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Martino E, Bartalena L, Trimarchi F. A dwarf woman in the funeral procession of Hippolytus and Phaedra. J Endocrinol Invest 2024; 47:1311-1312. [PMID: 38055126 DOI: 10.1007/s40618-023-02244-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Accepted: 11/09/2023] [Indexed: 12/07/2023]
Affiliation(s)
| | - L Bartalena
- School of Medicine, University of Insubria, Varese, Italy
| | - F Trimarchi
- Dipartimento di Medicina Clinica e Sperimentale, University of Messina, Messina, Italy.
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Cappellani D, Bartalena L, Bogazzi F. Short review: novel concepts in the approach to patients with amiodarone-induced thyrotoxicosis. J Endocrinol Invest 2024; 47:275-283. [PMID: 37731073 PMCID: PMC10859339 DOI: 10.1007/s40618-023-02168-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 07/25/2023] [Indexed: 09/22/2023]
Abstract
INTRODUCTION Amiodarone-induced thyrotoxicosis is associated with high morbidity and mortality rates. The approach to this condition is widely variable across different medical specialists and even among expert endocrinologists. As a matter of fact, the approach to amiodarone-induced thyrotoxicosis has always been considered difficult, due to diagnostic uncertainties easily resulting in missteps, and therapeutic challenges easily resulting in unresponsiveness or slow-responsiveness to the administered drugs. PURPOSE Our purpose is to review novelties emerged during the last years about this condition, with the aim to provide novel insights on the diagnostic and therapeutic management of this challenging condition.
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Affiliation(s)
- D Cappellani
- Department of Clinical and Experimental Medicine, Unit of Endocrinology, University of Pisa, Ospedale Cisanello, via Paradisa 2, 56124, Pisa, Italy
| | - L Bartalena
- School of Medicine, University of Insubria, Varese, Italy
| | - F Bogazzi
- Department of Clinical and Experimental Medicine, Unit of Endocrinology, University of Pisa, Ospedale Cisanello, via Paradisa 2, 56124, Pisa, Italy.
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Abstract
BACKGROUND Thyroid eye disease (TED) is an autoimmune disorder of the orbit and the most frequent extrathyroidal manifestation of Graves' disease but it may rarely occur in euthyroid/hypothyroid patients with chronic autoimmune thyroiditis. EPIDEMIOLOGY TED is a relatively infrequent disorder, particularly in its severe forms. Men tend to have more severe TED at an older age. The prevalence of TED is lower than in the past among patients with recent onset Graves' hyperthyroidism, and moderate-to-severe forms requiring aggressive treatments are no more than 5% to 6% of all cases. NATURAL HISTORY After an initial inflammatory (active) phase and a plateau phase, TED stabilizes and eventually inactivates (inactive or burnt-out phase) after an estimated period of 18-24 months. Minimal-to-mild TED often remits spontaneously, but complete restitutio ad integrum almost never occurs when TED is more than mild. RISK FACTORS Several risk factors contribute to its development on a yet undefined genetic background. Cigarette smoking is the most important of them, but thyroid dysfunction (both hyper- and hypothyroidism), radioactive iodine therapy (if not accompanied by low-dose steroid prophylaxis), elevated thyrotropin receptor antibodies, and, probably, hypercholesterolemia represent relevant modifiable risk factors. Early diagnosis, control and removal of modifiable risk factors, and early treatment of mild forms of GO (local treatment and selenium) may effectively limit the risk of progression to more severe forms.
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Affiliation(s)
| | - Daniela Gallo
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Maria Laura Tanda
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - George J Kahaly
- Department of Medicine I, Johannes Gutenberg University, Mainz, Germany
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Kustrimovic N, Gallo D, Piantanida E, Bartalena L, Lai A, Zerbinati N, Tanda ML, Mortara L. Regulatory T Cells in the Pathogenesis of Graves' Disease. Int J Mol Sci 2023; 24:16432. [PMID: 38003622 PMCID: PMC10671795 DOI: 10.3390/ijms242216432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Revised: 11/12/2023] [Accepted: 11/13/2023] [Indexed: 11/26/2023] Open
Abstract
Maintaining a delicate balance between the prompt immune response to pathogens and tolerance towards self-antigens and commensals is crucial for health. T regulatory (Treg) cells are pivotal in preserving self-tolerance, serving as negative regulators of inflammation through the secretion of anti-inflammatory cytokines, interleukin-2 neutralization, and direct suppression of effector T cells. Graves' disease (GD) is a thyroid-specific autoimmune disorder primarily attributed to the breakdown of tolerance to the thyroid-stimulating hormone receptor. Given the limitations of currently available GD treatments, identifying potential pathogenetic factors for pharmacological targeting is of paramount importance. Both functional impairment and frequency reduction of Tregs seem likely in GD pathogenesis. Genome-wide association studies in GD have identified polymorphisms of genes involved in Tregs' functions, such as CD25 (interleukin 2 receptor), and Forkhead box protein P3 (FOXP3). Clinical studies have reported both functional impairment and a reduction in Treg frequency or suppressive actions in GD, although their precise involvement remains a subject of debate. This review begins with an overview of Treg phenotype and functions, subsequently delves into the pathophysiology of GD and into the existing literature concerning the role of Tregs and the balance between Tregs and T helper 17 cells in GD, and finally explores the ongoing studies on target therapies for GD.
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Affiliation(s)
- Natasa Kustrimovic
- Center for Translational Research on Autoimmune and Allergic Disease—CAAD, Università del Piemonte Orientale, 28100 Novara, Italy
| | - Daniela Gallo
- Endocrine Unit, Department of Medicine and Surgery, University of Insubria, ASST dei Sette Laghi, 21100 Varese, Italy (M.L.T.)
| | - Eliana Piantanida
- Endocrine Unit, Department of Medicine and Surgery, University of Insubria, ASST dei Sette Laghi, 21100 Varese, Italy (M.L.T.)
| | - Luigi Bartalena
- Endocrine Unit, Department of Medicine and Surgery, University of Insubria, ASST dei Sette Laghi, 21100 Varese, Italy (M.L.T.)
| | - Adriana Lai
- Endocrine Unit, Department of Medicine and Surgery, University of Insubria, ASST dei Sette Laghi, 21100 Varese, Italy (M.L.T.)
| | - Nicola Zerbinati
- Dermatology Unit, Department of Medicine and Surgery, University of Insubria, ASST dei Sette Laghi, 21100 Varese, Italy
| | - Maria Laura Tanda
- Endocrine Unit, Department of Medicine and Surgery, University of Insubria, ASST dei Sette Laghi, 21100 Varese, Italy (M.L.T.)
| | - Lorenzo Mortara
- Immunology and General Pathology Laboratory, Department of Biotechnology and Life Sciences, University of Insubria, 21100 Varese, Italy
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Parameswaran R, de Jong MC, Kit JLW, Sek K, Nam TQ, Thang TV, Khue NT, Aye TT, Tun PM, Cole T, Miller JA, Villa M, Khiewvan B, Sirinvaravong S, Sin YL, Muhammad R, Jap TS, Agrawal A, Rajput R, Fernando R, Sumanatilleke M, Suastika K, Shong YK, Lang B, Bartalena L, Yang SP. 2021 Asia-Pacific Graves' Disease Consortium Survey of Clinical Practice Patterns in the Management of Graves' Disease. Endocrine 2023; 79:135-142. [PMID: 36129592 DOI: 10.1007/s12020-022-03193-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Accepted: 09/03/2022] [Indexed: 01/07/2023]
Abstract
AIM Although Graves' disease (GD) is common in endocrine practices worldwide, global differences in diagnosis and management remain. We sought to assess the current practices for GD in countries across Asia and the Pacific (APAC), and to compare these with previously published surveys from North America and Europe. METHODS A web-based survey on GD management was conducted on practicing clinicians. Responses from 542 clinicians were received and subsequently analysed and compared to outcomes from similar surveys from other regions. RESULTS A total of 542 respondents participated in the survey, 515 (95%) of whom completed all sections. Of these, 86% were medical specialists, 11% surgeons, and 3% nuclear medicine physicians. In addition to serum thyroid-stimulating hormone (TSH) and free thyroxine assays, most respondents would request TSH-receptor autoantibody (TRAb) measurement (68%) during initial work-up. Thyroid ultrasound is requested by about half of respondents (53%), while the use of nuclear medicine scans is limited. The preferred first-line treatment is anti-thyroid drug (ATD) therapy (79%) with methimazole (MMI) or carbimazole (CBZ), followed by radioiodine (RAI; 19%) and surgery (2%). In case of surgery, one-third of respondents would opt for a subtotal rather than a total thyroidectomy. In case of mild Graves orbitopathy (GO), ATDs (67%) remains the preferred treatment, but a larger proportion of clinicians prefer surgery (20%). For a patient with intention to conceive, the preferred treatment pattern remained unchanged, although propylthiouracil (PTU) became the preferred ATD-agent during the first trimester. In comparison to European and American practices, marked differences were noted in the relatively infrequent usage of nuclear medicine scans and the overall higher use of a ATDs and β-blockers and adjunctive ATD-treatment during RAI in the APAC-group. CONCLUSION Although regional differences regarding the diagnosis and management of GD are apparent in this first pan-Asia-Pacific survey, this study reveals the overall approach to the management of this disease in Asia-Pacific generally tends to fall between the trends appreciated in the American and European cohorts.
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Affiliation(s)
- Rajeev Parameswaran
- Department of Endocrine Surgery, National University Hospital, Singapore, Singapore.
- Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.
| | | | - James Lee Wai Kit
- Department of Endocrine Surgery, National University Hospital, Singapore, Singapore
| | - Kathleen Sek
- Department of Endocrinology, National University Hospital, Singapore, Singapore
| | - Tran Quang Nam
- Department of Endocrinology, University of Medicine and Pharmacy, Ho Chi Minh City, Vietnam
| | - Tran Viet Thang
- Department of Endocrinology, University of Medicine and Pharmacy, Ho Chi Minh City, Vietnam
| | - Nguyen Thy Khue
- Department of Endocrinology, University of Medicine and Pharmacy of Ho Chi Minh City, Ho Chi Minh City, Vietnam
| | - Than Than Aye
- Department of Diabetes and Endocrinology, University of Medicine 2, Yangon, Myanmar
| | - Phone Myint Tun
- Department of Otolaryngology, Grand Hantha International Hospital, Yangon, Myanmar
| | - Timothy Cole
- Department of Biochemistry & Molecular Biology, Monash University, Wellington Road, Clayton, VIC, 3800, Australia
| | - Julie A Miller
- Endocrine Surgery Unit, The Royal Melbourne Hospital, and Department of Surgery, Melbourne University, Parkville, VIC, Australia
| | - Michael Villa
- Philippines Center for Diabetes, Thyroid and Endocrine Disorders, St. Luke's Medical Center, Global City, Taguig, Philippines
| | - Benjapa Khiewvan
- Division of Nuclear Medicine, Department of Radiology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Sirinart Sirinvaravong
- Division of Endocrinology and Metabolism, Department of Medicine, Siriraj Hospital, Mahidol University, Nakhon, Thailand
| | - Yong Lit Sin
- Department of Medicine, Hospital Tuanku Jaa'far Seremban, Seremban, Malaysia
| | - Rohaizak Muhammad
- Department of Surgery, Univ Keb Malaysia Medical Centre, Kuala Lumpur, Malaysia
| | - Tjin Shing Jap
- Department of Endocrinology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Amit Agrawal
- Department of Endocrine Surgery, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
| | - Rajesh Rajput
- Department of Endocrinology, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak, India
| | - Ranil Fernando
- Department of Surgery, North Colombo Teaching Hospital Ragama, Ragama, Sri Lanka
| | | | - Ketut Suastika
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Faculty of Medicine, Udayana University, Bali, Indonesia
| | - Young Kee Shong
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Brian Lang
- Division of Endocrine Surgery at Queen Mary Hospital, Pok Fu Lam, Hong Kong
| | - Luigi Bartalena
- Division of Endocrinology, University of Insubria, Varese, Italy
| | - Samantha Peiling Yang
- Department of Endocrinology, National University Hospital, Singapore, Singapore.
- Division of Endocrinology, Yong Loo Lin School of Medicine, National University of, Singapore, Singapore.
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Gallo D, Bruno A, Gallazzi M, Cattaneo SAM, Veronesi G, Genoni A, Tanda ML, Bartalena L, Passi A, Piantanida E, Mortara L. Immunomodulatory role of vitamin D and selenium supplementation in newly diagnosed Graves' disease patients during methimazole treatment. Front Endocrinol (Lausanne) 2023; 14:1145811. [PMID: 37124743 PMCID: PMC10141462 DOI: 10.3389/fendo.2023.1145811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 03/03/2023] [Indexed: 05/02/2023] Open
Abstract
Introduction Methimazole (MMI) represents the conventional therapeutic agent for Graves' disease (GD) hyperthyroidism, but MMI efficacy is limited since it marginally affects the underlying autoimmune process. In a previous study, we randomly assigned 42 newly diagnosed GD patients with insufficient vitamin D (VitD) and selenium (Se) levels to treatment with MMI alone (standard) or combined with selenomethionine and cholecalciferol (intervention) and observed a prompter resolution of hyperthyroidism in the intervention group. Methods In the present study, we aimed to explore changes in peripheral T regulatory (Treg) and circulating natural killer (NK) cell frequency, circulating NK cell subset distribution and function, during treatment. Results At baseline, circulating total CD3-CD56+NK cells and CD56bright NK cells were significantly higher in GD patients than in healthy controls (HC) (15.7 ± 9.6% vs 9.9 ± 5.6%, p=0.001; 12.2 ± 10.3% vs 7.3 ± 4.1%, p=0.02, respectively); no differences emerged in Treg cell frequency. Frequencies of total NK cells and CD56bright NK cells expressing the activation marker CD69 were significantly higher in GD patients than in HC, while total NK cells and CD56dim NK cells expressing CD161 (inhibitory receptor) were significantly lower. When co-cultured with the K562 target cell, NK cells from GD patients had a significantly lower degranulation ability compared to HC (p<0.001). Following 6 months of treatment, NK cells decreased in both the intervention and MMI-alone groups, but significantly more in the intervention group (total NK: -10.3%, CI 95% -15.8; -4.8% vs -3.6%, CI 95% -9; 1.8%, p=0.09 and CD56bright NK cells: -6.5%, CI 95% -10.1; -3 vs -0.9%, CI 95% -4.4; 2%, p=0.03). Compared to baseline, CD69+ NK cells significantly decreased, while degranulation ability slightly improved, although no differences emerged between the two treatment groups. Compared to baseline, Treg cell frequency increased exclusively in the intervention group (+1.1%, CI 95% 0.4; 1.7%). Discussion This pilot study suggested that VitD and Se supplementation, in GD patients receiving MMI treatment, modulates Treg and NK cell frequency, favoring a more pronounced reduction of NK cells and the increase of Treg cells, compared to MMI alone. Even if further studies are needed, it is possible to speculate that this immunomodulatory action might have facilitated the prompter and better control of hyperthyroidism in the supplemented group observed in the previous study.
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Affiliation(s)
- Daniela Gallo
- Endocrine Unit, Department of Medicine and Surgery, University of Insubria, Azienda Socio-Sanitaria Territoriale dei Sette Laghi, Varese, Italy
| | - Antonino Bruno
- Immunology and General Pathology Laboratory, Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy
- Laboratory of Innate Immunity, Unit of Molecular Pathology, Biochemistry, and Immunology, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) MultiMedica, Milan, Italy
| | - Matteo Gallazzi
- Immunology and General Pathology Laboratory, Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy
- Laboratory of Innate Immunity, Unit of Molecular Pathology, Biochemistry, and Immunology, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) MultiMedica, Milan, Italy
| | | | - Giovanni Veronesi
- Research Centre in Epidemiology and Preventive Medicine (EPIMED), Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Angelo Genoni
- Azienda Socio-Sanitaria Territoriale dei Sette Laghi, Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Maria Laura Tanda
- Endocrine Unit, Department of Medicine and Surgery, University of Insubria, Azienda Socio-Sanitaria Territoriale dei Sette Laghi, Varese, Italy
| | - Luigi Bartalena
- Endocrine Unit, Department of Medicine and Surgery, University of Insubria, Azienda Socio-Sanitaria Territoriale dei Sette Laghi, Varese, Italy
| | - Alberto Passi
- Laboratory of Clinical Chemical Analysis, Department of Medicine and Surgery, University of Insubria, Azienda Socio-Sanitaria dei Sette Laghi, Varese, Italy
| | - Eliana Piantanida
- Endocrine Unit, Department of Medicine and Surgery, University of Insubria, Azienda Socio-Sanitaria Territoriale dei Sette Laghi, Varese, Italy
| | - Lorenzo Mortara
- Immunology and General Pathology Laboratory, Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy
- *Correspondence: Lorenzo Mortara,
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Gallo D, De Vito A, Roncoroni R, Bruno A, Piantanida E, Bartalena L, Tanda ML, Mortara L, Acquati F. A potential role of human RNASET2 overexpression in the pathogenesis of Graves' disease. Endocrine 2023; 79:55-59. [PMID: 36180758 DOI: 10.1007/s12020-022-03207-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 09/20/2022] [Indexed: 01/07/2023]
Abstract
Genetic variation of the gene encoding for the only human enzyme of the T2 ribonucleases family (RNASET2) emerged in genome-wide association studies as a putative risk hotspot for Graves' disease (GD). T2 ribonucleases activities include immune regulation, induction of cell apoptosis and differentiation. Several reports supported the hypothesis that RNASET2 represents a "danger" message addressed to the innate immune system in peculiar conditions. This was a longitudinal, case-control study. RNASET2 protein levels were assessed in blood samples from 34 consecutive newly diagnosed GD patients and in healthy controls. At enrollment, RNASET2 levels were significantly higher in GD patients (98.5 ± 29.1 ng/ml) compared to healthy controls (72.5 ± 27.9 ng/ml, p = 0.001). After 6 months of methimazole treatment, RNASET2 levels significantly decrease and return to levels similar to healthy controls (62.4 ± 22 ng/ml, p = 0.69). These preliminary results suggest that RNASET2 is overexpressed in patients with GD and might represent an "alarm signal" generated by thyroid cells in response to endogenous or environmental stress to alert the immune system.
