A radioimmunoassay for thyrocalcitonin

Medullary Thyroid Cancer with Paraganglioma-Like Pattern Diagnosed During Pregnancy: A Case Report and Literature Revision

INTRODUCTION

Medullary thyroid carcinoma (MTC) is an infrequent thyroid malignancy rarely observed and managed during pregnancy. An accurate diagnostic workup is extremely important in this clinical setting to correctly diagnose and treat the disease, avoiding both maternal and fetal complications.

OBJECTIVE

We report our experience in managing an MTC incidentally diagnosed during pregnancy in a 28-year female, highlighting critical aspects through the diagnostic workup. Additionally, we provide a literature revision searching on PubMed terms related to "medullary thyroid carcinoma", "primary thyroid paraganglioma", "paraganglioma-like medullary thyroid cancer" in relationship with a nodular appearance at neck US, serum CT measurement, cytological and histological findings.

METHODS

Specimens for cytological evaluation were stained with the Papanicolaou method while tissue sections were stained with hematoxylin and eosin and Congo red stain. Immunohistochemical evaluation was also performed for thyroid transcription factor-1, enolase, thyroglobulin, cytokeratin, chromogranin A, S-100 protein, glial fibrillary acidic protein, calcitonin and Ki-67.

RESULTS

Serum CT was incidentally found to be elevated in two consecutive venous samples. However, the cytological assessment of the fine needle aspiration (FNAc) showed "cells with round-shaped nuclei and granular chromatin, organized to form nests or syncytial flaps, scattered among histocytes, and immunocytochemical positivity for CT, thyroid transcriptional factor-1, cytokeratin, S-100 protein", highlighting a suspicion of both MTC and intrathyroidal paraganglioma. MTC was finally supposed after the evidence of a really elevated CT (3,726 pg/ml) measurement in the FNA washout fluid. After a careful discussion about both risks and benefits, the patient decided to postpone the surgery after the delivery.

CONCLUSION

The histological diagnosis finally confirmed a rare case of paraganglioma-like MTC (T1 N0 Mx), emphasizing the complexity of our differential diagnosis, between an MTC and a thyroidal paraganglioma. In similar cases, due to a relevant impact on surgical timing, patients should be adequately informed about both risk and benefits of the surgery during pregnancy, and a careful management of the disease is required until and after surgery.

Ultrastructural Evaluation of Thyroid Parafollicular Cells of Pigs with Naturally Occurring Atrophic Rhinitis

The thyroid parafollicular cells of 4-month-old control pigs and pigs with naturally occurring atrophic rhinitis were evaluated ultrastructurally. Significant difference was not observed in populations of parafollicular cells between the 2 groups of pigs. Parafollicular cells occurred in actively synthesizing and storage phases of the secretory cycle in both groups. Actively synthesizing cells had a well-developed endoplasmic reticulum, aggregated ribosomes, and prominent Golgi apparatuses with prosecretory granules. The cytoplasm of parafollicular cells in the storage phase was packed with electron-dense secretory granules. The Golgi apparatus and ergastoplasm were less prominent. There was no evidence to suggest that an interference in the synthesis or release of thyrocalcitonin by parafollicular cells was of criologic importance in the pathogenesis of atrophic rhinitis.

Calcitonin as Biomarker for the Medullary Thyroid Carcinoma

Calcitonin (CTN) is a polypeptide hormone consisting of 32 amino acids with a disulfide bridge between position 1 and 7 that is mainly produced by the C-cells of thyroid gland. The measurement of CTN concentrations in blood reflects C-cell activity and is performed in general by immunoassay methods. However, there are analytical, physiological, pharmacological, and pathological factors that can influence results of serum CTN values. Due to the influence of these factors, there is a high variability in assay-dependent cutoffs used to discriminate between MTC, C-cell hyperplasia (CCH), and the absence of the pathological impairment of C-cells. There is a lot of evidence that the measurement of serum CTN concentrations in patients with thyroid nodules can lead to an earlier diagnosis of MTC or CCH than the exclusive use of imaging procedures and/or fine-needle aspiration cytology. Basal CTN concentrations higher than 60-100 pg/mL are highly indicative for the diagnosis MTC. In the range between cutoff and 60 pg/mL CTN, both MTC and HCC may be a relevant diagnosis. PCT and CTN appear to have a comparable diagnostic capability to diagnose MTCs. However, "positive" PCT values of more than 50 pg/mL may be reached also in subclinical infections and will lead, therefore, to an overdiagnosis of the tumor. Pentagastrin- or calcium-stimulated serum CTN concentrations higher than cutoff values might improve diagnostics of MTC, but the non-availability of the first and the lacking of relevant cutoff values for the second tool favors the use of only basal values currently.

