume (P<0.0001) as well as higher rate of liver metastasis (27.27% vs. 16.67%) compared to CAF bearing mice. Finally, by applying cytokine antibody array for CM of both CAF and NAF, high level of IL-6, GRO, MCP-1 was observed in both CAF and NAF derived CM, with NAF even higher. For NAF, higher level of RANTES and GRO were observed.

Our findings provided evidence that fibroblasts with different derivations play different roles in mediating thyroid cancer growth and progression.

Detecting methylated DNA from peripheral blood (PB) of patients with malignant tumors have been reported for screening and prognostication of tumor. This study aimed to verify methylation status of PTEN and RASSF1A gene in peripheral blood mono-nucleated cell (PBMC) of patients with papillary thyroid carcinoma (PTC) and analyze its correlation with clinicopathologic factors.

Eighty three patients who underwent thyroidectomy due to PTC and 41 age/sex matched healthy individuals were enrolled. PB had been collected, genomic DNA was extracted from PBMC and methylation-specific polymerase chain reaction (MS-PCR) of PTEN and RASSF1A was done. The outcomes were compared with clinicopathologic factors.

Sixty patients out of 83 (72.3%) could be identified of methylation of PTEN. PTEN methylated group showed larger tumor size (p=0.030). RASSF1A methylation was identified in 80.7% (67/83) and unmethylated group was inversely correlated with LN metastasis (p=0.017). Additionally, methylated DNA was observed in PBMC from age/sex matched healthy individuals (PTEN 14.6%, RASSF1A 9.8%).

PTEN and RASSF1A could be identified from PB of both patients with thyroid cancer and healthy controls, which showed relatively high success rate. PTEN methylated group showed larger tumor size and RASSF1A methylated group showed inverse correlation with lymph node metastasis.

C-met is frequently expressed at very high levels in papillary thyroid carcinomas (PTC) and the concurrent overexpression of the downstream molecule STAT3 suggest a major functional role of HGF/c-met/STAT3 signaling pathway in PTC. STAT3 may act as a negative regulator of tumor growth in thyroid cancer. C-Met is a tyrosine kinase receptor, which is encoded by the proto-oncogene c-met. This protein stimulates cell proliferation, motility, morphogenesis, invasion and metastasis of tumor cells. The aim of this study is to evaluate STAT3 and c-Met immunostaining clinical utility as markers of thyroid nodules malignancy and prognoses.

We analyzed 119 thyroid tissues including 79 benign hyperplasic goiters and 40 thyroid carcinomas (35 papillary and 5 follicular). All patients were managed according to a same standard protocol and followed for 1–10 years (Mo=5 years). According to their serum Tg levels and image results, they were classified as no evidence-of-disease (24 cases) or persistence of disease/recurrence (14 cases). Representative areas of each primary nodule tissue were selected for construction of a tissue microarray slide that was subjected to immunohistochemistry.

Cytoplasmic expression of STAT3 occurred in all thyroid tissues, including the FC. In addition, nuclear expression was observed in 66% of the goiters and in 34% of carcinomas (p<0.0001, sensitivity 97%, specificity 87%, PPV 93%, NPV 94%), suggesting the protein exerts a tumor suppressor role. However, al FC were negative for STAT3 nuclear staining. C-Met had a cytoplasmic expression in all cancer tissues (100%), but in only 2% of the goiters (p<0.0001, sensitivity 100%, specificity 98%, PPV 97%, NPV 100%). Neither c-Met nor STAT3 were associated with any clinical or pathological characteristic of aggressiveness. These proteins were also not related to patients' outcome.

We conclude that c-Met and STAT3 can be useful in the diagnostic of malignancy in thyroid nodules but do not appear to help define thyroid tumors aggressiveness.

In Japan, the treatment for thyroid cancer without distant metastasis (DM) is thyroid lobectomy, with DM is radioactive iodine (RAI) therapy after total thyroidectomy. Cases with DM gather in the specific hospital, because RAI where can be treated is limited. We compare the prognosis of follicular thyroid cancer (FTC) with DM to that without DM.

We analyzed 19 cases with FTC from January, 2005 to December, 2012. The sex comprised 5 men and 14 women. The age was an average of 59.0 years old, median 61 years old, from 28 to 86 years old. The follow-up was from 4 to 96 months, the mean was 40.3 months, and the median was 46 months. DM (+) group was 12 cases (63.2%), and DM (−) group was 7 cases (36.8%).