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Affiliation(s)
- Daniela Gallo
- Endocrine Unit, Department of Medicine and Surgery, University of Insubria, ASST dei Sette Laghi, 21100, Varese, Italy.
| | - Annarosaria De Vito
- Human Genetics Laboratory, Department of Biotechnology and Life Sciences, University of Insubria, 21100, Varese, Italy
| | - Rossella Roncoroni
- Human Genetics Laboratory, Department of Biotechnology and Life Sciences, University of Insubria, 21100, Varese, Italy
| | - Antonino Bruno
- Immunology and General Pathology Laboratory, Department of Biotechnology and Life Sciences, University of Insubria, 21100, Varese, Italy
- IRCCS MultiMedica, Milan, 20138, Italy
| | - Eliana Piantanida
- Endocrine Unit, Department of Medicine and Surgery, University of Insubria, ASST dei Sette Laghi, 21100, Varese, Italy
| | - Luigi Bartalena
- Endocrine Unit, Department of Medicine and Surgery, University of Insubria, ASST dei Sette Laghi, 21100, Varese, Italy
| | - Maria Laura Tanda
- Endocrine Unit, Department of Medicine and Surgery, University of Insubria, ASST dei Sette Laghi, 21100, Varese, Italy
| | - Lorenzo Mortara
- Immunology and General Pathology Laboratory, Department of Biotechnology and Life Sciences, University of Insubria, 21100, Varese, Italy
| | - Francesco Acquati
- Human Genetics Laboratory, Department of Biotechnology and Life Sciences, University of Insubria, 21100, Varese, Italy
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Cappellani D, Marconcini G, Manetti L, Bartalena L, Bogazzi F. Real-life data on the impact of medical therapy for amiodarone-induced thyrotoxicosis on CV events and hospitalizations. J Clin Endocrinol Metab 2022; 108:1298-1307. [PMID: 36585895 DOI: 10.1210/clinem/dgac756] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Revised: 12/09/2022] [Accepted: 12/28/2022] [Indexed: 01/01/2023]
Abstract
CONTEXT Patients with amiodarone-induced thyrotoxicosis (AIT) often receive the initial therapy for thyrotoxicosis in several different medical settings before admission to a referral center. Whether the first-line medical therapy (i.e. therapies for thyrotoxicosis at first diagnosis of AIT) affects the outcome of AIT patients is unknown. STUDY DESIGN Single-center historical-prospective cohort study of 313 AIT patients. METHODS Clinical and biochemical data were collected at first diagnosis, at a referral center, and during the course of AIT. Primary outcomes were cardiovascular events and hospitalizations. First-line therapies were considered appropriate when they included glucocorticoids for type 2 AIT and methimazole for type 1 AIT at the approved dosage, either alone (optimal medical therapy, OMT) or in combination (right-dose combination therapy, RCT). Other therapies were considered not appropriate, including no therapy. Duration of exposure to thyrotoxicosis was the time from first diagnosis of AIT to its remission. RESULTS 34.5% patients received appropriate therapies (28.1% OMT, 6.4% RCT), whereas the remaining (65.5%) received non-appropriate therapies. Cardiovascular events, and hospitalizations were more frequent in patients who received non-appropriate therapies (33.2% vs 4.5%, and 24.9% vs 6.5%, respectively; p<0.0001 for both). Appropriate therapies reduced serum thyroid hormone concentrations (p=0.018) from first diagnosis to referral, unlike the non-appropriate therapies. The duration of exposure to thyrotoxicosis was longer in patients receiving non-appropriate therapies and was a risk factor for arrhythmias (HR 1.004, p=0.0008), MACEs (HR 1.004, p=0.020) and hospitalizations (HR 1.006, p<.0001). CONCLUSIONS The first medical therapy of AIT influences the exposure time to thyrotoxicosis and the occurrence of cardiovascular events and hospitalizations.
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Affiliation(s)
- Daniele Cappellani
- Unit of Endocrinology, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Giulia Marconcini
- Unit of Endocrinology, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Luca Manetti
- Unit of Endocrinology, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Luigi Bartalena
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Fausto Bogazzi
- Unit of Endocrinology, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
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Bartalena L. Role of teprotumumab in the treatment of active moderate-to-severe Graves' orbitopathy. Eur Thyroid J 2022; 11:e220185. [PMID: 36479873 PMCID: PMC9716370 DOI: 10.1530/etj-22-0185] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 10/17/2022] [Indexed: 12/14/2022] Open
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Abstract
Graves' orbitopathy (GO) is an orbital autoimmune disorder and the main extrathyroidal manifestation of Graves' disease, the most common cause of hyperthyroidism. GO affects about 30% of Graves' patients, although fewer than 10% have severe forms requiring immunosuppressive treatments. Management of GO requires a multidisciplinary approach. Medical therapies for active moderate-to-severe forms of GO (traditionally, high-dose glucocorticoids) often provide unsatisfactory results, and subsequently surgeries are often needed to cure residual manifestations. The aim of this review is to provide an updated overview of current concepts regarding the epidemiology, pathogenesis, assessment, and treatment of GO, and to present emerging targeted therapies and therapeutic perspectives. Original articles, clinical trials, systematic reviews, and meta-analyses from 1980 to 2021 were searched using the following terms: Graves' disease, Graves' orbitopathy, thyroid eye disease, glucocorticoids, orbital radiotherapy, rituximab, cyclosporine, azathioprine, teprotumumab, TSH-receptor antibody, smoking, hyperthyroidism, hypothyroidism, thyroidectomy, radioactive iodine, and antithyroid drugs. Recent studies suggest a secular trend toward a milder phenotype of GO. Standardized assessment at a thyroid eye clinic allows for a better general management plan. Treatment of active moderate-to-severe forms of GO still relies in most cases on high-dose systemic-mainly intravenous-glucocorticoids as monotherapy or in combination with other therapies-such as mycophenolate, cyclosporine, azathioprine, or orbital radiotherapy-but novel biological agents-including teprotumumab, rituximab, and tocilizumab-have achieved encouraging results.
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Affiliation(s)
- Luigi Bartalena
- Department of Medicine and SurgeryUniversity of InsubriaVareseItaly
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Bartalena L, Marcocci C, Tanda ML, Marinò M. Reply to Letter to the Editor by Dr. Terry J. Smith regarding teprotumumab and ototoxicity. J Endocrinol Invest 2022; 45:1603-1604. [PMID: 35633498 DOI: 10.1007/s40618-022-01829-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Accepted: 05/24/2022] [Indexed: 01/22/2023]
Affiliation(s)
- L Bartalena
- Department of Medicine and Surgery, University of Insubria, Via Ravasi, 2, 21100, Varese, Italy.
| | - C Marcocci
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - M L Tanda
- Department of Medicine and Surgery, University of Insubria, Via Ravasi, 2, 21100, Varese, Italy
| | - M Marinò
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
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Bartalena L, Marinò M, Marcocci C, Tanda ML. Teprotumumab for Graves' orbitopathy and ototoxicity: moving problems from eyes to ears? J Endocrinol Invest 2022; 45:1455-1457. [PMID: 35403994 DOI: 10.1007/s40618-022-01791-w] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 03/22/2022] [Indexed: 02/01/2023]
Affiliation(s)
- L Bartalena
- Emeritus Professor of Endocrinology, Department of Medicine and Surgery, University of Insubria, Via Guicciardini, 9, 21100, Varese, Italy.
| | - M Marinò
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - C Marcocci
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - M L Tanda
- Emeritus Professor of Endocrinology, Department of Medicine and Surgery, University of Insubria, Via Guicciardini, 9, 21100, Varese, Italy
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Trimarchi F, Arvat E, Bartalena L, Colao A. L’ambulatorio di Endocrinologia durante e dopo la pandemia da COVID-19: opinioni e riflessioni. L'Endocrinologo 2022. [PMCID: PMC8864458 DOI: 10.1007/s40619-022-01036-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Francesco Trimarchi
- Dipartimento di Medicina Clinica e Sperimentale, Università degli Studi di Messina, Messina, Italia
- Accademia Peloritana dei Pericolanti, Messina, Italia
| | - Emanuela Arvat
- Dipartimento di Scienze Mediche, Università degli Studi di Torino, Torino, Italia
| | - Luigi Bartalena
- E-i-C, Journal of Endocrinological Investigation, Dipartimento di Medicina e Chirurgia, Università dell’Insubria, Varese, Italia
| | - Annamaria Colao
- Presidente SIE, Dipartimento di Medicina Clinica e Chirurgia, Unesco Chair Health Education and Sustainable Development, Università di Napoli Federico II, Napoli, Italia
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Bartalena L, Piantanida E, Gallo D, Ippolito S, Tanda ML. Management of Graves' hyperthyroidism: present and future. Expert Rev Endocrinol Metab 2022; 17:153-166. [PMID: 35287535 DOI: 10.1080/17446651.2022.2052044] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Accepted: 03/08/2022] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Graves' disease (GD) is an autoimmune disorder due to loss of tolerance to the thyrotropin receptor (TSHR) and ultimately caused by stimulatory TSHR antibodies (TSHR-Ab). GD may be associated with extrathyroidal manifestations, mainly Graves' orbitopathy. Treatment of GD relies on antithyroid drugs (ATDs), radioactive iodine (RAI), thyroidectomy. The major ATD limitation is the high recurrence rate after treatment. The major drawback of RAI and thyroidectomy is the inevitable development of permanent hypothyroidism. AREAS COVERED Original articles, clinical trials, systematic reviews, meta-analyses from 1980 to 2021 were searched using the following terms: Graves' disease, management of Graves' disease, antithyroid drugs, radioactive iodine, thyroidectomy, Graves' orbitopathy, thyroid-eye disease. EXPERT OPINION ATDs are the first-line treatment worldwide, are overall safe and usually given for 18-24 months, long-term treatment may decrease relapses. RAI is safe, although associated with a low risk of GO progression, particularly in smokers. Thyroidectomy requires skilled and high-volume surgeons. Patients play a central role in the choice of treatment within a shared decision-making process. Results from targeted therapies acting on different steps of the autoimmune process, including iscalimab, ATX-GD-59, rituximab, blocking TSHR-Ab, small molecules acting as antagonists of the TSHR, are preliminary or preclinical, but promising in medium-to-long perspective.
