Evidence from autoimmune thyroiditis of skewed X-chromosome inactivation in female predisposition to autoimmunity

The etiologic factors in the development of autoimmune thyroid diseases (AITDs) are not fully understood. We investigated the role of skewed X-chromosome inactivation (XCI) mosaicism in female predisposition to AITDs. One hundred and ten female AITDs patients (81 Hashimoto's thyroiditis (HT), 29 Graves' disease (GD)), and 160 female controls were analyzed for the androgen receptor locus by the HpaII/polymerase chain reaction assay to assess XCI patterns in DNA extracted from peripheral blood cells. In addition, thyroid biopsy, buccal mucosa, and hair follicle specimens were obtained from five patients whose blood revealed an extremely skewed pattern of XCI, and the analysis was repeated. Skewed XCI was observed in DNA from peripheral blood cells in 28 of 83 informative patients (34%) as compared with 10 of 124 informative controls (8%, P<0.0001). Extreme skewing was present in 16 patients (19%), but only in three controls (2.4%, P<0.0001). The buccal mucosa, and although less marked, the thyroid specimens also showed skewing. Analysis of two familial cases showed that only the affected individuals demonstrate skewed XCI patterns. Based on these results, skewed XCI mosaicism may play a significant role in the pathogenesis of AITDs.

Skeletal muscle disorders associated with inflammatory bowel diseases: occurrence of myositis in a patient with ulcerative colitis and Hashimoto's thyroiditis--case report and review of the literature

Ulcerative colitis (UC) and Crohn's disease are inflammatory bowel diseases often associated with extra-intestinal manifestations. Of these, neutrophilic dermatoses and arthropathies are the more frequently observed, while the occurrence of striated muscle disorders, namely, myositis, has been very rarely diagnosed in these kinds of patients. The coexistence of immuno-mediated diseases in patients with inflammatory bowel diseases and myositis suggests a common aetiopathogenetic mechanism underlying these conditions. The present report refers to a rare case of a 51-year-old female with UC and Hashimoto's thyroiditis who developed myositis.

Flow cytometry phenotypization of thyroidal lymphoid infiltrate and functional status in Hashimoto's thyroiditis

OBJECTIVE

To evaluate the thyroidal lymphoid infiltrate (TLI) in thyroidal functional status (TFS) for differences among patients with Hashimoto's thyroiditis (HT).

STUDY DESIGN

Flow-cytometry (FC) was applied to thyroidal fine-needle cytology samples in 57 patients. TLI was analyzed using a fluorescence-activated cell sorter (FACS) scan and fluorescence antibodies CD3, CD4, CD5, CD8, CD10, and CD19 and kappa and lambda light chains. TFS was determined by serum thyroid-stimulating hormone (TSH), FT3 and FT4 immunoassays, in specific clinical settings, to classify the cases as hyperthyroid, euthyroid and hypothyroid. FC assessment was then compared with the corresponding TFS.

RESULTS

B-lymphocytes were present in 44 cases (77%). T-lymphocytes were present in all the cases; CD4/CD8 = 2:1 ratio was observed in 16 euthyroid, 1 hyperthyroid and 3 hypothyroid; CD4/CD8 > or = 3:1 ratio in 22 euthyroid, 2 hyperthyroid and 2 hypothyroid cases; CD4/CD8 < or = 1:1 ratio in 1 euthyroid, 3 hyperthyroid and in 7 hypothyroid cases. Grouping hyperthyroid and hypothyroid cases, a significant association was observed with the CD4/CD8 < or = 1:1 ratio (p < 0.01).

CONCLUSION

Intrathyroidal CD4/CD8 < 1:1 ratio might be the expression of intense apoptosis in the early phases of HT, generally followed by the restoration of CD4/CD8 balance; persistence of increased intrathyroidal CD8 might be related to intense thyroidal damage and thus an increasing risk of hypothyroidism.

Ectopic lingual thyroid tissue and acquired hypothyroidism: case report

Ectopic thyroid tissue with thyroid gland in its normal location is an extremely rare phenomenon. We present a case of a 38-year-old woman who was referred to our hospital with symptoms of hypothyroidism. Thyroid hormone measurement revealed clinical hypothyroidism with elevated anti-thyroid antibodies, neck ultrasonography showed a small tissue with the characteristic of Hashimoto thyroiditis, while the scintigraphy demonstrated only a lingual thyroid. Treatment consisted in L-thyroxine replacement to the euthyroid state. We reviewed the literature with respect to the embryological background and the clinical management of such cases.

