Tumor Grade and Molecular Characteristics Associated with Survival in Sporadic Medullary Thyroid Carcinoma

Background: The International Medullary Thyroid Carcinoma Grading System (IMTCGS) divides medullary thyroid carcinoma (MTC) into two categories, high- and low-grade tumors, which has a profound impact on patient outcomes. The aim of this study was to explore the association between IMTCGS grading, clinical data, and molecular status in sporadic MTC. Methods: A retrospective cohort study was performed on consecutive sporadic MTCs from patients undergoing initial surgery between January 2000 and January 2022 at the Padua Endocrine Surgery Unit. Clinical, pathological, and follow-up data were collected, tumors were graded, and somatic mutations of RET and RAS genes were analyzed. Patient outcomes were based on Ct levels and MTC-related deaths. Survival analyses were carried out employing the Kaplan-Meier method and the log-rank test. A Cox proportional hazard regression model was employed for multivariable survival analysis with the following covariates: somatic RET mutation, MTC stage at diagnosis, sex, age at diagnosis, and IMTCGS grade. Results: We included 141 consecutive sporadic MTCs. The median follow-up was 80.0 months (interquartile ranges: 41.5-122.5 months). Seventeen patients (12.1%) died from disease-related causes. 107/141 (76.9%) were classified as low-grade tumors, 32/141 (23.1%) as high-grade. Patients carrying a RET mutation had more aggressive features and shorter disease-specific survival (DSS) (p = 0.001) and were more frequently classified high-grade than low-grade MTC (p < 0.001). At multivariable survival analysis, only IMTCGS grading was independently associated with DSS (hazard ratio 8.8 [confidence interval: 2.7-28.3], p = 0.005). RET mutations, in particular RET-M918T, were more frequent in high-grade than in low-grade MTC (68.8% vs. 29.4% mutated in RET, 46.9% vs. 12.7% mutated in RET-M918T; p < 0.001). None of the high-grade tumors was mutated in the RAS gene, but the mutation was present in 11.8% of low-grade tumors. Conclusions: IMTCGS grading was associated with DSS independently of other clinical, pathological, and molecular factors. Moreover, MTC grading was associated with RET and RAS patterns, which explains, at least in part, the molecular basis of the aggressive behavior of high-grade MTC.

Circulating miR-146a predicts glucocorticoid response in thyroid eye disease

Objective

Thyroid eye disease (TED) is an immune-mediated disorder of the eye. Intravenous glucocorticoid (GC) is the first-line treatment for patients with active moderate-to-severe TED. However, the response rate is between 50% and 80%. There are still no simple and reliable markers of responsiveness to GC therapy. We aimed to explore the possible role of miR-146a and miR-21 as predictors of responsiveness to GC treatment in TED.

Methods

We carried out a prospective longitudinal study on 30 consecutive adult patients with active moderate-to-severe TED and eligible for GC therapy. All patients received the standard GC treatment with methylprednisolone i.v. In cases of progressive worsening of Gorman Score for diplopia or with duction restriction <30° in at least two consecutive controls, patients also underwent orbital radiotherapy. Response to GC treatment was defined as a decrease of two or more points in the clinical activity score (CAS) or CAS <4/10 at 24 weeks. Circulating miRNAs were extracted from patients' serum and quantified by real-time PCR.

Results

Twenty-three (77%) patients responded to GC. Thyroid surgery, higher CAS, greater proptosis and higher pre-treatment circulating levels of miR-146a emerged as predictive factors of responsiveness to GC. A ROC analysis revealed that miR-146a could predict responsiveness to GC with a positive predictive value of 100%.

Conclusion

This is the first study investigating the role of pre-treatment circulating miR-21 and miR-146a to predict responsiveness to GC in TED. miR-146a emerged as a simple, objective, new marker of GC sensitivity that could be used to avoid ineffective administration of GC therapy to TED patients.

Safety and efficacy of prophylactic treatment for hyperthyroidism induced by iodinated contrast media in a high-risk population

Introduction

The use of iodinated contrast media (ICM) can lead to thyrotoxicosis, especially in patients with risk factors, such as Graves' disease, multinodular goiter, older age, and iodine deficiency. Although hyperthyroidism may have clinically relevant effects, whether high-risk patients should receive prophylactic treatment before they are administered ICM is still debated.

Aim of the study

We aimed to demonstrate the safety and efficacy of prophylactic treatment with sodium perchlorate and/or methimazole to prevent ICM-induced hyperthyroidism (ICMIH) in a population of high-risk cardiac patients. We ran a cost analysis to ascertain the most cost-effective prophylactic treatment protocol. We also aimed to identify possible risk factors for the onset of ICMIH.