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Affiliation(s)
- Luigi Bartalena
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Eliana Piantanida
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Daniela Gallo
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Silvia Ippolito
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Maria Laura Tanda
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
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Gallo D, Mortara L, Veronesi G, Cattaneo SAM, Genoni A, Gallazzi M, Peruzzo C, Lasalvia P, Moretto P, Bruno A, Passi A, Pini A, Nauti A, Lavizzari MA, Marinò M, Lanzolla G, Tanda ML, Bartalena L, Piantanida E. Add-On Effect of Selenium and Vitamin D Combined Supplementation in Early Control of Graves' Disease Hyperthyroidism During Methimazole Treatment. Front Endocrinol (Lausanne) 2022; 13:886451. [PMID: 35784564 PMCID: PMC9240752 DOI: 10.3389/fendo.2022.886451] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 05/03/2022] [Indexed: 01/14/2023] Open
Abstract
Prompt and stable control of hyperthyroidism is fundamental to avoid the detrimental effects of thyroid hormone excess, and antithyroid drugs, mainly methimazole (MMI), represent the first-line treatment for Graves' disease (GD) hyperthyroidism. Decreased serum concentrations of selenium (Se) and calcifediol (25(OH)D, VitD) have been reported in newly diagnosed GD patients in observational studies. Low Se levels might exacerbate oxidative stress by compromising the antioxidant machinery's response to reactive oxygen species, and low VitD levels might hamper the anti-inflammatory immune response. We performed a randomized controlled clinical trial (EudraCT 2017-00505011) to investigate whether Se and cholecalciferol (VitD) addition to MMI is associated with a prompter control of hyperthyroidism. Forty-two consecutive patients with newly-onset GD and marginal/insufficient Se and VitD levels were randomly assigned to treatment with either MMI monotherapy or MMI combined with Se and VitD. Se treatment was withdrawn after 180 days, while the other treatments were continued. Combination therapy resulted in a significantly greater reduction in serum FT4 concentration at 45 days (-37.9 pg/ml, CI 95%, -43.7 to -32.2 pg/ml) and 180 days (-36.5 pg/ml, CI 95%, -42 to -30.9 pg/ml) compared to MMI monotherapy (respectively: -25.7 pg/ml, CI 95%, -31.6 to -19.7 pg/ml and -22.9 pg/ml, CI 95%, -28 to -17.3 pg/ml, p 0.002). Data at 270 days confirmed this trend (-37.8 pg/ml, CI 95%, -43.6 to -32.1 pg/ml vs -24.4 pg/ml, CI 95%, -30.3 to -18.4 pg/ml). The quality of life (QoL) score was investigated by the validated "Thyroid-related Patient-Reported Outcome" questionnaire (ThyPRO). ThyPRO composite score showed a greater improvement in the intervention group at 45 days (-14.6, CI 95%, -18.8 to -10.4), 180 (-9, CI 95%, -13.9 to -4.2) and 270 days (-14.3, CI 95%, -19.5 to -9.1) compared to MMI group (respectively, -5.2, CI 95%, -9.5 to -1; -5.4, CI 95%, -10.6 to -0.2 and -3.5, CI 95%, -9 to -2.1, p 0-6 months and 6-9 months <0.05). Our results suggest that reaching optimal Se and VitD levels increases the early efficacy of MMI treatment when Se and VitD levels are suboptimal.
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Affiliation(s)
- Daniela Gallo
- Endocrine Unit, Department of Medicine and Surgery, University of Insubria, Azienda Socio Sanitaria Territoriale (ASST) dei Sette Laghi, Varese, Italy
- *Correspondence: Eliana Piantanida, ; Daniela Gallo,
| | - Lorenzo Mortara
- Immunology and General Pathology Laboratory, Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy
| | - Giovanni Veronesi
- Research Center in Epidemiology and Preventive Medicine (EPIMED), University of Insubria, Varese, Italy
| | - Simona AM Cattaneo
- Immuno-hematology and Transfusion Medicine, ASST dei Sette Laghi, Varese, Italy
| | - Angelo Genoni
- Laboratory of Microbiology, Department of Biotechnology and Life Science, University of Insubria, Varese, Italy
| | - Matteo Gallazzi
- Immunology and General Pathology Laboratory, Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy
| | - Carlo Peruzzo
- Occupational, Preventive and Toxicology Unit, ASST Sette Laghi, Varese, Italy
| | - Paolo Lasalvia
- Research Center in Epidemiology and Preventive Medicine (EPIMED), University of Insubria, Varese, Italy
| | - Paola Moretto
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Antonino Bruno
- Immunology and General Pathology Laboratory, Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy
- Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) MultiMedica, Milan, Italy
| | - Alberto Passi
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
- Laboratory of Clinical Chemical Analysis, ASST dei Sette Laghi, Varese, Italy
| | - Andrea Pini
- Laboratory of Clinical Chemical Analysis, ASST dei Sette Laghi, Varese, Italy
| | - Andrea Nauti
- Laboratory of Clinical Chemical Analysis, ASST dei Sette Laghi, Varese, Italy
| | | | - Michele Marinò
- Department of Clinical and Experimental Medicine, Endocrinology Unit II, University of Pisa and University Hospital of Pisa, Pisa, Italy
| | - Giulia Lanzolla
- Department of Clinical and Experimental Medicine, Endocrinology Unit II, University of Pisa and University Hospital of Pisa, Pisa, Italy
| | - Maria Laura Tanda
- Endocrine Unit, Department of Medicine and Surgery, University of Insubria, Azienda Socio Sanitaria Territoriale (ASST) dei Sette Laghi, Varese, Italy
| | - Luigi Bartalena
- Endocrine Unit, Department of Medicine and Surgery, University of Insubria, Azienda Socio Sanitaria Territoriale (ASST) dei Sette Laghi, Varese, Italy
| | - Eliana Piantanida
- Endocrine Unit, Department of Medicine and Surgery, University of Insubria, Azienda Socio Sanitaria Territoriale (ASST) dei Sette Laghi, Varese, Italy
- *Correspondence: Eliana Piantanida, ; Daniela Gallo,
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Bartalena L, Piantanida E, Tanda ML. Statins for Graves' orbitopathy: a new tool for prevention and treatment? Lancet Diabetes Endocrinol 2021; 9:726-727. [PMID: 34592165 DOI: 10.1016/s2213-8587(21)00268-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 09/13/2021] [Indexed: 10/20/2022]
Affiliation(s)
- Luigi Bartalena
- Department of Medicine & Surgery, University of Insubria, 21100 Varese, Italy.
| | - Eliana Piantanida
- Department of Medicine & Surgery, University of Insubria, 21100 Varese, Italy
| | - Maria Laura Tanda
- Department of Medicine & Surgery, University of Insubria, 21100 Varese, Italy
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Kahaly GJ, Bartalena L. Response to comment by Smith on the 2021 EUGOGO guidelines. Eur J Endocrinol 2021; 185:L15-L16. [PMID: 34619658 DOI: 10.1530/eje-21-0967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Accepted: 10/01/2021] [Indexed: 11/08/2022]
Affiliation(s)
- George J Kahaly
- Department of Medicine I, Johannes Gutenberg-University (JGU) Medical Center, Mainz, Germany
| | - Luigi Bartalena
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
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Cappellani D, De Marco G, Ferrarini E, Torregrossa L, Di Certo AM, Cosentino G, Urbani C, Marconcini G, Mattiello A, Manetti L, Agretti P, Basolo F, Tonacchera M, Bartalena L, Bogazzi F. Identification of Two Different Phenotypes of Patients with Amiodarone-Induced Thyrotoxicosis and Positive Thyrotropin Receptor Antibody Tests. Thyroid 2021; 31:1463-1471. [PMID: 34271828 DOI: 10.1089/thy.2021.0118] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Introduction: Serum thyrotropin (TSH) receptor antibodies (TRAbs) are occasionally found in patients with amiodarone-induced thyrotoxicosis (AIT), and usually point to a diagnosis of type 1 AIT (AIT1) due to Graves' disease (GD). However, the TRAb role and function in AIT have not been clarified. Methods: A retrospective cohort study of 309 AIT patients followed at a single academic center over a 30-year period. AIT TRAb-positive patients (n = 21, 7% of all cases) constituted the study group; control groups consisted of type 2 AIT (AIT2) TRAb-negative patients (n = 233), and 100 non-AIT patients with GD. Clinical and biochemical data at diagnosis and during the course of disease were compared. Histological samples of patients who had total thyroidectomy were reviewed. Stored serum samples were used for a functional assay of TRAb class G immunoglobulins (IgGs) in Chinese hamster ovary (CHO) cells stably transfected with complementary DNA encoding for the TSH receptor. Results: TRAb-positive patients were grouped according to color flow Doppler sonography, radioactive iodine thyroid uptake, and duration of amiodarone therapy before thyrotoxicosis in type 1 (n = 9, 43%; TRAb1) or type 2 (n = 12, 57%; TRAb2) AIT. TRAb1 patients had clinical and biochemical features indistinguishable from GD controls, and were responsive to methimazole. Conversely, TRAb2 patients had clinical features similar to AIT2 controls, and were responsive to glucocorticoids, but not to methimazole. The CHO cell functional assay demonstrated that TRAb1 IgGs had a stimulatory effect on cyclic AMP production, which was absent in TRAb2 IgGs. Pathology in TRAb1 showed hyperplastic thyroid follicles and mild lymphocyte infiltration, reflecting thyroid stimulation. On the contrary, TRAb2 samples revealed follicle destruction, macrophage infiltration, and sometimes fibrosis, consistent with a destructive process. Conclusions: Almost 60% of TRAb-positive AIT patients had a destructive thyroiditis. TRAb-positive tests in AIT patients do thus not necessarily imply a diagnosis of GD and AIT1, and should be evaluated in the clinical and biochemical setting of each AIT patient and confirmed by measuring thyroid-stimulating immunoglobulins.