Ductal Metaplasia in Chronic Lymphocytic Thyroiditis as a Manifestation of Phylogenic Regression to an Exocrine Structure

From a morphologic and functional point of view the thyroid can be considered as both an exocrine and endocrine organ. Firstly, thyroglobulin is secreted at the apical pole of the thyrocyte. Secondly, after endocytosis thyroglobulin is lysed and T3 and T4 are secreted at the basal pole into the bloodstream. However, usually exocrine glands are constituted of 2 well separate components: an acinus/alveolar component and an exocrine duct component. Under particular conditions such as chronic injury the acinus/alveolar component is rapidly destroyed, whereas the ductal component seems to be far more resistant and can proliferate giving rise to a tubular network described as "ductulus reaction" or "ductal metaplasia." Normal exocrine ducts and metaplastic ducts exhibit common genetic and phenotypic features directly related to their tubular morphology. In this study, we describe in lymphocytic autoimmune thyroiditis the appearance of ductal-like structures which displayed the features of ductal metaplasia.

RET/papillary thyroid cancer rearrangement in nonneoplastic thyrocytes: follicular cells of Hashimoto's thyroiditis share low-level recombination events with a subset of papillary carcinoma

CONTEXT

RET/papillary thyroid cancer (PTC) is a marker for papillary thyroid carcinoma, but its specificity has been questioned because of the disputed identification of RET/PTC in Hashimoto's thyroiditis (HT), oncocytic tumors, and other thyroid lesions.

OBJECTIVE

The objective of this study was to determine 1) whether RET/PTC occurs in nonneoplastic follicular cells of HT, and 2) its recombination rate in thyroid tumors.

DESIGN/PATIENTS

Forty-three samples from 31 cases of HT were examined using interphase fluorescence in situ hybridization (FISH) with RET probes spanning the breakpoint region; real-time RT-PCR to quantify RET/PTC1, RET/PTC3, and c-RET transcripts; and RT-PCR after laser capture microdissection to enrich samples for follicular cells. The results were compared with those similarly obtained in 34 papillary carcinomas, eight thyroid oncocytic tumors, and 21 normal thyroids.

RESULTS

Normal samples showed no RET rearrangement. Sixty-eight percent (15 of 22) of HT were positive by FISH; in all thyroiditis, signals were localized to rare nonneoplastic follicular cells; low-level RET/PTC was identified in 17% (five of 29) of thyroiditis cases by real-time RT-PCR and in an additional six of 11 real-time negative cases after increasing sensitivity with laser capture microdissection. Low RET/PTC1 levels were detected in 26% (nine of 34) of papillary carcinomas with an expression pattern and proportion of FISH-positive cells similar to those of the thyroiditis. Forty-seven percent (16 of 34) of papillary carcinomas and one oncocytic carcinoma expressed high RET/PTC1 mRNA levels.

CONCLUSIONS

Low-level RET/PTC recombination occurs in nonneoplastic follicular cells in HT and in a subset of papillary thyroid carcinomas. RET/PTC expression variability should be taken into account for the molecular diagnosis of thyroid lesions. Overlapping molecular mechanisms may govern early stages of tumor development and inflammation in the thyroid.

Comparative Study of Angiogenesis in Thyroid Glands With Graves Disease and Hashimoto's Thyroiditis

Angiogenesis entails the sprouting of new vessels from pre-existing vasculature. In adults, angiogenesis occurs in the thyroid gland during disease processes such as hyperplastic goiter, Graves disease, thyroiditis, and cancer. In the present study multiple morphologic characteristics of microvessels were measured in and compared between 18 cases of Graves disease, 29 cases of Hashimoto's thyroiditis, and 15 control cases. All histologic sections were immunostained for CD31. Quantification of microvessel density (MVD), major axis length, minor axis length, area, perimeter and shape factor was performed by image analysis. MVD was increased significantly in both forms of autoimmune thyroid disease. Significantly higher values were found in Graves disease in comparison to Hashimoto's thyroiditis. In contrast, major axis length, minor axis length, and area had significantly higher values in Hashimoto's thyroiditis than in Graves disease. The statistical analysis revealed MVD as the unique significant morphometric factor discriminating the two autoimmune entities.

A diagnostic pitfall: Nodular tumor-like squamous metaplasia with Hashimoto's thyroiditis mimicking a sclerosing mucoepidermoid carcinoma with eosinophilia

Nodular tumor-like squamous metaplasia with Hashimoto's thyroiditis is an exceptional, benign condition presenting diagnostic difficulties for the pathologist. The main differential diagnosis is a sclerosing mucoepidermoid carcinoma (SMC) with eosinophilia. One case arising in a 50-year-old Caucasian man is reported. Histologically, the nodule consisted of large nests of squamous cells surrounded by connective tissue in Hashimoto's thyroiditis. We present the different histological criteria, allowing us to eliminate an SMC and other neoplastic tumors of the thyroid. The etiology of this tumor-like lesion, which is still under debate, is discussed.