Highlights in thyroidology: a historical vignette

This review gives a historical overview about the development of today's understanding of benign thyroid diseases and the possibilities of their treatment.Little was known about the thyroid gland until the nineteenth century: the state of knowledge was (1) that something in food, especially in seaweed, avoided the development of goiters, (2) that goiters seemed to have something to do with cretinism, and (3) that the thyroid gland is an organ consisting of two lobes connected by an isthmus. Shortly after the detection of iodine in 1811, its impact on its ability to avoid the development and the growing of goiters has been realized. The existence of iodine within the thyroid and in human plasma was detected approximately a decade later. The clinical picture of hyperthyroidism including endocrine orbitopathy was described in detail in the middle of the nineteenth century, the etiology of the disease remaining, however, unclear until a century later. In early nineteenth century, surgical goiter exstirpation was the only available form of treatment. Vienna and Berne were the centers leading worldwide in their expertise. Subcutaneous injections of sheep thyroid extracts were developed for treatment of postoperative hypothyroidism as well as congenital myxedema. Another approach suggested by Swiss surgeons was thyroid transplantation. Radioiodine therapy of hyperthyroidism was introduced in the middle of the twentieth century. Thyrostatic drugs are available since about the same time. The different forms of thyroiditis were described at the turn of the twentieth century. The etiology of chronic autoimmune thyroiditis was, however, clarified only some 50 years later independently by two groups of scientists, one in London, UK, and the other in Buffalo, USA. Thyroxine was isolated from bovine thyroid extracts in the beginning of the twentieth century. Its synthesis and correct chemical structure were described some 10 years later. The existence of 3,5,3'-triiodothyronine (T3), the biologically most active thyroid hormone, was detected in the 1950s of the past century by a group in Paris and another in London. The extrathyroidal conversion of thyroxine to T3, as the main source of circulating T3, was suggested shortly thereafter and substantiated in 1970. Finally, the development of the radioimmunoassay method for determination of hormone serum concentrations in 1959 enabled today's exact laboratory diagnosis of thyroid diseases.

Oral calcitonin

Calcitonin is a hormone secreted by the C-cells of the thyroid gland in response to elevations of the plasma calcium level. It reduces bone resorption by inhibiting mature active osteoclasts and increases renal calcium excretion. It is used in the management of postmenopausal osteoporosis, Paget’s disease of bone, and malignancy-associated hypercalcemia. Synthetic and recombinant calcitonin preparations are available; both have similar pharmacokinetic and pharmacodynamic profiles. As calcitonin is a peptide, the traditional method of administration has been parenteral or intranasal. This hinders its clinical use: adherence with therapy is notoriously low, and withdrawal from clinical trials has been problematic. An oral formulation would be more attractive, practical, and convenient to patients. In addition to its effect on active osteoclasts and renal tubules, calcitonin has an analgesic action, possibly mediated through β-endorphins and the central modulation of pain perception. It also exerts a protective action on cartilage and may be useful in the management of osteoarthritis and possibly rheumatoid arthritis. Oral formulations of calcitonin have been developed using different techniques. The most studied involves drug-delivery carriers such as Eligen^® 8-(N-2hydroxy-5-chloro-benzoyl)-amino-caprylic acid (5-CNAC) (Emisphere Technologies, Cedar Knolls, NJ). Several factors affect the bioavailability and efficacy of orally administered calcitonin, including amount of water used to take the tablet, time of day the tablet is taken, and proximity to intake of a meal. Preliminary results looked promising. Unfortunately, in two Phase III studies, oral calcitonin (0.8 mg with 200 mg 5-CNAC, once a day for postmenopausal osteoporosis and twice a day for osteoarthritis) failed to meet key end points, and in December 2011, Novartis Pharma AG announced that it would not pursue further clinical development of oral calcitonin for postmenopausal osteoporosis or osteoarthritis. A unique feature of calcitonin is that it is able to uncouple bone turnover, reducing bone resorption without affecting bone formation and therefore increasing bone mass and improving bone quality. This effect, however, may be dose-dependent, with higher doses inhibiting both resorption and formation. Because so many factors affect the pharmacokinetics and pharmacodynamics of calcitonin, especially orally administered calcitonin, much work remains to be done to explore the full pharmacologic spectrum and potential of calcitonin and determine the optimum dose and timing of administration, as well as water and food intake.