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Affiliation(s)
- Daniele Cappellani
- Endocrinology Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Giuseppina De Marco
- Endocrinology Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Eleonora Ferrarini
- Endocrinology Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Liborio Torregrossa
- Pathology Unit, Department of Surgical, Medical, Molecular Pathology and Critical Area, University of Pisa, Pisa, Italy
| | - Agostino Maria Di Certo
- Endocrinology Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Giada Cosentino
- Endocrinology Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Claudio Urbani
- Endocrinology Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Giulia Marconcini
- Endocrinology Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Alessandro Mattiello
- Endocrinology Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Luca Manetti
- Endocrinology Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Patrizia Agretti
- Laboratory of Chemistry and Endocrinology, University Hospital of Pisa, Pisa, Italy
| | - Fulvio Basolo
- Pathology Unit, Department of Surgical, Medical, Molecular Pathology and Critical Area, University of Pisa, Pisa, Italy
| | - Massimo Tonacchera
- Endocrinology Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Luigi Bartalena
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Fausto Bogazzi
- Endocrinology Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
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Bartalena L, Kahaly GJ, Baldeschi L, Dayan CM, Eckstein A, Marcocci C, Marinò M, Vaidya B, Wiersinga WM. The 2021 European Group on Graves' orbitopathy (EUGOGO) clinical practice guidelines for the medical management of Graves' orbitopathy. Eur J Endocrinol 2021; 185:G43-G67. [PMID: 34297684 DOI: 10.1530/eje-21-0479] [Citation(s) in RCA: 316] [Impact Index Per Article: 105.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Accepted: 07/23/2021] [Indexed: 11/08/2022]
Abstract
Graves' orbitopathy (GO) is the main extrathyroidal manifestation of Graves' disease (GD). Choice of treatment should be based on the assessment of clinical activity and severity of GO. Early referral to specialized centers is fundamental for most patients with GO. Risk factors include smoking, thyroid dysfunction, high serum level of thyrotropin receptor antibodies, radioactive iodine (RAI) treatment, and hypercholesterolemia. In mild and active GO, control of risk factors, local treatments, and selenium (selenium-deficient areas) are usually sufficient; if RAI treatment is selected to manage GD, low-dose oral prednisone prophylaxis is needed, especially if risk factors coexist. For both active moderate-to-severe and sight-threatening GO, antithyroid drugs are preferred when managing Graves' hyperthyroidism. In moderate-to-severe and active GO i.v. glucocorticoids are more effective and better tolerated than oral glucocorticoids. Based on current evidence and efficacy/safety profile, costs and reimbursement, drug availability, long-term effectiveness, and patient choice after extensive counseling, a combination of i.v. methylprednisolone and mycophenolate sodium is recommended as first-line treatment. A cumulative dose of 4.5 g of i.v. methylprednisolone in 12 weekly infusions is the optimal regimen. Alternatively, higher cumulative doses not exceeding 8 g can be used as monotherapy in most severe cases and constant/inconstant diplopia. Second-line treatments for moderate-to-severe and active GO include (a) the second course of i.v. methylprednisolone (7.5 g) subsequent to careful ophthalmic and biochemical evaluation, (b) oral prednisone/prednisolone combined with either cyclosporine or azathioprine; (c) orbital radiotherapy combined with oral or i.v. glucocorticoids, (d) teprotumumab; (e) rituximab and (f) tocilizumab. Sight-threatening GO is treated with several high single doses of i.v. methylprednisolone per week and, if unresponsive, with urgent orbital decompression. Rehabilitative surgery (orbital decompression, squint, and eyelid surgery) is indicated for inactive residual GO manifestations.
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Affiliation(s)
- L Bartalena
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - G J Kahaly
- Department of Medicine I, Johannes Gutenberg-University (JGU) Medical Center, Mainz, Germany
| | - L Baldeschi
- Department of Ophthalmology, Cliniques Universitaires Saint Luc, Catholic University of Louvain, Brussels, Belgium
| | - C M Dayan
- Thyroid Research Group, Cardiff University School of Medicine, Cardiff, UK
| | - A Eckstein
- Clinic for Ophthalmology, University Clinic, Essen, Germany
| | - C Marcocci
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - M Marinò
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - B Vaidya
- Department of Endocrinology, Royal Devon & Exeter Hospital and University of Exeter Medical School, Exeter, UK
| | - W M Wiersinga
- Amsterdam University Medical Center, Amsterdam, the Netherlands
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20
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Trimarchi F, Martino E, Bartalena L. Comics' representation of Graves' orbitopathy, by Emil Ferris. J Endocrinol Invest 2021; 44:1799-1800. [PMID: 33389596 DOI: 10.1007/s40618-020-01469-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Accepted: 11/15/2020] [Indexed: 10/22/2022]
Affiliation(s)
- F Trimarchi
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy.
- Accademia Peloritana dei Pericolanti at the University of Messina, Messina, Italy.
| | | | - L Bartalena
- Endocrine Unit, Department of Medicine and Surgery, University of Insubria, Varese, Italy
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21
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Ippolito S, Cusini C, Lasalvia P, Gianfagna F, Veronesi G, Gallo D, Masiello E, Premoli P, Sabatino J, Mercuriali A, Lai A, Piantanida E, Tanda ML, Bartalena L. Change in newly diagnosed Graves' disease phenotype between the twentieth and the twenty-first centuries: meta-analysis and meta-regression. J Endocrinol Invest 2021; 44:1707-1718. [PMID: 33346898 PMCID: PMC8285314 DOI: 10.1007/s40618-020-01479-z] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 11/09/2020] [Indexed: 12/11/2022]
Abstract
PURPOSE According to a few recent studies, the clinical phenotype of Graves' disease (GD) at onset is becoming milder in recent years, in terms of prevalence and severity of hyperthyroidism, goiter and overt eye disease. The aim of this study was to assess the change in GD phenotype across the late twentieth and the early twenty-first centuries. MATERIALS AND METHODS We carried out a systematic search of studies published between 1/1/1980 and 12/31/2017 describing naïve GD patients at diagnosis. We collected epidemiological, clinical, biochemical and serological data reported in the selected studies, and (1) conducted a single-arm meta-analysis to compare clinical and biochemical characteristics of naïve GD patients before and after year 2000 and (2) performed a meta-regression to identify the trend of the observed clinical presentations. RESULTS Eighty selected articles were related to the period before the year 2000, 30 to the years 2000-2017. According to demographics, the two defined populations were homogeneous at meta-analysis: overall estimated female prevalence was 81% [95% CI 79-82], mean estimated age of the entire population was 39.8 years [95% CI 38.4-41.1], with no significant differences between pre- and post-2000 groups (p > 0.05). The overall estimated prevalence of smokers was 40% [95% CI 33-46], with no significant difference between the two groups (p > 0.05). Mean estimated free thyroxine (FT4) and free triiodothyronine (FT3) levels at diagnosis were higher in the pre-2000 group: 4.7 ng/dl [95% CI 4.5-4.9] for FT4 and 14.2 pg/ml [95% CI 13.3-15.1] for FT3, as compared to the post-2000 group: 3.9 ng/dl [95% CI 3.6-4.2] for FT4 and 12.1 pg/ml [95% CI 11.0-13.3] for FT3 (all p < 0.01). Goiter estimated prevalence was higher in the pre-2000 group, 87% [95% CI 84-90], than in the post-2000 group, 56% [95% CI 45-67]. Estimated prevalence for Graves' Orbitopathy (GO) was 34% [95% CI 27-41] in the pre-2000 group and 25% [95% CI 19-30] in the post-2000 group (p = 0.03). Accordingly, meta-regression adjusted for covariates showed an average annual reduction of FT4 (- 0.040 ± 0.008 ng/dl, p < 0.0001), FT3 (- 0.316 ± 0.019 pg/ml, p < 0.0001), goiter prevalence (- 0.023 ± 0.008%, p = 0.006), and goiter size (- 0.560 ± 0.031 ml, p < 0.0001). CONCLUSIONS Our meta-analysis and meta-regression confirmed that GD phenotype at diagnosis is nowadays milder than in the past; we hypothesize that conceivable factors involved in this change are iodoprophylaxis, worldwide decrease in smoking habits, larger use of contraceptive pill and micronutrient supplementation, as well as earlier diagnosis and management.
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Affiliation(s)
- S Ippolito
- Department of Medicine and Surgery, University of Insubria, 21100, Varese, Italy
| | - C Cusini
- Department of Medicine and Surgery, University of Insubria, 21100, Varese, Italy
| | - P Lasalvia
- Research Centre in Epidemiology and Preventive Medicine (EPIMED), University of Insubria, 21100, Varese, Italy
| | - F Gianfagna
- Research Centre in Epidemiology and Preventive Medicine (EPIMED), University of Insubria, 21100, Varese, Italy
- Mediterranea Cardiocentro, 80122, Napoli, Italy
| | - G Veronesi
- Research Centre in Epidemiology and Preventive Medicine (EPIMED), University of Insubria, 21100, Varese, Italy
| | - D Gallo
- Department of Medicine and Surgery, University of Insubria, 21100, Varese, Italy
| | - E Masiello
- Department of Medicine and Surgery, University of Insubria, 21100, Varese, Italy
| | - P Premoli
- Department of Medicine and Surgery, University of Insubria, 21100, Varese, Italy
| | - J Sabatino
- Department of Medicine and Surgery, University of Insubria, 21100, Varese, Italy
| | - A Mercuriali
- Department of Medicine and Surgery, University of Insubria, 21100, Varese, Italy
| | - A Lai
- Department of Medicine and Surgery, University of Insubria, 21100, Varese, Italy
| | - E Piantanida
- Department of Medicine and Surgery, University of Insubria, 21100, Varese, Italy
| | - M L Tanda
- Department of Medicine and Surgery, University of Insubria, 21100, Varese, Italy
| | - L Bartalena
- Department of Medicine and Surgery, University of Insubria, 21100, Varese, Italy.
- Department of Medicine and Surgery, University of Insubria, Endocrine Unit, ASST dei Sette Laghi, Viale L. Borri, 57, 21100, Varese, Italy.