Immunoexpression of the CD30 ligand/CD30 and IL-6/IL-6R signals in thyroid autoimmune diseases

To elucidate the role of Th2 cytokines in autoimmune thyroid diseases, we have studied by immunohistochemistry the expression of two Th2 ligand/receptor systems (CD30-L/CD30 and IL-6/IL-6R) in goitrous Graves' disease (GD) and Hashimoto's thyroiditis (HT). A total number of 50 nodular goiters (NG), including 10 GD showing a lymphoid aggregate grade I, 30 HT 8 of which had a lymphoid aggregate of grade I, 12 of grade II and 10 grade III, and 10 colloid goiters have been evaluated. In addition, 5 normal thyroids were included in the study as controls. Reactivity of ligand and cognate receptor of both CD30-L/CD30 and IL-6/IL-6R pathways was observed in a greater proportion of GD, compared to HT (P<0.005). In HT, the expression of CD30-L/CD30 system was detected more frequently than IL-6/IL-6R (P<0.05) and showed an inverse correlation with the grade of lymphoid aggregate, whereas IL-6/IL-6R correlated positively with lymphocyte infiltration (P<0.05). Based on our results concerning a dominance of Th2 cytokines in GD, we postulate that CD30-L/CD30 and IL-6/IL-6R systems could play a major role in the pathogenesis of GD. However, the expression of CD30L/CD30 and IL-6/IL-6R in HT suggests that Th2 mechanisms are involved also in tissue damage of HT. The two systems could contribute to drive the autoimmune response skewing toward a Th2 phenotype and this appears to be correlated with the lymphoid aggregate grade.

A case of multifocal fibrosclerosis with intracardiac solid masses

We report an extremely rare case of multifocal fibrosclerosis (MFS) with intracardiac solid masses. A 70-year-old woman with Hashimoto's disease had pericardial thickening and intracardiac masses. Histology of pericardiectomy showed only fibrosis. The clinical diagnosis was constrictive pericarditis. She died of postoperative infectious mediastinitis and cerebral infarction. Postmortem examination revealed intracardiac solid masses contiguous to thickened pericardium. Multifocal areas of fibrosis were also seen in the pericardium, mediastinum, abdominal cavity, and the retroperitoneum. The intracardiac masses and the areas of fibrosis were composed of collagenous fibers with various intensities of inflammatory infiltrates and sclerotic changes. Neoplastic changes were not observed. These histological features were similar to that of MFS. The intracardiac masses are interpreted as one of the manifestations of MFS. This is the first case of MFS accompanied with intracardiac solid masses.

Association between breast cancer and autoimmune thyroid disorders: no increase of lymphocytic infiltrates in breast malignant tissues

An association between thyroid autoimmunity and breast cancer (BC) has been consistently reported, but the cause of this association is still unknown. The role of lymphocytic infiltration (LI) in breast tumorigenesis is controversial and several data suggest that in BC an increase of lymphoid cell infiltrates or a dysfunctional local immune response may be detected very early during tumor development. Chronic autoimmune thyroiditis is characterized by different degrees of LI in thyroid gland and BC cells share some antigenic properties similar to those detected in thyroid tissue, such as sodium iodide symporter (NIS) and peroxidase activity. The aim of this study was to evaluate the frequency and amount of LI in malignant and in normal peritumoral breast tissues, as expression of autoimmune morphological changes, in a group of BC patients with thyroid autoimmunity. We suppose that an increased LI in breast tissues of this group of patients may help explain the association between BC and thyroid autoimmunity. The study group included 26 BC patients with thyroperoxidase antibodies positivity (TPOAb+), 14 of them (53.8%) with Hashimoto's thyroiditis (HT), and 30 BC patients with no evidence of thyroid autoimmune disorders. Malignant and surrounding normal breast tissues were assessed for LI. The amount of LI was scored as very scanty or scanty (LI S) and moderate or marked (LI M), independently by two expert pathologists. LI S was detected in 19/26 (73.1%) BC tissues from patients with TPOAb positivity and LI M in 7 (26.9%). All BC patients with HT had LI S. LI S was detected in 25/30 (83%) and LI M in 5/30 (17%) of BC tissue from patients with no thyroid autoimmunity. The difference in the amount of LI of BC tissues in patient with or without autoimmune thyroid disorders was not significant. The LI was generally absent or very scanty in remote breast tissue in all cases. In conclusion, in breast malignancies the presence of humoral and/or clinical evidence of thyroid autoimmunity is not associated to autoimmune morphological changes of cancer and peritumoral normal tissue. The LI does not seem to have any role in tumorigenesis in patients with BC and thyroid autoimmunity.

Massive squamous metaplasia of the thyroid gland – Report of three cases

Three cases of massive squamous cell metaplasia in Hashimoto's thyroiditis are reported. The patients were two men and one woman aged 24, 52, and 55 years, respectively. In all three patients, the glandular parenchyma was replaced by hypocellular fibrous tissue with scattered chronic inflammatory infiltrate. Follicular cells were almost absent; the majority of residual epithelial cells formed squamous nests that were partly solid and partly cystic. There were three types of epithelial cells - squamous, basaloid, and follicular, with oncocytic differentiation. The squamous and basaloid cells showed strong positivity high molecular weight (HMW) cytokeratin, moderate to strong expression of galectin-3 (2/3), and nuclear expression of p63 protein (2/3). The staining pattern of p63 was identical to that of HMW, with predominant positivity at the periphery of cell nests. In one case, weak but unequivocal positivity of thyroid transcription factor-1 also was present. We believe that metaplasia was caused by Hashimoto's thyroiditis. The cases presented here are extremely rare, and only two convincing similar cases have been reported in the English literature so far. They may represent a diagnostic pitfall and should not be misdiagnosed as a malignancy, in particular as squamous cell or mucoepidermoid carcinoma.