Materials and methods

We performed a longitudinal retrospective study on 61 patients admitted to a tertiary-level cardiology unit for diagnostic and/or therapeutic ICM-procedures. We included patients with available records of thyroid function tests performed before and after ICM were administered, who were at high risk of developing ICMIH. Patients were given one of two different prophylactic treatments (methimazole alone or both methimazole and sodium perchlorate) or no prophylactic treatment. The difference between their thyroid function at the baseline and 11-30 days after the ICM-related procedure was considered the principal endpoint.

Results

Twenty-three (38%) of the 61 patients were given a prophylactic treatment. Thyroid function deteriorated after the administration of ICM in 9/61 patients (15%). These cases were associated with higher plasma creatinine levels at admission, higher baseline TSH levels, lower baseline FT4 levels, and no use of prophylactic treatment. The type of prophylaxis provided did not influence any onset of ICMIH. A cost-benefit analysis showed that prophylactic treatment with methimazole alone was less costly per person than the combination protocol. On multivariate analysis, only the use of a prophylactic treatment was independently associated with a reduction in the risk of ICMIH. Patients not given any prophylactic treatment had a nearly five-fold higher relative risk of developing ICMIH.

Conclusion

Prophylactic treatment can prevent the onset of ICMIH in high-risk populations administered ICM. Prophylaxis is safe and effective in this setting, especially in cardiopathic patients. Prophylaxis with methimazole alone seems to be the most cost-effective option.

Therapeutic Plasma Exchange for the Treatment of Hyperthyroidism: Approach to the Patient with Thyrotoxicosis or Antithyroid-Drugs Induced Agranulocytosis

Primary hyperthyroidism is an endocrine disorder characterized by excessive thyroid hormone synthesis and secretion by the thyroid gland. Clinical manifestations of hyperthyroidism can vary from subclinical to overt forms. In rare cases, hyperthyroidism may represent a clinical emergency, requiring admission to an intensive care unit due to an acute and severe exacerbation of thyrotoxicosis, known as a thyroid storm. First-line treatment of hyperthyroidism is almost always based on medical therapy (with thioamides, beta-adrenergic blocking agents, glucocorticoids), radioactive iodine or total thyroidectomy, tailored to the patient’s diagnosis. In cases of failure/intolerance/adverse events or contraindication to these therapies, as well as in life-threatening situations, including a thyroid storm, it is necessary to consider an alternative treatment with extracorporeal systems, such as therapeutic plasma exchange (TPE). This approach can promptly resolve severe conditions by removing circulating thyroid hormones. Here we described two different applications of TPE in clinical practice: the first case is an example of thyrotoxicosis due to amiodarone treatment, while the second one is an example of a severe adverse event to antithyroid drugs (agranulocytosis induced by methimazole).

P418 CARDIOMETABOLIC ALTERATIONS IN OBESE PATIENTS WITH OBSTRUCTIVE SLEEP APNEA SYNDROME

Background

Obesity and Obstructive Sleep Apnea Syndrome (OSAS) has been recognized as two of the major cardiac risk factors and they often coexist in one patient. OSAS increase the risk of as myocardial infarction, heart failure and arrhythmias. On the other hand, obesity is and independent predictor of cardiovascular mortality since it causes insulin resistance, dyslipidemia, sympathetic hyperactivation, chronic inflammation and endothelial dysfunction.

Aim

To evaluate cardiometabolic profile, echocardiographic alterations and the presence of arrhythmias in obese patients with Obstructive Sleep Apnea Syndrome and non obese patients.

Patients and Methods

67 obese patients (37 male/30 female) and 52 non obese patients (40 male/12 female) were enrolled. All subjects underwent anthropometrical evaluation and a venous blood sample for biochemical and hormonal determinations including fasting plasma glucose, fasting plasma insulin, Hba1c and OGTT to 5 hours. The insulin resistance was evaluated by HOMA–IR. All the patients underwent echocardiographic examination, polysomnographic evaluation, in order to diagnose the OSAS, and a simultaneous 12–lead Holter ECG to evaluate the presence of nocturnal arrhythmias.

Results

As expected, we found a better antropometrics profile in non obese patients. Obese patients display a severe OSAS compared to non–obese patient as shown by higher values of AHI (26.37 ±24.95 vs 16.58 ±14.07; P &lt; 0.05), TC90 (19.61 ±24.45 vs 8.63 ±17.80; P &lt; 0.05) and ODI (40.55 ±27.41 vs 21.06 ±22.78; P &lt; 0,05). In obese patients we also found a significant reduction of both ejection fraction (55.54 ±7.97 vs 66.52 ±8.95; P &lt; 0.05) and A–wave (0.75 ±0.17 vs 0.83 ±0.19; P &lt; 0.05). In 20% of obese patients, 12–lead Holter ECG showed the presence of cardiac pause &gt; 3 sec during apnea. In obese population alone we demonstrated a significant negative correlation between AHI and E–wave (r= –0.3; P = 0.04) and a positive correlation with interventricular septum (r = 0.38; P = 0.01) and left ventricular mass (r = 0.32; P = 0.02). Post–hoc analysis shown how these findings maintained statistical significance even when the obese patients were stratified in subgroups according to the severity of OSAS.