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Affiliation(s)
- F Trimarchi
- Accademia Peloritana Dei Pericolanti at the University of Messina, Messina, Italy.
| | | | - L Bartalena
- Endocrine Unit, Department of Medicine and Surgery, University of Insubria, ASST Dei Sette Laghi, Varese, Italy
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Žarković M, Wiersinga W, Perros P, Bartalena L, Donati S, Okosieme O, Morris D, Fichter N, Lareida J, Daumerie C, Burlacu MC, Kahaly GJ, Pitz S, Beleslin B, Ćirić J, Ayvaz G, Konuk O, Törüner FB, Salvi M, Covelli D, Curro N, Hegedüs L, Brix T. Antithyroid drugs in Graves' hyperthyroidism: differences between "block and replace" and "titration" regimes in frequency of euthyroidism and Graves' orbitopathy during treatment. J Endocrinol Invest 2021; 44:371-378. [PMID: 32524368 DOI: 10.1007/s40618-020-01320-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2020] [Accepted: 05/30/2020] [Indexed: 02/08/2023]
Abstract
PURPOSE Whereas antithyroid drugs (ATD) are the preferred treatment modality for Graves' hyperthyroidism (GH), there is still controversy about the optimal regimen for delivering ATD. To evaluate whether 'Block and Replace' (B + R) and 'Titration' (T) regimes are equivalent in terms of frequency of euthyroidism and Graves' Orbitopathy (GO) during ATD therapy. METHODS A prospective multicentre observational cohort study of 344 patients with GH but no GO at baseline. Patients were treated with ATD for 18 months according to B + R or T regimen in line with their institution's policy. RESULTS Baseline characteristics were similar in both groups. In the treatment period between 6 and 18 months thyrotropin (TSH) slightly increased in both groups, but TSH was on average 0.59 mU/L (95% CI 0.27-0.85) lower in the B + R group at all time points (p = 0.026). Serum free thyroxine (FT4) remained stable during the same interval, with a tendency to higher values in the B + R group. The point-prevalence of euthyroidism (TSH and FT4 within their reference ranges) increased with longer duration of ATD in both groups; it was always higher in the T group than in the B + R group: 48 and 24%, respectively, at 6 months, 81 and 58% at 12 months, and 87 and 63% at 18 months (p < 0.002). There were no significant differences between the B + R and T regimens with respect to the fall in thyrotropin binding inhibiting immunoglobulins (TBII) or thyroid peroxidase antibodies (TPO-Ab). GO developed in 15.9% of all patients: 9.1 and 17.8% in B + R group and T group, respectively, (p = 0.096). GO was mild in 13% and moderate-to-severe in 2%. CONCLUSION The prevalence of biochemical euthyroidism during treatment with antithyroid drugs is higher during T compared to B + R regimen. De novo development of GO did not differ significantly between the two regimens, although it tended to be higher in the T group. Whether one regimen is clinically more advantageous than the other remains unclear.
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Affiliation(s)
- M Žarković
- School of Medicine, University of Belgrade, Belgrade, Serbia.
- Clinic of Endocrinology Clinical Centre of Serbia, Belgrade, Serbia.
| | - W Wiersinga
- Department of Endocrinology and Metabolism, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - P Perros
- Department of Endocrinology, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - L Bartalena
- School of Medicine, University of Insubria, Varese, Italy
| | - S Donati
- School of Medicine, University of Insubria, Varese, Italy
| | - O Okosieme
- Department of Endocrinology, Institute of Molecular and Experimental Medicine, Cardiff University School of Medicine, Cardiff, UK
| | - D Morris
- Cardiff Eye Unit, University Hospital of Wales, Cardiff, UK
| | - N Fichter
- Interdisciplinary Centre for Graves' Orbitopathy, Olten and University Eye Hospital, Basel, Switzerland
| | - J Lareida
- Interdisciplinary Centre for Graves' Orbitopathy, Olten and University Eye Hospital, Basel, Switzerland
| | - C Daumerie
- Department of Endocrinology, Université Catholique de Louvain, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - M-C Burlacu
- Department of Endocrinology, Université Catholique de Louvain, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - G J Kahaly
- Department of Medicine I, Johannes Gutenberg University Medical Center, Mainz, Germany
| | - S Pitz
- Orbital Center, Ophthalmic Clinic, Buergerhospital, Frankfurt, Germany
| | - B Beleslin
- School of Medicine, University of Belgrade, Belgrade, Serbia
- Clinic of Endocrinology Clinical Centre of Serbia, Belgrade, Serbia
| | - J Ćirić
- School of Medicine, University of Belgrade, Belgrade, Serbia
- Clinic of Endocrinology Clinical Centre of Serbia, Belgrade, Serbia
| | - G Ayvaz
- Department of Endocrinology and Metabolism, Faculty of Medicine, Gazi University, Ankara, Turkey
| | - O Konuk
- Department of Ophthalmology, Faculty of Medicine, Gazi University, Ankara, Turkey
| | - F B Törüner
- Department of Endocrinology and Metabolism, Faculty of Medicine, Gazi University, Ankara, Turkey
| | - M Salvi
- Graves' Orbitopathy Unit, Department of Clinical Science and Community Health, Fondazione Ca'Granda IRCCS, University of Milan, Milan, Italy
| | - D Covelli
- Graves' Orbitopathy Unit, Department of Clinical Science and Community Health, Fondazione Ca'Granda IRCCS, University of Milan, Milan, Italy
| | - N Curro
- Department of Ophthalmology, Fondazione IRCCS Ca'Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - L Hegedüs
- Department of Endocrinology and Metabolism, Odense University Hospital, University of Southern Denmark, Odense, Denmark
| | - T Brix
- Department of Endocrinology and Metabolism, Odense University Hospital, University of Southern Denmark, Odense, Denmark
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Trimarchi F, Martino E, Bartalena L. A young lady with goiter by Mario Sironi (1885-1961). J Endocrinol Invest 2021; 44:207-208. [PMID: 32596766 DOI: 10.1007/s40618-020-01345-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Accepted: 06/23/2020] [Indexed: 10/24/2022]
Affiliation(s)
- F Trimarchi
- Accademia Peloritana dei Pericolanti at the University of Messina, Messina, Italy.
| | | | - L Bartalena
- Department of Medicine and Surgery, University of Insubria, Endocrine Unit, ASST dei Sette Laghi, Varese, Italy
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25
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Bartalena L, Piantanida E, Tanda ML. Methimazole Treatment and Acute Pancreatitis: Both Caution and Reassurance Are Needed. J Clin Endocrinol Metab 2020; 105:5902592. [PMID: 32895723 DOI: 10.1210/clinem/dgaa636] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 09/04/2020] [Indexed: 11/19/2022]
Affiliation(s)
- Luigi Bartalena
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Eliana Piantanida
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Maria Laura Tanda
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
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26
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Perros P, Žarković MP, Panagiotou GC, Azzolini C, Ayvaz G, Baldeschi L, Bartalena L, Boschi AM, Nardi M, Brix TH, Covelli D, Daumerie C, Eckstein AK, Fichter N, Ćirić S, Hegedüs L, Kahaly GJ, Konuk O, Lareida JJ, Okosieme OE, Leo M, Mathiopoulou L, Clarke L, Menconi F, Morris DS, Orgiazzi J, Pitz S, Salvi M, Muller I, Knežević M, Wiersinga WM, Currò N, Dayan CM, Marcocci C, Marinò M, Möller L, Pearce SH, Törüner F, Bernard M. Asymmetry indicates more severe and active disease in Graves' orbitopathy: results from a prospective cross-sectional multicentre study. J Endocrinol Invest 2020; 43:1717-1722. [PMID: 32474767 PMCID: PMC7652741 DOI: 10.1007/s40618-020-01258-w] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2020] [Accepted: 04/13/2020] [Indexed: 11/24/2022]
Abstract
PURPOSE Patients with Graves' orbitopathy can present with asymmetric disease. The aim of this study was to identify clinical characteristics that distinguish asymmetric from unilateral and symmetric Graves' orbitopathy. METHODS This was a multi-centre study of new referrals to 13 European Group on Graves' Orbitopathy (EUGOGO) tertiary centres. New patients presenting over a 4 month period with a diagnosis of Graves' orbitopathy were included. Patient demographics were collected and a clinical examination was performed based on a previously published protocol. Patients were categorized as having asymmetric, symmetric, and unilateral Graves' orbitopathy. The distribution of clinical characteristics among the three groups was documented. RESULTS The asymmetric group (n = 83), was older than the symmetric (n = 157) group [mean age 50.9 years (SD 13.9) vs 45.8 (SD 13.5), p = 0.019], had a lower female to male ratio than the symmetric and unilateral (n = 29) groups (1.6 vs 5.0 vs 8.7, p < 0.001), had more active disease than the symmetric and unilateral groups [mean linical Activity Score 3.0 (SD 1.6) vs 1.7 (SD 1.7), p < 0.001 vs 1.3 (SD 1.4), p < 0.001] and significantly more severe disease than the symmetric and unilateral groups, as measured by the Total Eye Score [mean 8.8 (SD 6.6) vs 5.3 (SD 4.4), p < 0.001, vs 2.7 (SD 2.1), p < 0.001]. CONCLUSION Older age, lower female to male ratio, more severe, and more active disease cluster around asymmetric Graves' orbitopathy. Asymmetry appears to be a marker of more severe and more active disease than other presentations. This simple clinical parameter present at first presentation to tertiary centres may be valuable to clinicians who manage such patients.