Restricted kappa/lambda light chain ratio by flow cytometry in germinal center B cells in Hashimoto thyroiditis

To determine the diagnostic significance of the kappa/lambda ratio in germinal center (GC) B cells in Hashimoto thyroiditis (HT), we used 4-color flow cytometry to immunophenotype 27 samples (21 patients) of well-characterized HT B-cell clonality was analyzed further by polymerase chain reaction (PCR) of the immunoglobulin heavy chain (IgH) and bcl-2/IgH fusion genes using DNA extracted from aspirate smears and/or paraffin-embedded tissues. By flow cytometric analysis, the CD10+ GC B cells had a higher mean +/- SD kappa/lambda ratio than the CD10- B cells (5.1 +/- 3.3 vs 2.0 +/- 0.8; P < .0001, Student t test). In 18 samples (67%), CD10+ GC B cells had a kappa/lambda ratio greater than 3.07 (the upper limit of kappa/lambda ratio reported in reactive nodes; range, 3.2-14.4 in the 18 cases). Cases tested by PCR showed no evidence of a clonal proliferation. None of 21 cases developed lymphoma during clinical follow-up of up to 3 years. The kappa/lambda ratio of CD10+ GC B cells in HT can be skewed markedly beyond that reported in reactive lymph nodes. This finding frequently is present in HT. Pathologists should be familiar with this phenomenon to prevent misdiagnosis of follicular lymphoma in patients with HT.

[On the mechanisms of thyrocyte proliferation and death in autoimmune thyroid diseases]

Lymphocytes isolated from diffuse toxic goiter (Graves' disease, GD) stimulate the proliferation of "normal" thyrocytes (isolated from euthyroid goiter) in primary culture, and give them the properties of GD-thyrocytes (loss of sensitivity to the growth-promoting factors of FCS and lesser capacity of binding antibodies from GD patients' serum). The complement-free sera of GD patients (but not the sera of patients with Hashimoto's thyroiditis, HT) induce the death of "normal" thyrocytes more rarely than full-complement sera do. Both types of serum cytotoxicity are manifested on GD-thyrocytes much more rarely than on "normal" cells. The Fas-receptor on GD-thyrocytes in situ is expressed less than on "normal" and especially on HT-cells. The level of soluble Fas-ligand in the serum of some complement-free patients was found to be increased. These sera induce apoptosis in "normal" thyrocytes, but not in GD-cells nor in human skin fibroblasts. In the authors' opinion, the proliferation of GD-thyrocytes in situ is stimulated by intrathyroid lymphocytes, which directly stimulate this process and induce the loss of receptors which mediate the cytotoxic effects of serum factors.

[The frequency of CTLA-4 gene polymorphism at position 49 exon 1 in children with Hashimoto's thyroiditis]

INTRODUCTION

The cytotoxic T lymphocyte antigen-4 (CTLA-4) is a molecule present on T cells that plays a critical role in the down regulation of antigen-activated immune responses. Its gene polymorphism is a strong candidate gene for conferring susceptibility to thyroid autoimmunity. THE AIM of the study was to analyse the frequency of CTLA-4 exon 1 polymorphism (A49G) in children with Hashimoto's thyroiditis.

MATERIAL AND METHODS

Blood samples from 68 children were analysed: 30 with Hashimoto's thyroiditis and 38 healthy, age-matched controls, mean age: 13.6 years. CTLA-4 exon 1 polymorphism (A49G) was defined by the PCR method and single-strand conformational polymorphism analysis and confirmed by using BbvI enzyme. Statistical analysis was performed using the t- test and Chi-square test.

RESULTS

Polymorphism analysis showed that statistically significant more patients with Hashimoto's thyroiditis were homozygous for G (Ala), and G allele frequency was significant higher than in the control group.

CONCLUSION

The results confirmed the association between CTLA-4 exon 1 polymorphism (A49G) and Hashimoto's thyroiditis in polish children.

BRAF mutation is unusual in chronic lymphocytic thyroiditis-associated papillary thyroid carcinomas and absent in non-neoplastic nuclear atypia of thyroiditis

Chronic lymphocytic thyroiditis (CLT) has an epidemiological relationship to papillary thyroid carcinoma (PTC). The follicular epithelium in CLT can be markedly atypical, with cytologic changes ranging from oncocytic morphology to clearing and overlapping. At the molecular level, the association between CLT and PTC is more controversial. In order to further characterize the molecular changes in CLT, this study examined the BRAF gene in 27 patient samples with CLT and without carcinoma and 28 samples with CLT and carcinoma (12 conventional papillary carcinomas, 13 follicular variants, and 3 tall cell variants). Microdissection, PCR, and sequencing of exon 15 of the BRAF gene were performed. BRAF mutations were uncommon in the cases studied with only two microscopic and two clinically sized PTCs had BRAF mutations (14%). There was no evidence of BRAF mutation in any of the areas with atypical follicular epithelium in CLT. These data suggest that BRAF is a less frequent mechanism of tumorigenesis in a background of CLT and that BRAF mutation is not present in the atypical follicular epithelium of CLT.