DM (+) group performed total thyroidectomy in all cases, and RAI in 9 cases that overall status had good. It was 54.5% of 5-year survival rates. DM (−) group performed TSH suppressive therapy after thyroid lobectomy in all cases. It was 5-year disease-free survival rate 100%.

DM (+) group tended to have worse 5-year survival rate than DM (−) group. However, we can expect that prognosis of FTC with DM is prolonged if we provide appropriate treatment. FTC without DM is performed TSH suppressive therapy after thyroid lobectomy, and good prognosis is obtained.

The incidence of newly diagnosed thyroid cancer (TC) continues to increase. TC is the most common cancer in adolescents and young adult (AYA) females ages 15–29 and second for ages 30–39. However, little research details the unmet support needs and survivorship concerns of TC patients.

TC patients >15 years of age completed online surveys through the thyroid cancer survivor website. Patients rated the importance of receiving various medical/physical (M/Ph), practical, and emotional/psychological (E/Ps) realms of information during diagnosis and treatment, as well as their recollection of receiving such information. Comparison was made between AYAs and those ≥40 years at diagnosis.

Of 1113 respondents, most were female (88.3%), part Caucasian (92.3%), and treated in academic and private urban settings across the country with eventual total thyroidectomy (95.6%) and radioiodine (RAI) (80.4%). More than 80% of patients rated receiving information about most M/Ph matters very or extremely important and >70% felt similarly about E/Ps concerns. However, few recalled receiving any information besides that surrounding surgery or RAI. AYA respondents were more often female, non-white, Hispanic, married with children, living with a spouse/significant other, unemployed at diagnosis (all p<0.001) and reported more RAI (p=0.005). AYAs placed less importance on many M/Ph and practical matters but not E/Ps ones (Table 1). They less commonly recalled receiving information on recurrence (p=0.038), long-term side effects (p=0.024), coping strategies (p=0.049), support groups (p=0.019), opportunities for meeting other survivors (p=0.009) or help with treatment decisions (p=0.036). Additionally, AYAs reporting receiving significantly less information and care for their E/Ps concerns compared to older patients (16.1% v 22.4%, p=0.016).

Conclusion: TC patients place high importance on receiving information about most aspects of TC treatment and survivorship care. However, these information needs and survivorship concerns are largely unmet, especially among AYAs. Establishing multidisciplinary and survivorship-focused TC care may alleviate some of these unmet information and support needs.

Cowden Syndrome (CS) is a dominantly inherited tumor syndrome and is diagnosed either by the presence of germline PTEN gene mutation (mut+) or clinical criteria. Thyroid cancer (TC) has the earliest onset (at age 20–30) and 2nd highest lifetime risk (35%) of CS-associated malignancies. Because CS also includes many common benign diagnoses, it may be difficult to recognize and its prevalence underestimated. Our aim was to evaluate the prevalence of CS when screening is a routine part of initial consultation of patients with thyroid disease.

New patients without a CS diagnosis presenting to thyroid surgery clinic at a tertiary referral center were prospectively screened for CS using International Cowden Consortium (ICC) operational diagnostic criteria. Cleveland Clinic Risk Score to predict PTEN mut+status was calculated. Patients with suspicion of clinical diagnosis or ≥3% risk score were referred to genetics. CS prevalence was determined and correlated to patient's presenting thyroid diagnosis.

65 consecutive patients were screened: 2/19 (10.5%) with benign thyroid disease and 5/46 (10.8%) with TC met ICC criteria for CS diagnosis. PTEN mut+ risk score was ≥3% in 7/19 (36.8%) patients with benign disease and 11/46 (23.9%) with TC. Of 18 (28%) patients eligible for referral to genetics, 9 accepted this recommendation and 5 completed formal consultation to date. Pending test results include PTEN (n=3), BRCA (n=1) and Fragile X/array CGH/ Sotos Syndrome (n=1). Of patients meeting ICC criteria for CS, 43% had risk scores <3%. Thus, screening with risk calculator only would have missed 3 patients satisfying clinical diagnosis.

In this first prospective study of its kind, CS prevalence was 10% among patients with both benign and malignant thyroid disease. We demonstrate that CS can be successfully recognized via thorough medical history and PTEN mutation risk calculation. This screening algorithm may need refinement to address the large number of at-risk patients identified. Given high CS-related lifetime cancer risks and opportunity for cancer prevention, efforts to screen patients for CS appear feasible and advisable.