Routine serum calcitonin measurement in the evaluation of thyroid nodules

Calcitonin (CT) is secreted mainly by parafollicular C cells. In normal subjects, serum CT (sCT) levels are low and barely detectable by commonly used assays. Increased sCT levels are highly suggestive of medullary thyroid carcinoma (MTC). Since the clinical manifestation of MTC is a thyroid nodule, either single or in the context of a multinodular goitre, the routine measurement of sCT in the evaluation of thyroid nodule(s) facilitates the diagnosis of MTC. sCT measurement is indeed more sensitive than cytology in finding MTC. There are two major benefits from this clinical practice: (a) the surgeon is alerted to the need to perform total thyroidectomy and central compartment lymphadenectomy, which is the minimal surgical treatment for MTC; and (b) the outcome of MTC is favourably affected because it is usually identified at a less advanced stage. However, other non-MTC causes of hypercalcitoninaemia and false sCT positivity do exist and must be recognized. The differential diagnosis is possible using previously validated assays against possible sources of interference, and performing stimulation tests with pentagastrin or, eventually, calcium infusion.

Calcitonin receptor-stimulating peptide-1 regulates ion transport and growth of renal epithelial cell line LLC-PK1

Calcitonin receptor-stimulating peptide-1 (CRSP-1) is a peptide recently identified from porcine brain by monitoring the cAMP production through an endogenous calcitonin (CT) receptor in the renal epithelial cell line LLC-PK(1). Here we investigated the effects of CRSP-1 on the ion transport and growth of LLC-PK(1) cells. CRSP-1 inhibited the growth of LLC-PK(1) cells with a higher potency than porcine CT. CRSP-1 enhanced the uptake of (22)Na(+) into LLC-PK(1) cells more strongly than did CT and slightly reduced the (45)Ca(2+) uptake. The enhancement of the (22)Na(+) uptake was abolished by 5-(N-ethyl-N-isopropyl) amiloride, a strong Na(+)/H(+) exchanger (NHE) inhibitor for NHE1, even at a concentration of 1x10(-8)M, although other ion transporter inhibitors did not affect the (22)Na(+) uptake. These results indicate that CRSP-1 enhances the (22)Na(+) uptake by the specific activation of NHE1. Taken together, CRSP-1 is considered to be a new regulator for the urinary ion excretion and renal epithelial cell growth.

A noncompetitive enzyme immunoassay (hetero-two-site enzyme immunoassay) for salmon calcitonin: determination of the bioavailability of subcutaneous salmon calcitonin and its correlation with the hypocalcemic activity in rats

A noncompetitive enzyme immunoassay method (hetero-two-site enzyme immunoassay) for salmon calcitonin (SCT) and its usability for the pharmacokinetic study are described. The method in brief proceeds as follows: centrifugal filtration through a polysaccharide membrane to remove plasma proteins, biotinylation, trapping onto an anti-SCT IgG-coated polystyrene ball, acid elution, coupling with affinity-purified anti-SCT Fab'-peroxidase conjugate, final trapping onto streptavidin-coated polystyrene balls, and measurement of peroxidase activity bound to the balls by fluorometry. The practical detection limit of SCT was 0.1 pg (30 amol)/assay and 2 pg/ml as the assay sample's concentration, which was at least fivefold lower than those previously reported by competitive radioimmunoassays. The application of this method has enabled us to 1) directly estimate the bioavailability of SCT dosed subcutaneously at the therapeutic levels (1.2 and 4.7 micrograms/kg) for its antiosteoporotic effect as compared to an intravenous dose (1.2 micrograms/kg) and 2) search for the relationship between blood level and the hypocalcemic activity of SCT. The pharmacokinetic parameters of subcutaneous SCT (1.2 and 4.7 micrograms/kg) thus estimated were as follows: the area under the blood concentration-time curve (AUC) = 89 and 550 pg.hr/ml, and mean residence time (MRT) = 44 and 65 minutes, respectively, when the AUC for an intravenous SCT (1.2 micrograms/kg) = 160 pg.hr/ml and the MRT = 10 minutes.