Role of FNA in the medical management of minimally enlarged thyroid

Fine-needle aspiration (FNA) of thyroid is a cost-effective and simple diagnostic tool in the initial screening of patients with thyroid nodules. But, its role in a clinically normal thyroid or a minimally enlarged thyroid in a symptomatic patient suspected of having thyroid dysfunction is unknown. With our 2-yr experience in a setup of a tertiary health care hospital in a developing country, we have aimed to implement a management protocol using FNA thyroid done without ultrasound guidance and TSH estimation done during the same visit in symptomatic patients suspected of having thyroid pathology but presenting with no goiter or having minimally enlarged thyroid with no palpable nodules. The thyroid enlargement in 172 cases were graded with the criteria endorsed by WHO, Pan American Health Organization, and International Council for Control of Iodine Deficiency Disorders into grade 0, 1, and 2. The cases were evaluated cytologically and correlated with TSH values according to the algorithm formulated by the authors. FNA was diagnostic in 86.6, 98, and 100% in grade 0, 1, and 2 goiters, respectively. 52.3% (n = 90), 19.8% (n = 34), 16.9% (n = 29) of cases were diagnosed as Hashimoto's thyroiditis (HT), colloid goiter (CG), and lymphocytic thyroiditis (LT). Sixteen had a combination of LT and CG (n = 6), HT and CG (n = 6), papillary carcinoma (n = 2), and diffuse hyperplasia (n = 2). No statistically significant difference (P = 0.4586) was noted between the groups of patients with grade 0 and grade 1-2 goiter, who underwent FNAC. 38.95% of patients (n = 67) with TSH values greater than 10 microIU/ml and considered hypothyroid showed features of HT/LT at FNA. 23.83% (n = 41) having TSH values between 5 and 10 microIU/ml (subclinical hypothyroidism) also showed features of HT/LT at FNA. Both groups were treated with thyroxine. 35.46% (n = 61) of cases with TSH values within normal range (0.5-5.1 microIU/ml) and considered euthyroid showed a spectrum of lesions at cytology other than HT and LT. They are being followed up to detect them at an early stage of subclinical hypothyroidism. Only 13 cases (7.5%) who were serologically euthyroid showed HT/LT and are being followed-up. Thus, the authors advocate FNA of the thyroid as a single simple cost-effective office procedure in the medical management of all nonpalpable/minimally enlarged thyroid in patients suspected of having thyroid pathology and/or in combination with TSH values. FNA helps in early detection of subclinical hypothyroidism, which is of utmost importance in pregnant women and further makes possible availability of baseline values for future reference. With the implementation of this protocol of FNA thyroid without imaging, we affirm that the practice of cytology which differs in different geographic areas and from country to country depending on economy and availability of infrastructure can be made more user-friendly.

Use of a thin-layer technique in thyroid fine needle aspiration

OBJECTIVE

To investigate the efficacy of the ThinPrep Processor (Cytyc Corporation, Boxborough, Massachusetts, U.S.A) in fine needle aspiration (FNA) of thyroid gland lesions.

STUDY DESIGN

This study included 459 thyroid FNA specimens obtained from patients who came to our endocrinology department with various thyroid disorders over 3 years. The cytologic material was prepared using both the conventional and ThinPrep method in the first 2 years (285 cases), while in the last one only the ThinPrep method was used (1 74 cases). The smears were stained using a modified Papanicolaou procedure and May-Grünwald-Giemsa stain. Immunocytochemistry was performed on thin-layer slides using specific monoclonal antibodies when needed. Thin-layer and direct smear diagnoses were compared with the final cytologic or histologic diagnoses, when available.

RESULTS

Our cases included 279 adenomatoid nodules, 15 cases of Hashimoto thyroiditis, 45 follicular neoplasms, 14 Hürthle cell tumors, 58 papillary carcinomas and 1 5 anaplastic carcinomas. Thin-layer preparations showed a trend toward a lower proportion of inadequate specimens and a lower false negative rate. Cytomorphologic features showed some differences between the 2 methods. Colloid was less frequently observed on ThinPrep slides, while nuclear detail and micronucleoli were more easily detected with this technique. Moreover, ThinPrep appeared to be the appropriate method for the use of ancillary techniques in suspicious cases.

CONCLUSION

Thin-layer cytology improves the diagnostic accuracy of thyroid FNA and offers the possibility of performing new techniques, such as immunocytochemistry, on the same sample in order to detect malignancy as well as the type and origin of thyroid gland neoplasms.