Because death is uncommon in thyroid cancer patients, the factors important in predicting survival, and especially the unique role of age in cancer prognosis, remain understudied.

To determine prognostic groups for overall survival in thyroid cancer and to assess relative effects of prognostic factors, we evaluated overall survival in 131,484 well-differentiated thyroid cancer patients who were affiliated with the National Cancer Database between 1998 and 2005. Multivariable analyses were performed using survival trees, random forest, and Cox proportional hazards regression. Patient, tumor, and treatment variables were included in the analyses.

Using survival trees, we identified five distinct prognostic groups (p<0.0001). The 5-year and 10-year overall survival of each prognostic group was as follows: 99% and 97%, 97% and 91%, 91% and 77%, 80% and 56%, and 53% and 22%. The most important factor in determining survival was age <versus ≥63 years. In patients ≥63 years, only clinical characteristics such as age, distant metastases, and lymph node involvement were important factors in defining the prognostic groups. In contrast, in patients ≤62 years, gender and insurance status also influenced the prognostic groups. Lymph node metastases only affected overall survival in patients age 50–82. With Cox proportional hazards regression, in addition to patient age being an important prognostic indicator, presence of distant metastases [adjusted hazard ratio + 95% confidence interval=3.75 (95% CI 3.45–4.06)] and Medicaid insurance [2.22 (2.00–2.46)] were also important factors in predicting death in thyroid cancer patients.

Age ≥63 is the most important prognostic indicator for thyroid cancer. The age at which lymph node involvement influences outcome, is greater than previously believed. These findings have implications for patient outcome, cancer staging, and treatment.

To evaluate the efficacy of radiofrequency ablation (RFA) in the treatment of loco-regional metastatic well-differentiated thyroid carcinoma.

Between March 2008 and October 2011, 35 metastatic thyroid carcinomas (mean diameter, 9.1 mm; range, 4.0–26.0 mm) in 32 patients (25 women, 7 men; mean age, 53.0 years) were treated with RFA. Metastatic thyroid carcinomas were detected by regular ultrasound follow-up examination and were confirmed by biopsy. Patients had fewer than three metastatic tumors (two in 3 patients; one in 29 patients) in the neck and infeasible condition to surgery. Total forty five RFA sessions (average 1.3, range 1–3) were performed. Post-RFA biopsy was performed in 21 carcinomas and 14 carcinomas did the follow-up ultrasonography. Pre- and post-RFA serum thyroglobulin value were evaluated in 26 patients.

On 21 post-RFA ultrasound-guided biopsy, 20 carcinomas were negative for malignancy and RFA session was completed. One of two carcinomas in one patient showed remaining carcinoma on post-RFA biopsy and was surgically removed. After RFA, the mean largest diameter decreased from 9.1 mm (range 4–26 mm) to 1.3 mm (range 0–15.0 mm) with overall 85.7% decrease, as did mean volume, from 394.6 mm3 (range 18.9–4792.0 mm3) to 49.8 mm3 (range 0–1099.6 mm3) with overall 88.6% decrease. At the last follow-up ultrasound examination, thirty one metastatic tumors had completely disappeared (31/33, 93.9%) and two tumors showed decreased volume (volume reduction rate, 84% and 53%) with tiny calcified nodule and hypoechoic nodule with internal hyperechoic dot, respectively. The serum thyroglobulin concentration in 19 of 26 patients showed overall 44.9% decrease (from 11.8 ng/ml to 6.5 ng/ml). Six patients had voice change immediately after RFA. Voice change was spontaneously recovered in 5 patients and was improved after vocal cord medialization in one patient.

Although surgery is the choice of treatment, RFA is minimally invasive effective modality and may have a role in treatment of loco-regional metastatic well-differentiated thyroid carcinoma in patients with infeasible condition to surgery.

Postoperative hypocalcemia is a common complication after total thyroidectomy. This study aimed to evaluate clinicopatholgic risk factors and biochemical predictors for the development of hypocalcemic symptoms according to postoperative days (POD) after total thyroidectomy.

Medical records of 988 patients who underwent total thyroidectomy from March 2008 to December 2010 were reviewed. Clinicopathologic characteristics and biochemical data were compared across symptomatic and asymptomatic patients. The optimal cut-off and associated predictive value of each biochemical parameter at each time point was evaluated using receiver operator characteristic (ROC) curves.