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Affiliation(s)
- P Perros
- Department of Endocrinology, Level 6, Leazes Wing, Royal Victoria Infirmary, Newcastle upon Tyne, NE1 4LP, Tyne, UK.
| | - M P Žarković
- Faculty of Medicine, University of Belgrade, Dr Subotića 8, Belgrade, Serbia
| | - G C Panagiotou
- Department of Endocrinology, Level 6, Leazes Wing, Royal Victoria Infirmary, Newcastle upon Tyne, NE1 4LP, Tyne, UK
| | - C Azzolini
- Department of Medicine and Surgery, Section of Ophthalmology, School of Medicine, University of Insubria, Via Guicciardini 9, 21100, Varese, Italy
| | - G Ayvaz
- Department of Endocrinology, Yüksek Ihtisas University Ankara Koru Hastanesi, 1450. Sk. No:13, Kızılırmak, 06510, Çankaya, Ankara, Turkey
| | - L Baldeschi
- Department of Ophthalmology, Université Catholique de Louvain, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - L Bartalena
- Endocrine Unit, University of Insubria, Ospedale di Circolo, Viale Borri, 57 21100, Varese, Italy
| | - A M Boschi
- Department of Ophthalmology, Université Catholique de Louvain, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - M Nardi
- Dipartimento di Patologia Chirurgica Medica, Molecolare e Dell'Area Critica, Università di Pisa, Pisa, Italy
| | - T H Brix
- Department of Endocrinology and Metabolism, Odense University Hospital, 5000, Odense, Denmark
| | - D Covelli
- Graves' Orbitopathy Center, Endocrinology, Fondazione IRCCS Cà Granda, University of Milan, via Sforza, 35 - I-20122, Milan, Italy
| | - C Daumerie
- Department of Endocrinology, Université Catholique de Louvain, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - A K Eckstein
- Department of Ophthalmology, University of Duisburg-Essen, 45122, Essen, Germany
| | - N Fichter
- Interdisciplinary Centre for Graves' Orbitopathy, 4600, Olten, Switzerland
| | - S Ćirić
- Clinic of Endocrinology, Clinical Centre of Serbia, Belgrade, Serbia
| | - L Hegedüs
- Department of Endocrinology and Metabolism, Odense University Hospital, 5000, Odense, Denmark
| | - G J Kahaly
- Department of Medicine I, Johannes Gutenberg University Medical Center, 55101, Mainz, Germany
| | - O Konuk
- Department of Ophthalmology, Faculty of Medicine, Gazi University, Besevler, Ankara, 06500, Turkey
| | - J J Lareida
- Interdisciplinary Centre for Graves' Orbitopathy, 4600, Olten, Switzerland
| | - O E Okosieme
- Thyroid Research Group, Cardiff University School of Medicine, Cardiff, UK
| | - M Leo
- Department of Clinical and Experimental Medicine, University of Pisa, Via Paradisa 2, 56124, Pisa, Italy
| | - L Mathiopoulou
- Department of Endocrinology, Level 6, Leazes Wing, Royal Victoria Infirmary, Newcastle upon Tyne, NE1 4LP, Tyne, UK
| | - L Clarke
- Newcastle Eye Centre, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - F Menconi
- Department of Clinical and Experimental Medicine, University of Pisa, Via Paradisa 2, 56124, Pisa, Italy
| | - D S Morris
- Cardiff Eye Unit, University Hospital of Wales, Cardiff, UK
| | - J Orgiazzi
- Department of Endocrinology, Centre Hospitalier Lyon-Sud, Lyon, France
| | - S Pitz
- Orbital Center, Ophthalmic Clinic, Bürger Hospital, Frankfurt, Germany
| | - M Salvi
- Graves' Orbitopathy Center, Endocrinology, Fondazione IRCCS Cà Granda, University of Milan, via Sforza, 35 - I-20122, Milan, Italy
| | - I Muller
- Graves' Orbitopathy Center, Endocrinology, Fondazione IRCCS Cà Granda, University of Milan, via Sforza, 35 - I-20122, Milan, Italy
| | - M Knežević
- Medical School, Clinic for Ophthalmology, Clinical Center of Serbia, University of Belgrade, Belgrade, Serbia
| | - W M Wiersinga
- Department of Endocrinology, Academic Medical Center, Amsterdam, Netherlands
| | - N Currò
- Department of Surgery, Ophthalmology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - C M Dayan
- Thyroid Research Group, Cardiff University School of Medicine, Cardiff, UK
| | - C Marcocci
- Department of Clinical and Experimental Medicine, University of Pisa, Via Paradisa 2, 56124, Pisa, Italy
| | - M Marinò
- Department of Clinical and Experimental Medicine, University of Pisa, Via Paradisa 2, 56124, Pisa, Italy
| | - L Möller
- Interdisciplinary Centre for Graves' Orbitopathy, 4600, Olten, Switzerland
| | - S H Pearce
- Department of Endocrinology, Level 6, Leazes Wing, Royal Victoria Infirmary, Newcastle upon Tyne, NE1 4LP, Tyne, UK
| | - F Törüner
- Department of Endocrinology, Faculty of Medicine, Gazi University, Besevler, Ankara, 06500, Turkey
| | - M Bernard
- Neuro-Ophthalmology Outpatient Clinics, GHE-Hospices Civils de Lyon and Lyon 1 University, Lyon, France
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27
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Bartalena L, Wiersinga WM. Proposal for Standardization of Primary and Secondary Outcomes in Patients with Active, Moderate-to-Severe Graves' Orbitopathy. Eur Thyroid J 2020; 9:3-16. [PMID: 33511081 PMCID: PMC7802435 DOI: 10.1159/000510700] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 08/04/2020] [Indexed: 01/02/2023] Open
Abstract
Standardization of treatment outcomes in randomized clinical trials (RCTs) for active, moderate-to-severe Graves' orbitopathy (GO) is needed to make results of different RCTs comparable and to draw sound conclusions on the efficacy of a given treatment. Both subjective patient-reported outcome (PRO) and objective clinician-reported outcome (CRO) are important in this regard. In this paper, it is proposed that primary PRO should be the evaluation of treatment-related changes in the quality of life by the use of a validated and disease-specific questionnaire (GO-QoL). The proposed primary CRO is a revised composite index, which includes only objective items and provides an overall assessment of the effects of treatment. Secondary outcomes should also be provided in RCTs to show the effects of treatment on individual features of GO, as well on persistence of activity (by the 7-item Clinical Activity Score), safety, relapses of GO, need for subsequent medical and/or surgical treatments, and other indicators (orbital volume, cytokines, TSH receptor antibody levels). Assessment of the overall response to treatment by primary and secondary outcomes should be made 3 months after treatment completion.
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Affiliation(s)
- Luigi Bartalena
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
- *Luigi Bartalena, Endocrine Unit, Department of Medicine and Surgery, University of Insubria, ASST dei Sette Laghi, Viale Borri, 57, IT–21100 Varese (Italy), , or, Wilmar M. Wiersinga, Department of Endocrinology and Metabolism, Academic Medical Center, University of Amsterdam, Meibergdreef 9, NL–1105AZ Amsterdam (The Netherlands),
| | - Wilmar M. Wiersinga
- Department of Endocrinology and Metabolism, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
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28
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Cappellani D, Urbani C, Manetti L, Martino E, Bartalena L, Bogazzi F. Effect of high-dose intravenous glucocorticoid therapy on serum thyroid hormone concentrations in type 2 amiodarone-induced thyrotoxicosis: an exploratory study. J Endocrinol Invest 2020; 43:1637-1643. [PMID: 32300976 DOI: 10.1007/s40618-020-01252-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 04/08/2020] [Indexed: 11/27/2022]
Abstract
PURPOSE Type 2 amiodarone-induced thyrotoxicosis (AIT2) is a form of drug-induced destructive thyroiditis, usually treated with oral glucocorticoids (oGCs). Our objective was to investigate the short-term effects of intravenous glucocorticoids (ivGCs) on serum thyroid hormone concentrations in patients with AIT2. METHODS Exploratory study of three naive AIT2 patients treated with iv methylprednisolone (two pulses of 400 mg with no interpulse oGCs), followed by oGCs, matched 1:3 with AIT2 patients treated with oGCs alone. Changes in serum thyroid hormone concentrations were evaluated in the short-term period (24 h and 7 days) and after a cumulative dosage of 400 and 800 mg equivalents of methylprednisolone; in addition, healing time and duration of exposure to GCs were calculated. RESULTS During the first 24 h of treatment, serum FT4 concentrations increased in ivGCs patients, and decreased in oGCs patients (+ 3.3% vs - 10.7%, respectively, p = 0.025). After 7 days, serum FT4 and FT3 concentrations decreased significantly in both groups, with no statistical difference between them (p = 0.439 for FT4 and p = 0.071 for FT3), even though the cumulative GCs dose was higher in ivGCs than in oGCs patients (800 mg vs 280 mg, p = 0.008). Furthermore, the iv administration of single 400 mg pulses of methylprednisolone resulted in a less significant decrease in serum thyroid hormone concentrations when compared to equivalent GCs doses fractionated in several consecutive days (p = 0.021 for FT4 and p = 0.052 for FT3). There were no significant differences in the healing time (p = 0.239) and duration of exposure to GCs (p = 0.099). CONCLUSIONS High-dose ivGCs therapy does not offer advantages over standard oGCs therapy in the rapid, short-term control of AIT2.
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Affiliation(s)
- D Cappellani
- Department of Clinical and Experimental Medicine, Unit of Endocrinology, University of Pisa, Ospedale Cisanello, via Paradisa 2, 56124, Pisa, Italy
| | - C Urbani
- Department of Clinical and Experimental Medicine, Unit of Endocrinology, University of Pisa, Ospedale Cisanello, via Paradisa 2, 56124, Pisa, Italy
| | - L Manetti
- Department of Clinical and Experimental Medicine, Unit of Endocrinology, University of Pisa, Ospedale Cisanello, via Paradisa 2, 56124, Pisa, Italy
| | - E Martino
- Department of Clinical and Experimental Medicine, Unit of Endocrinology, University of Pisa, Ospedale Cisanello, via Paradisa 2, 56124, Pisa, Italy
| | - L Bartalena
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - F Bogazzi
- Department of Clinical and Experimental Medicine, Unit of Endocrinology, University of Pisa, Ospedale Cisanello, via Paradisa 2, 56124, Pisa, Italy.