[The surface CD152 (CTLA-4) expression on peripheral blood lymphocytes in children with Hashimoto's thyroiditis]

INTRODUCTION

The cytotoxic T lymphocyte-associated antigen-4 (CTLA-4) is a transmembrane molecule present on T cells that plays a critical role in the down regulation of antigen-activated immune response. Its gene polymorphism is a strong candidate gene for conferring susceptibility to thyroid autoimmunity. THE AIM of the study was to analyse the surface CTLA-4 (CD 152) expression on peripheral blood lymphocytes.

MATERIAL AND METHODS

Blood samples from 66 children were analysed: 36 with Hashimoto's thyroiditis and 30 healthy, age-matched controls, mean age: 13.4 years. The percentages of peripheral blood lymphocyte subsets were analysed by evaluation of CD antigens surface expression with three colour flow cytometry using Coulter EPICS XL cytometer. CD28, CD152, CD4, CD8 antigens were evaluated. Statistical analysis was performed using t- test and other tests of the Statistica programme. P-value <0.05 was considered as statistically significant.

RESULTS

In children with Hashimoto's thyroiditis the surface expression of CD8(+) CD152(+) T cells was statistically significant lower than in healthy controls. P-value was 0,02. Percentage of other CD examined in the study did not differ significantly in patients and in the control group.

CONCLUSION

In children with Hashimoto's thyroiditis the surface expression of CTLA-4 (CD152) on peripheral blood lymphocytes CD8(+) was statistically significantly lower than in healthy controls.

Graves' disease and Hashimoto's thyroiditis in monozygotic twins: case study as well as transcriptomic and immunohistological analysis of thyroid tissues

OBJECTIVE

To report on the rare simultaneous occurrence of Graves' disease (GD) and Hashimoto's thyroiditis (HT) in monozygotic twins.

DESIGN

We compared the pattern of thyroid tissue-derived cDNAs to gain insight into previous and ongoing immune destruction and reconstruction processes using microarrays. The results were confirmed by immunohistology and real-time PCR.

RESULTS

Destruction of thyroid tissue in HT reduced levels of thyrocyte-related cDNAs and cDNAs encoding extracellular matrix components, but increased levels of proteases involved in extracellular matrix degradation compared with GD. Lymphocytic infiltrates forming ectopic follicles replaced the thyroid tissue almost completely in HT. Thus, lymphocyte-related cDNA levels were higher in HT than in GD. The same was true for many chemokines and their receptors, which not only enable migration towards the thyroid but also maintain the lymphocytic infiltrate. HT also showed increased levels of cDNAs encoding molecules related to apoptosis than did GD. Surprisingly, the Th1- and Th2-specific cytokine profiles suggested for HT and GD respectively could not be confirmed. cDNAs encoding factors and receptors involved in angiogenesis were increased in GD compared with HT.

CONCLUSIONS

Comparison of gene expression reflects the cellular differences between the two types of autoimmune thyroid disease in twins with identical genetic and similar environmental background.

Risk Factors for the Development of Hypothyroidism After Hemithyroidectomy

OBJECTIVES

To assess the incidence of hypothyroidism after hemithyroidectomy and to identify risk factors for the development of hypothyroidism.

DESIGN

Retrospective analysis.

SETTING

A tertiary care academic medical center.

PATIENTS

The study included 90 patients who underwent a hemithyroidectomy from 1999 to 2004.

MAIN OUTCOME MEASURES

Hypothyroidism was defined as a serum thyrotropin level greater than 6.0 mIU/L at least 8 weeks after hemithyroidectomy. All patients were analyzed for age, sex, surgical indications, preoperative and postoperative thyrotropin levels, weight of resected specimen, final pathologic analysis, and length of follow-up. Multivariate analysis was performed to identify multiple risk factors for the development of hypothyroidism.

RESULTS

The final pathologic analysis demonstrated 49 follicular adenomas, 17 cases of Hashimoto thyroiditis, 10 multinodular goiters, and 14 other abnormalities. The overall incidence of the development of hypothyroidism after hemithyroidectomy was 27% (24 of 90 patients). When the groups were broken down by pathologic diagnosis, the incidence of hypothyroidism developing during follow-up among the Hashimoto thyroiditis and multinodular goiter groups was 59% and 50%, respectively. Also, the patients who developed hypothyroidism were noted to have statistically significant higher preoperative serum thyrotropin levels (3.15 mIU/L vs 1.95 mIU/L; P<.001) than those who remained euthyroid. There was no relationship between age, sex, or weight of the resected tissue and the subsequent risk of hypothyroidism.

CONCLUSIONS

The overall incidence of posthemithyroidectomy hypothyroidism was 27%, and the majority of cases developed in the first 6 to 12 months after surgery. Risk factors for the development of hypothyroidism include pathologic diagnosis (Hashimoto thyroiditis and multinodular goiter) as well as a high-normal serum thyrotropin level. Routine monitoring of serum thyrotropin levels should be performed in all patients who undergo a hemithyroidectomy.