Detection of calcitonin gene expression in human infant and monkey carotid body chief cells by in situ hybridization

Calcitonin mRNA was detected in human and monkey carotid bodies by in situ hybridization histochemistry, using a 35S-labeled oligonucleotide probe for human calcitonin. In both human and monkey carotid body, moderate to high hybridization signal for calcitonin mRNA was observed in all cases. The hybridization signal in the formalin-fixed, paraffin-embedded samples was comparable to that obtained from frozen paraformaldehyde-fixed tissue. Our observations extend the finding of calcitonin-like immunoreactivity in the carotid body chief cells and indicate that calcitonin is produced in the carotid body, probably in the chief cells.

The effects of forskolin and calcium ionophore A23187 on secretion and cytoplasmic RNA levels of Chromogranin-A and calcitonin

We have studied the regulation of the secretion and cytoplasmic RNA levels of calcitonin (CT) and Chromogranin-A (CgA) to determine if the biosynthesis and secretion of these two substances are controlled in a coordinated fashion. The studies were conducted in two cell lines, a medullary thyroid carcinoma (MTC) cell line and a lung tumor (BEN) cell line. Both cell types secrete CT and CgA. Forskolin treatment resulted in a significant increase in the secretion of CT and CgA in each cell line and in CT-specific cytoplasmic RNA in the MTC cell line. Treatment with calcium ionophore A23187 resulted in significantly increased secretion of both substances in the lung tumor cells but not in the medullary thyroid carcinoma cells. A significant increase in CT-specific or CgA-specific cytoplasmic RNA was not seen in either cell line. We conclude that the secretion of CT and CgA are regulated in a coordinated fashion in these cell lines through processes that are calcium-mediated and processes that involve cyclic AMP-dependent protein kinase A. However, each of these regulatory pathways is not always operative in a given tissue. The coordinate regulation of the secretion of CT and CgA supports the hypothesis that CgA participates in the secretory process of its associated hormones.

The clinical outcome of prospective screening for multiple endocrine neoplasia type 2a. An 18-year experience

An important question facing physicians who care for families with multiple endocrine neoplasia type 2a is whether prospective screening to detect early abnormalities of the thyroid, parathyroid, or adrenal glands favorably influences the ultimate course of the disease. An 18-year study of a large family has allowed us to examine the effect of early treatment on the clinical course of the disease. Of 22 patients who underwent thyroidectomy for early C-cell abnormalities, 19 remained free of detectable medullary thyroid carcinoma according to all criteria, at a mean of 11 years after thyroidectomy. None of the 22 patients had evidence of parathyroid disease either at the time of surgery or after a mean follow-up of 10 years. Prospective screening for adrenal medullary abnormalities by means of measurement of 24-hour urinary epinephrine excretion and the ratio of urinary epinephrine to norepinephrine was predictive of pheochromocytoma in 10 of 11 patients (with a false negative result in one patient) but was not useful in diagnosing adrenal medullary hyperplasia. We conclude that regular, prospective screening and early treatment of the manifestations of multiple endocrine neoplasia can prevent metastasis of medullary thyroid carcinoma and the morbidity and mortality caused by pheochromocytoma.