Hypocalcemic symptoms developed in 414 patients (41.9%). Age <45 years (p<0.0001), female gender (p<0.0001), and bilateral central compartment node dissection (p=0.031) were independent risk factors for development of hypocalcemic symptoms. Biochemical predictors of hypocalcemic symptom development with the highest positive predictive values (PPV) at each POD were intact parathyroid hormone (iPTH) <4.9 pg/mL (PPV=78.4%) on POD1, iPTH <7.6 pg/mL (PPV=79.9%) on POD2, and iPTH <7.3 pg/mL (PPV=87.2%) on POD3. Biochemical predictors of non-development of hypocalcemic symptoms with the highest negative predictive value (NPV) were iPTH >4.9 pg/mL (NPV=88.0%) on POD1, calcium >7.5 mg/dL (NPV=93.8%) on POD2, and calcium >7.5 mg/dL and phosphate <5.3 mg/dL (NPV=99.0%) on POD3.

Biochemical markers measured on POD 2 and 3 can be applied to more accurately predict hypocalcemic symptoms compared with those at 1 h postoperatively and on POD 1.

It has been reported that papillary thyroid microcarcinoma (PTM) is now the most commonly diagnosed endocrine malignancy. It has been estimated that, if approximately 10% of the population of the USA harbors this latent disease, paying just for the FNA biopsy and the thyroidectomy, presently mandated to manage this PTM ‘tsunami’, would bankrupt the American health system! The ATA and ETA Guidelines recommend thyroidectomy and lifelong thyrotropin suppression for papillary thyroid cancers (PTC) of 1 cm or less. By contrast, Ito in Japan has been willing to manage the majority of his PTM patients with observation alone. In the USA, patients with a new diagnosis of PTM are starting to question the dogma of the Guidelines and are willing to be observed or to be treated by less invasive procedures than partial or total thyroidectomy.

After more than two decades of employing ultrasound-guided percutaneous ethanol ablation (UPEA) in controlling nodal metastases in the postoperative necks of 146 personal PTC patients, we felt confident in offering UPEA of cancer foci in the intact thyroid to those patients who have decided against surgical resection of their PTMs. Here we describe our initial experience in the first three patients that we have so treated.

The first patient (M58) had bilateral foci (5 and 9 mm diameter); larger (140 mm3 volume) treated with 0.7 cc; smaller (31 mm3) with 0.65 cc. At 12 months after UPEA, neither PTM had Doppler flow and both were smaller (140 to 83 and 31 to 23 mm3). Second patient (F36) with FDG-positive 7 mm PTM received 1.25 cc, disappeared on PET at 4 months, avascular and smaller (44 to 5 mm3) at 5 months. Third patient (F53) had bilateral foci (10 and 5 mm) treated with total 2.45 cc and at 3 months avascular and smaller (250 to 21; 42 to 25 mm3).

To summarize, we have successfully treated with UPEA five foci of PTM in three intact thyroids. No patient developed a painful thyroiditis and none had hoarseness or hypocalcemia. UPEA was well tolerated as an outpatient procedure under local anesthetic and was substantially cheaper than conventional surgery. We conclude that, for PTM patients who refuse surgery, UPEA may prove to be a long-term superior alternative to observation alone.

Papillary thyroid carcinomas(PTC) less than 2 cm in size are believed to be a less aggressive subset of PTC which behave more like benign lesions and are often more conservatively treated. However, it is unclear whether carcinoma no larger than 2.0 cm in diameter can be expected to have a similar favorable clinical behavior as tumors no larger than 1.0 cm. Therefore, to address this question and to characterize the biology and optimal treatment for PTC less than 2 cm, we performed a retrospective chart review.

From October 2001 to March 2013, 670 patients underwent surgery for PTC less than 2 cm. Data from these patients were retrospectively analyzed.

The mean age of these patients was 43.2 years and 91.3% were female. 53.0% of the patients underwent a total or near-total thyroidectomy. Of the 670 patients, 204 (30.4%) had lymph node metastases. The patients present with signs of aggressiveness including multifocality (27.2%), bilaterality (19.7%), capsular invasion (44.9%). Lymph node metastases were associated with tumor size (p<0.0001), capsular invasion (p<0.0001) and bilaterality (p=0.002) but not multifocality, age and sex. With follow-up of up to 138 months, 7 patients had a local recurrence, recurrence rate was 1.0%, and no patients currently have active disease. No patients have died during this period.