Maltoma of the thyroid and Sjögren's syndrome in a woman with Hashimoto's thyroiditis

We report the case of a 70-yr-old woman with maltoma of the thyroid, Sjögren's syndrome, and a history of Hashimoto's thyroiditis. The patient underwent a total thyroidectomy for a recently growing mass of the thyroid, while being treated with L-thyroxine for Hashimoto's thyroiditis. Postoperatively, routine histologic examination was consistent with the diagnosis of chronic lymphocytic thyroiditis of autoimmune etiology. Three years later, the patient presented with high temperature, anorexia, and coughing. This time, a microscopic examination of deeper thyroid tissue sections and an immunohistochemical study revealed a low-grade, non-Hodgkin lymphoma, MALT type. Simultaneously, the diagnosis of Sjögren's syndrome was established and the patient is currently under investigation for generalized lymphoma. This case clearly demonstrates the difficulty in differentially diagnosing Hashimoto's thyroiditis from low-grade MALT lymphoma by the use of routine histologic examination.

Specimen adequacy and diagnostic specificity of ultrasound-guided fine needle aspirations of nonpalpable thyroid nodules

Ultrasound-guided fine needle aspiration (USG-FNA) is a safe, effective, and dependable test used to assess thyroid nodules. However, the size of the lesion can adversely affect the outcome of the procedure. The aim of this study was to assess specimen adequacy and diagnostic specificity in USG-FNA of thyroid nodules measuring < or = 1.5 cm. A total of 219 thyroid FNAs were performed in a one year; 26 were obtained by pathologists, 139 by clinicians, and 54 by radiologists under ultrasound guidance. Of the 54 ultrasound-guided aspirates, 19 cases (35%) were performed on nodules < or = 1.5 cm (range 0.8-1.5 cm, mean 1.3 cm). Cytologic material from these 19 cases was reviewed along with corresponding available follow-up surgical material. Standard criteria for specimen adequacy and established morphologic criteria for diagnostic specificity were assessed in each case. All 19 cases met criteria for specimen adequacy, and in 17 cases (89%) specific cytologic diagnoses were made (cellular/adenomatous nodule--2 cases, colloid nodule--10 cases, Hashimoto's thyroiditis--4 cases, and papillary cystic carcinoma--1 case). The diagnoses were confirmed by surgical follow-up in six cases including the case of papillary carcinoma. One case diagnosed as suspicious for a papillary carcinoma subsequently was found to be a follicular adenoma by histology. In one case, a diagnosis of lymphocytic thyroiditis versus intrathyroidal lymphoid tissue was made (See Table I). In majority of cases of USG-FNA of nonpalpable thyroid nodules, adequate material may be obtained for a specific cytopathologic diagnosis.

A case of Hashimoto's encephalopathy: Association with sensory ganglionopathy

We report a case of Hashimoto's encephalopathy with prominent unsteadiness of gait. Nerve conduction studies and electromyographic findings were consistent with a sensory ganglionopathy. Symptoms and clinical findings resolved with high-dose corticosteroid therapy and paralleled the levels of anti-microsomal antibodies. Sensory ganglionopathy seems to be another aspect of the broad clinical syndrome labeled Hashimoto's encephalopathy.

Isolation of thyroid cells obtained by fine-needle aspiration biopsy

Usually thyroid cells isolated from tissue obtained by surgery or thyroid cell lines are used to investigate the pathogenesis of autoimmune thyroid diseases. Isolation and cultivation of thyrocytes from fine-needle aspiration biopsy (FNAB) has not yet been published. The aim of this study was to isolate and cultivate thyrocytes from samples of FNAB. FNAB samples were obtained from nine adults and nine children with Hashimoto's thyroiditis (HT). The aspiration material was filtered resulting in small samples of tissue on the surface of the filter membrane. These tissue fragments were digested by collagenase I and dispase II. The yielding cells were cultivated for 3 weeks in Ham's F12 Kaighn's Modification medium in presence of 1 mU/mL bovine thyrotropin (TSH), 10 microg/mL human insulin, 6 microg/mL transferrin, and 10(-8) M hydrocortisone. Finally, isolated thyroid cells were characterized by determination of gene expression of thyrotropin receptor (TSHR), thyroperoxidase (TPO), and thyroglobulin (Tg) using a nested reverse transcriptase-polymerase chain reaction (RT-PCR). Thyroid cells obtained by FNAB can be maintained over a time period of approximately 3 weeks. Depending on the sample size a final number of 1000-14,000 cells was gained per FNAB. In addition, all cells isolated by the described method expressed TPO mRNA. TSHR mRNA was found in 4 samples, whereas 15 samples were Tg mRNA-positive. There were no differences with respect to the expression TSHR and TPO mRNA between samples from adults and children. The isolation and cultivation of thyroid cells obtained by FNAB has been established. In contrast to surgical specimen, this technique provides an easy access to thyrocytes derived from individual patients allowing repeated sampling to investigate the time progression of the chronic disease or the effect of treatment over time.