Provocative testing for occult medullary carcinoma of the thyroid: findings in seven children with multiple endocrine neoplasia type IIa

A rise in the serum calcitonin (CT) following provocative testing has facilitated making the diagnosis of occult medullary carcinoma of the thyroid (MCT) or C cell hyperplasia (CCH) in asymptomatic children of kindred with multiple endocrine neoplasia (MEN) type IIa. Findings were reviewed for seven children varying in age from 3 to 16 years screened at our institution between 1976 and 1986. Three had elevated basal calcitonin (S-CT). Six had significant elevation of calcitonin (delta-CT) after stimulation. Total thyroidectomy was performed in all seven. Five had MCT with bilobar involvement in three. CCH was present in all five. Two patients had no gross, microscopic, or immunohistochemical evidence of MCT or CCH. One of three had an elevated S-CT. The other had a significant delta-CT. All patients have normal postoperative S-CT and delta-CT. Our experience indicates the importance of beginning stimulation tests of affected kindred at less than 3 years of age. It appears, however, that neither elevated S-CT or positive delta-CT are perfect predictors of parafollicular cell pathology. Solitary parathyroid enlargement, second thyroid malignancy, and branchial pouch anomalies may occur with MEN IIa. One patient with MCT had a focus of papillary carcinoma. One patient with primary hyperparathyroidism had a solitary enlarged parathyroid adenoma. Additional findings were the presence of nodules of ectopic thymus in close association with the thyroid gland in three patients.

Ectopic ACTH syndrome due to pheochromocytoma: case report and review of the literature

A 51-year-old female was diagnosed preoperatively to have a pheochromocytoma producing ACTH. This diagnosis was based upon her paroxysmal hypertension, hyperpigmentation, and hypokalemia. Elevated levels of serum and urine corticosteroids, plasma ACTH, urinary VMA, and catecholamines fell after a right adrenal pheochromocytoma was removed. Subsequently this tumor was found to have a high content of ACTH. Review of the literature indicates a mortality rate of 57% for this syndrome. Proper preoperative recognition and management can result in total cure.

Thyrocalcitonin: stimulation of secretion by pentagastrin

Administration of a small dose of pentagastrin, a synthetic pentapeptide containing the biologically active portion of the native hormone gastrin, results in a marked, rapid, transitory increase in thyrocalcitonin secretion in the pig. Gastrin or a related gastrointestinal peptide may be important in the physiological secretion of thyrocalcitonin, such as that which occurs when calcium salts are introduced into the gastrointestinal tract.

The clinical physiology of calcium homeostasis, parathyroid hormone, and calcitonin. I

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Effects of glucagon, dibutyryl cyclic 3',5'-adenosine monophosphate, and theophylline on calcitonin secretion in vitro

The secretion of calcitonin by slices of porcine thyroid glands has been investigated. Calcitonin in the incubation medium was determined by radioimmunoassay. Secretion of calcitonin was diminished when calcium or magnesium was omitted and was increased stepwise as the concentration of calcium or magnesium in the incubation medium was increased. Calcitonin secretion was augmented substantially when either the quantity of thyroid tissue or volume of incubation medium was increased. Secretion of calcitonin was stimulated by glucagon, theophylline, and dibutyryl cyclic 3',5'-adenosine monophosphate. It is concluded that calcitonin secretion is regulated by the concentration of calcium and magnesium, that secretion may be inhibited by calcitonin or a precursor and that secretion can be stimulated by increasing the concentration of cyclic 3',5'-adenosine monophosphate in the parafollicular cells of the thyroid gland.

Fine structural alterations in thyroid parafollicular cells of cows in response to experimental hypercalcemia induced by vitamin D

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Amino acid sequence of salmon ultimobranchial calcitonin

Salmon ultimobranchial calcitonin has been isolated and rendered pure, as demonstrated by several chemical criteria. Its amino acid sequence was determined by means of manual Edman degradation of the intact molecule and of several peptide subfragments. Results of automated degradation provided confirmation of the structure. The salmon molecule possesses, in common with other calcitonins, a 32-amino acid peptide chain terminating in prolinamide and containing half-cystine residues at positions 1 and 7. Although the sequence of the salmon hormone differs considerably from that of the porcine, bovine and human calcitonins, the four hormones are homologous in 9 of 32 positions. The much higher biological potency possessed by the salmon calcitonin makes it of particular interest for future structure function studies.