In PTC less than 2 cm in size, progressively increasing frequency of signs of tumor aggressiveness including bilaterality, capsular invasion and lymph node metastasis with increasing tumor size.

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Pediatric patients diagnosed with papillary thyroid cancer (PTC) have a high incidence of regional metastasis. Total thyroidectomy (TTx) with varying extent of lymph node dissection is believed to be the best surgical approach to decrease the risk for repeat surgical procedures. Younger age and the annual volume of thyroid cancer surgeries performed are proposed to be the greatest predictors of post-operative complications, however, there are few studies that have attempted to correlate extent of disease as a potential confounding variable.

Retrospective chart review of all thyroidectomies performed at the Children's Hospital of Philadelphia between January 1, 2009, and March 1, 2013.

Over the time of review, 157 thyroid surgeries were performed on 140 subjects ≤18 years of age; median age was 15 years (IQR 13–17), 108 were females. Nodules and abnormal cervical adenopathy were noted on physical exam in 80 (76.2%) and 17 (16.2%), respectively. Pre-operative ultrasound (US) confirmed abnormal central or lateral lymph nodes in 13 (12.6%). 39 subjects underwent lobectomy and 66 TTx with or without neck dissection. Parathyroid glands were visualized and left in situ in 71 (67.6%) and auto-transplanted in 33 (31.4%) subjects. Post-operative hypocalcemia was observed in 40 (38.9%): 16 (48%) after parathyroid gland reimplantation and 14 (28%) with glands left in situ (p=0.037). Sustained hypoparathyroidism was seen in 12% of subjects with parathyroid gland reimplantation compared to 6.3% of subjects whose glands remained in situ (p=0.027). In subjects with sustained hypoparathyroidism, 13.9% underwent a TTx with central neck dissection and 36.4% had TTx with central and lateral neck dissection. Sustained hypocalcemia was significantly associated with central (N1a) and lateral (N1b) neck metastasis confirmed on final pathology (p=0.025).

The extent of lymphatic involvement and method of parathyroid gland management are strongly associated with post-operative hypoparathyroidism in children with PTC undergoing thyroidectomy.

The vessel-sealing (VS) instruments have been shown to decrease operative time (OT) compared to knot-tying in thyroid surgery. The first generation VS instrument (Ethicon CS-14), a shortened version of a laparoscopic instrument designed for vessel ligation with limited dissecting abilities. The second generation instrument (Ethicon Harmonic Focus), designed to mimic a Kelly clamp with both dissecting and ligating functionality. The impact of this new technology on operative efficiency, in particular surgeon to surgeon variability, has not been studied in the literature.

Between 2000–2011, 839 patients underwent total thyroidectomy without nodal dissection by 3 endocrine surgeons at a tertiary medical center. The procedures were done using a first-generation VS device in 53% and a second-generation in 47%. Clinical parameters and VS device (CS-14 versus Focus) were prospectively collected and analyzed using Student's t, Chi-square, univariate and multivariate analyses. Data are expressed as mean±SEM.

There were 675 women and 164 men. The overall OT was 143±1 mins, and incision size 4.8±0.1 cm. The strongest independent predictor of decreased OT was the use of the second-generation VS device that reduced OT for surgeon 1 from 126 to 111 (15 mins less), for surgeon 2 from 169 to 146 (23 mins less), for surgeon 3 from 179 to 153 minutes (26 mins less), p<0.001. In addition to the surgeon (Hazard Ratio: 9.2) and device model (HR: 7.9), other independent predictors of longer OT were younger age (HR: 3.9 min/year), male sex (HR: 6.1), increasing BMI (HR: 3.9 min/kg/m2), increasing specimen weight (HR: 4.1 min/gr), increasing specimen size (HR: 2.3 min/cm), and thyroiditis vs cancer or multi-nodular goiter (HR: 2.2), p<0.05 in univariate analyses. The presence of a resident vs fellow did not affect OT (p=0.119).

The VS device type, surgeon, and specimen weight were most consistent predictors of OT for total thyroidectomy. The results show that all 3 surgeons demonstrated improved operative times using the second-generation VS devices. We feel that, this effect is not due to faster VS times per se, but to improved ergonomics of the devices with grater use as a dissector and fewer instrument exchanges.

BRAF^V600E mutation is the most common genetic alteration in papillary thyroid carcinoma (PTC). Some studies showed that Hashimoto's thyroiditis (HT) was associated with a higher risk of PTC and coexistence of HT was associated with better prognosis. This study was to determine a correlation between BRAF^V600E and presence of HT in patients with PTC and their association with other clinicopathological factors.