Eosinophilic fasciitis associated with autoimmune phenomena after bone marrow transplantation: report of two cases

Between January 1992 and May 2004, 189 patients underwent allogeneic bone marrow transplantation (BMT) for haematological malignancies from HLA-identical sibling donors in our transplantation unit. Of the 189 patients, 2 developed eosinophilic fasciitis (EF). The first patient developed Hashimoto's thyroiditis and EF 11 and 21 months after BMT, respectively. In the second patient EF occurred 9 months after BMT, accompanied by antinuclear antibodies, antiextractable nuclear antigens and antigliadin antibodies. Both patients were treated with extracorporeal photochemotherapy (ECP), resulting in improvement of fasciitis in both and normalization of antithyroid antibodies in the first patient. Our data confirm the rarity of fasciitis after BMT and the efficacy of ECP, recently applied experimentally in one patient for the treatment of fasciitis after BMT. Moreover, we report for the first time the association of fasciitis with autoimmune phenomena after BMT. The correlation between the two entities is supported by remission of Hashimoto's thyroiditis after ECP treatment for fasciitis.

[BRAFV599E mutation and RET/PTC rearrangements in papillary thyroid carcinoma]

OBJECTIVE

To detect the BRAF(V599E) mutation and the RET/PTC chimeric gene in benign and malignant thyroid diseases and to explore their correlation with the clinicopathologic features of papillary thyroid carcinoma (PTC).

METHODS

PCR and RT-PCR were employed to detect BRAF(V599E) mutation and RET/PTC chimeric genes in 95 frozen and parraffine-embeded thyroid tissue.

RESULTS

(1) BRAF(V599E) mutation was detected only in PTC (56%, 37/66) and had a high prevalence in both classic and tall cell types (70%, 29/41 and 2/3). However, follicular types of PTC and other benign and malignant thyroid diseases were negative for BRAF(V599E) mutation. (2) Fourteen (21.2%) PTC cases expressed RET/PTC chimeric gene. Among them, 5 cases (7.6%) were RET/PTC1 and 9 cases (13.6%) were RET/PTC3 respectively. (3) Statistic data did not show any correlation between the BRAF(V599E) mutation, RET/PTC and clinicopathologic features of PTC (P > 0.05). There was no overlap between BRAF(V599E) mutation and RET/PTC rearrangements.

CONCLUSIONS

(1) BRAF(V599E) mutation and RET/PTC rearrangements were unique to PTC. The high prevalence of BRAF(V599E) mutation indicates that it is an important molecular hallmark of PTC. (2) BRAF(V599E) mutation rate was high in classic type PTC and tall cell type inferred that BRAF(V599E) mutation played an important role in their etiopathogenesis. (3) There was no overlap between BRAF(V599E) mutation and RET/PTC rearrangements suggest that they are alternative events in PTC.

[Hashimoto's thyroiditis: indications for surgical treatment]

BACKGROUND

Hashimoto's thyroiditis (HT) is the prototypical example of autoimmune thyroiditis and the primary way to treat the disease is conservative. However, there are patients with HT, in which surgical treatment is mandatory.

AIM

Summarizing our institutional experience, to formulate the indications for surgical treatment of Hashimoto's thyroiditis.

MATERIALS AND METHODS

132 patients (131 females and 1 man, mean age 45 years) underwent surgery for HT in the period from 1.01.1987-1.01.2004. Serum thyroid hormone levels, autoimmune and ultrasonographic findings and FNA biopsy confirmed the diagnosis of HT in 115 (87.1%) patients. In the remaining 17 (12.9%) cases, the diagnosis was based on the intraoperative findings as well as on the histological results. From 1987 to 2002 year 110 patients with HT underwent surgery and for the period 01.01.2003 to 01.01.2004 - 22 (54.6%) patients 10 (45.4%) underwent conventional thyroid resection and 12 (54.6%)--argon plasma resection (APR/introduced in our practice since 2003). The indications for surgery were: thyromegaly with compression symptoms, non-responding to L-thyroxin treatment; nodular form of HT with dominant thyroid nodul over 2 cm in size; suspicion for neoplasm or an unsightly neck appearance due to a large goiter.

RESULTS

17(12.9%) patients with diffuse form of HT were surgically treated. Isthmectomy with bilateral medial partial thyroid resection was performed (in 14 cases by conventional method and in 3 by APR). In 81 (61.4%) patients with nodular form of HT isthmectomy with bilobar or unilobar partial or near total thyroid resections were performed (74 conventional resections and 7 APRs). Seven (5.5%) patients have had pseudonodules. In 6 from these cases conventional isthmectomy was performed and in 1 isthmectomy by APR. Coexistent HT with thyroid carcinoma was diagnosed in 27 (20.4%) patients. All underwent thyroidectomy (1 by APR).

CONCLUSIONS

Surgery has it's place and efficacy in the treatment of selected patients with Hashimoto's thyroiditis and compression symptoms or nodular forms with dominant nodules over 2 cm, suspicion for neoplasm or an unsightly neck appearance due to a large goiter. Argon plasma resection (APR) is a new, safe and promising technique of thyroid resection, particularly appropriate for patients with Hashimoto's thyroiditis.