Conclusions

Our data, even if preliminary, seem to indicate that OSAS is not only linked to obesity but it also acts as a negative factor on the cardiometabolic risk.

C77 EFFECT OF SACUBITRIL/VALSARTAN ON BOTH METABOLIC PARAMETER AND INSULIN RESISTANCE IN NON OBESE NON DIABETIC PATIENTS WITH HEART FAILURE

Background

Sacubitril/Valsartan has been shown to improve mortality and reduce hospitalizations in patients with heart failure with reduced ejection fraction (HFrEF). Moreover Sacubitril/Valsartan showed a significantly reduction in the HbA1c in diabetic patients. The effect of Sacubitril/Valsartan on metabolic parameter and insulin resistence in both, non obese and non diabetic patients, have not been previously described.

Aim

We evaluated the effects of the Sacubitril/Valsartan on both glycaemic and metabolic parameter, on HOMA–IR and on echocardiographic parameters in patients with HFrEF.

Methods

A total of 59 non obese and non diabetic patients with a diagnosis of HFrEF (EF &lt; 35%) have been enrolled. All the patients underwent a complete anthropometrical evaluation, laboratory determinations (including fasting glucose, fasting insulin, HbA1c) and echocardiogram evaluation. Data analysis was made after 24 weeks of treatment. The insulin resistance has been assessed by HOMA–IR.

Results

Data analysis demostrated a significant reduction in fasting plasma glucose (111.4 + 11.5 vs 106 + 10 mg/dl, P = 0.03), fasting plasma insulin (13.6 + 5.9 vs 10.5 + 4.4 µUI/ml), HbA1c value (6.14 + 0.5% vs 5.9 + 0.3%, P &lt; 0.01) and insulin resistance (HOMA–IR, 3.74 + 2.2 vs 2.7 + 2.1, P = 0.03). The echocardiogram evaluation showed a significant reduction of the end–diastolic left ventricular volume (168 + 44 vs 150 + 38 ml, P &lt; 0.05), a no significant reduction of the end–systolic left ventricular volume (98 + 26 vs 88 + 22 ml, P = 0.07), a significant reduction of E/e1 ratio and an average 7.8% increase in ejection fraction (EF), from a mean baseline of 32.3 + 2.4 to 40.1 + 3.8% (P &lt; 0.0001). No differences in interventricular septal (IVS) thickness, posterior wall (PW) thickness, A–wave, E–wave and E/A ratio have been observed. No differences in anthropometrical parameters (weight, body mass index, waist circumference) and blood pressure were observed.

Conclusions

Our data, even if preliminary, seem to indicate that sacubitril/valsartan might enhance glycaemic control and improve insulin resistance in non obese/non diabetic patients with HFrEF. Also, our data confirm that sacubitril/valsartan treatment is able to improve ejection fraction in HFrEF patients.

Effects of sacubitril/valsartan on both metabolic parameters and insulin resistance in prediabetic non-obese patients with heart failure and reduced ejection fraction

BACKGROUND

The effects of sacubitril/valsartan (sac/val) on metabolic parameters and insulin resistance (IR) in non-obese/prediabetic patients have not been previously described.

AIM

To evaluate the effects of sac/val on glycemic and metabolic parameters, Homeostatic Model Assessment of IR (HOMA-IR), and echocardiographic parameters in prediabetic patients with heart failure with reduced ejection fraction (HFrEF).

METHODS

Fifty-nine patients with HFrEF (EF < 35%) but without obesity and/or type 2 diabetes mellitus have been enrolled. All the patients at baseline and week 24 underwent complete anthropometrical evaluation and were subjected to an echocardiogram test. IR has been assessed by HOMA-IR.

RESULTS

After 24-week of treatment with sac/val, a significant reduction in fasting plasma glucose (109 ± 9 vs 103 ± 8 mg/dl, p < 0.0001), fasting plasma insulin (16 ± 4 vs 10 ± 4 UI/L), and hemoglobin A1c (HbA1c) value (6% ± 0.5% vs 5.3% ± 0.3%, p < 0.0001) was observed. Similarly, we observed a significant improvement in IR (HOMA-IR, 4.4 ± 0.9 vs 2.5 ± 0.6, p < 0.0001). The echocardiogram evaluation showed a significant reduction of the left ventricular end-diastolic volume (168 ± 24 vs 158 ± 22 ml, p < 0.05), a significant reduction of the left ventricular end-systolic volume (111 ± 26 vs 98 ± 22 ml, p < 0.005), and a significant reduction of E/e' ratio. Sac/val use was also associated with an average 5.1% increase in ejection fraction.

CONCLUSIONS

Our data seem to indicate that sal/val enhances metabolic control and improves insulin resistance also in prediabetic non-obese patients with HFrEF.