We enrolled 399 patients with classical PTC who evaluated BRAF^V600E status by using direct-sequencing. HT was defined as pathologically proven lymphocytic thyroiditis and/or positive serum anti-thyroperoxidase antibody.

Total 122 patients (28%) had PTC with coexistent HT. Coexistence of HT was significantly associated with female gender (p=0.04), younger age (p=0.05), and multifocal PTC (p=0.02). BRAF^V600E mutation was confirmed in 248 patients (62%). There was a significant correlation between with BRAF^V600E status and HT (p=0.004). BRAF^V600E was less common in PTC with coexistent HT (51%) as compared to PTC without HT (67%). PTC with BRAF^V600E mutation was significantly associated with more extrathyroidal invasion only (p=0.02). There was no significant difference in clinicopathologic parameters according to the coexistence of HT in patients with BRAF^V600E mutated PTC.

In this study, we found that BRAF^V600E mutation is less frequent in PTC with coexistent HT as compared to PTC without HT.

Black thyroid pigmentation is a rare entity. Previous small series suggest an association between black thyroid and thyroid cancer. The aim of this study was to examine this correlation.

A retrospective medical chart review was performed on 924 patients who underwent thyroid surgery at an academic university hospital.

Among 924 patients, 722 (78%) were female, and 202 (22%) were male, 403 (43.6%) were white, and 379 (41%) were African American. Black thyroid was diagnosed in 112 (12.1%) patients. The mean age for patients with black thyroid was 54.3±12.8 versus 51.2±15.7 for patients with non-black thyroid (P=0.05). Incidence of malignancy in black thyroid and non-black thyroid was 55.4% (62/112) and 32.8% (378/812) respectively; p<0.0001). In addition, incidence of papillary thyroid cancer among the black and non-black thyroid was 34.8% (39/112) and 20% (162/812) respectively; p<0.001. Black thyroid was also associated with a higher incidence of micro-carcinoma (76% vs. 59%, p=0.02). Incidence of multi-focal papillary carcinoma in black and non-black thyroid was 39% and 49% respectively (p=0.3).

The current study suggests that the incidence of malignancy is higher in black thyroid compared to non-black thyroid glands. This high risk warrants thorough pathological examination and prophylactic removal of incidentally found black thyroids.

Tyrosine kinase inhibitors (TKIs) represent an important therapeutic option for patients with metastatic cancer. Most TKI's inhibit angiogenesis via targeting of the tyrosine kinase domain of the vascular endothelial growth factor receptor (VEGF-R). Inhibition of VEGFR mediated signaling can lead to vascular endothelial cell apoptosis, inhibition of new vessel formation and vasoconstriction. The VEGF signaling pathway however, is a key mediator of angiogenesis in the proliferative phase of wound healing. In preclinical studies, VEGFR targeted therapies have been shown to impair wound healing, but the clinical relevance of this finding is unclear. Thus, how to approach wound healing in patients on TKIs is unclear.

We report 2 patients with progressive, end stage papillary thyroid carcinoma and wounds, who continued on a single investigational TKI.

Case #1: A 64 year-old Japanese-American male initiated TKI 12 days after surgical excision of a 3 cm subcutaneous abdominal wall metastasis. Thirty five days after surgery, the surgical wound dehisced resulting in a 3.3×5×1.5 cm wound, extending through the dermis and subcutaneous tissue with extensive undermining along the margin. Given the advanced stage of his disease and limited alternative options, TKI was continued. The wound was treated with calcium alginate and negative pressure therapy. The wound fully healed after 7 months.

Case #2: A 71 year-old Hispanic diabetic female on TKI therapy for 10 months developed a 1.5×1×0.2 cm open wound on her left shin resulting from cat scratches. She was treated with antibiotics, debridement and monitored by a wound specialist. Her wound healed completely over a 2 year period. During this 2 year period, brief interruptions and dose adjustments of therapy were necessary for unrelated side effects.

Two patients exhibited successful wound healing while continuing on TKI therapy. While caution must be exhibited, all wounds may not represent an absolute contraindication to TKI therapy. Continuation of TKI therapy and aggressive wound therapy supervised by a wound care specialist may be an option. Since both patients were treated with a single investigational TKI, these results may not be generalizable to the TKI class of drugs.

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