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Tanda ML, Gallo D, Ippolito S, Bartalena L, Piantanida E. Treatment of moderate-to-severe and active Graves' orbitopathy: a step forward from the OPTIC study. J Endocrinol Invest 2020; 43:1523-1525. [PMID: 32306294 DOI: 10.1007/s40618-020-01223-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Accepted: 03/13/2020] [Indexed: 12/12/2022]
Affiliation(s)
- M L Tanda
- Department of Medicine and Surgery, University of Insubria, Endocrine Unit, ASST dei Sette Laghi, Viale Borri, 57, 21100, Varèse, Italy
| | - D Gallo
- Department of Medicine and Surgery, University of Insubria, Endocrine Unit, ASST dei Sette Laghi, Viale Borri, 57, 21100, Varèse, Italy
| | - S Ippolito
- Department of Medicine and Surgery, University of Insubria, Endocrine Unit, ASST dei Sette Laghi, Viale Borri, 57, 21100, Varèse, Italy
| | - L Bartalena
- Department of Medicine and Surgery, University of Insubria, Endocrine Unit, ASST dei Sette Laghi, Viale Borri, 57, 21100, Varèse, Italy.
| | - E Piantanida
- Department of Medicine and Surgery, University of Insubria, Endocrine Unit, ASST dei Sette Laghi, Viale Borri, 57, 21100, Varèse, Italy
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Affiliation(s)
- F Trimarchi
- Accademia Peloritana dei Pericolanti at the University of Messina, Messina, Italy.
| | | | - L Bartalena
- Endocrine Unit, Department of Medicine and Surgery, University of Insubria, ASST dei Sette Laghi, Varese, Italy
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Cappellani D, Papini P, Di Certo AM, Morganti R, Urbani C, Manetti L, Tanda ML, Cosentino G, Marconcini G, Materazzi G, Martino E, Bartalena L, Bogazzi F. Duration of Exposure to Thyrotoxicosis Increases Mortality of Compromised AIT Patients: the Role of Early Thyroidectomy. J Clin Endocrinol Metab 2020; 105:5873248. [PMID: 32678873 DOI: 10.1210/clinem/dgaa464] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Accepted: 07/13/2020] [Indexed: 01/21/2023]
Abstract
CONTEXT Patients with amiodarone-induced thyrotoxicosis (AIT) and severely reduced left ventricular ejection fraction (LVEF) have a high mortality rate that may be reduced by total thyroidectomy. Whether in this subset of patients thyroidectomy should be performed early during thyrotoxicosis or later after restoration of euthyroidism has not yet been settled. OBJECTIVES Mortality rates, including peritreatment mortality and 5-year cardiovascular mortality, and predictors of death, evaluated by Cox regression analysis. METHODS Retrospective cohort study of 64 consecutive patients with AIT selected for total thyroidectomy from 1997 to 2019. Four groups of patients were identified according to serum thyroid hormone concentrations and LVEF: Group 1 (thyrotoxic, LVEF <40%), Group 2 (thyrotoxic, LVEF ≥40%), Group 3 (euthyroid, LVEF < 40%), Group 4 (euthyroid, LVEF ≥40%). RESULTS Among patients with low LVEF (Groups 1 and 3), mortality was higher in patients undergoing thyroidectomy after restoration of euthyroidism (Group 3) than in those submitted to surgery when still thyrotoxic (Group 1): peritreatment mortality rates were 40% versus 0%, respectively (P = .048), whereas 5-year cardiovascular mortality rates were 53.3% versus 12.3%, respectively (P = .081). Exposure to thyrotoxicosis was longer in Group 3 than in Group 1 (112 days, interquartile range [IQR] 82.5-140, vs 76 days, IQR 24.8-88.5, P = .021). Survival did not differ in patients with LVEF ≥40% submitted to thyroidectomy irrespective of being thyrotoxic (Group 2) or euthyroid (Group 4): in this setting, peritreatment mortality rates were 6.3% versus 4% (P = .741) and 5-year cardiovascular mortality rates were 12.5% and 20% (P = .685), respectively. Age (hazard ratio [HR] 1.104, P = .029) and duration of exposure to thyrotoxicosis (HR 1.004, P = .039), but not presurgical serum thyroid hormone concentrations (P = .577 for free thyroxine, P = .217 for free triiodothyronine), were independent predictors of death. CONCLUSIONS A prolonged exposure to thyrotoxicosis resulted in increased mortality in patients with reduced LVEF, which may be reduced by early thyroidectomy.
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Affiliation(s)
- Daniele Cappellani
- Unit of Endocrinology, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Piermarco Papini
- Unit of Endocrine Surgery, Department of Surgical, Medical, Molecular Pathology and Critical Area, University of Pisa, Pisa, Italy
| | - Agostino Maria Di Certo
- Unit of Endocrinology, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | | | - Claudio Urbani
- Unit of Endocrinology, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Luca Manetti
- Unit of Endocrinology, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Maria Laura Tanda
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Giada Cosentino
- Unit of Endocrinology, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Giulia Marconcini
- Unit of Endocrinology, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Gabriele Materazzi
- Unit of Endocrine Surgery, Department of Surgical, Medical, Molecular Pathology and Critical Area, University of Pisa, Pisa, Italy
| | - Enio Martino
- Unit of Endocrinology, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Luigi Bartalena
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Fausto Bogazzi
- Unit of Endocrinology, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
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Bartalena L, Chiovato L, Marcocci C, Vitti P, Piantanida E, Tanda ML. Management of Graves' hyperthyroidism and orbitopathy in time of COVID-19 pandemic. J Endocrinol Invest 2020; 43:1149-1151. [PMID: 32441005 PMCID: PMC7241069 DOI: 10.1007/s40618-020-01293-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 05/06/2020] [Indexed: 01/13/2023]
Affiliation(s)
- L Bartalena
- Endocrine Unit, Department of Medicine and Surgery, University of Insubria, ASST dei Sette Laghi, Viale Borri, 57, 21100, Varese, Italy.
| | - L Chiovato
- Unit of Internal Medicine and Endocrinology, Laboratory for Endocrine Disruptors, Istituti Clinici Scientifici Maugeri IRCCS, Pavia, Italy
| | - C Marcocci
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - P Vitti
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - E Piantanida
- Endocrine Unit, Department of Medicine and Surgery, University of Insubria, ASST dei Sette Laghi, Viale Borri, 57, 21100, Varese, Italy
| | - M L Tanda
- Endocrine Unit, Department of Medicine and Surgery, University of Insubria, ASST dei Sette Laghi, Viale Borri, 57, 21100, Varese, Italy
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Affiliation(s)
- F Trimarchi
- Accademia Peloritana dei Pericolanti at the University of Messina, Messina, Italy.
| | | | - L Bartalena
- Endocrine Unit, Department of Medicine & Surgery, University of Insubria, ASST dei Sette Laghi, Varese, Italy
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Piantanida E, Ippolito S, Gallo D, Masiello E, Premoli P, Cusini C, Rosetti S, Sabatino J, Segato S, Trimarchi F, Bartalena L, Tanda ML. The interplay between thyroid and liver: implications for clinical practice. J Endocrinol Invest 2020; 43:885-899. [PMID: 32166702 DOI: 10.1007/s40618-020-01208-6] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Accepted: 02/27/2020] [Indexed: 02/07/2023]
Abstract
A complex relationship exists between thyroid and liver in health and disease. Liver plays an essential physiological role in thyroid hormone activation and inactivation, transport, and metabolism. Conversely, thyroid hormones affect activities of hepatocytes and hepatic metabolism. Serum liver enzyme abnormalities observed in hypothyroidism may be related to impaired lipid metabolism, hepatic steatosis or hypothyroidism-induced myopathy. Severe hypothyroidism may have biochemical and clinical features, such as hyperammonemia and ascites, mimicking those of liver failure. Liver function tests are frequently abnormal also in hyperthyroidism, due to oxidative stress, cholestasis, or enhanced osteoblastic activity. Antithyroid drug-associated hepatotoxicity is a rare event, likely related mainly to an idiosyncratic mechanism, ranging from a mild hepatocellular damage to liver failure. Propylthiouracil-induced liver damage is usually more severe than that caused by methimazole. On the other hand, thyroid abnormalities can be found in liver diseases, such as chronic hepatitis C, liver cirrhosis, hepatocellular carcinoma, and cholangiocarcinoma. In particular, autoimmune thyroid diseases are frequently found in patients with hepatitis C virus infection. These patients, especially if thyroid autoimmunity preexists, are at risk of hypothyroidism or, less frequently, thyrotoxicosis, during and after treatment with interpheron-alpha alone or in combination with ribavirin, commonly used before the introduction of new antiviral drugs. The present review summarizes both liver abnormalities related to thyroid disorders and their treatment, and thyroid abnormalities related to liver diseases and their treatment.
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Affiliation(s)
- E Piantanida
- Endocrine Unit, Department of Medicine and Surgery, Ospedale Di Circolo, ASST Dei Sette Laghi, University of Insubria, Viale Borri, 57, Varese, Italy.
| | - S Ippolito
- Endocrine Unit, Department of Medicine and Surgery, Ospedale Di Circolo, ASST Dei Sette Laghi, University of Insubria, Viale Borri, 57, Varese, Italy
| | - D Gallo
- Endocrine Unit, Department of Medicine and Surgery, Ospedale Di Circolo, ASST Dei Sette Laghi, University of Insubria, Viale Borri, 57, Varese, Italy
| | - E Masiello
- Endocrine Unit, Department of Medicine and Surgery, Ospedale Di Circolo, ASST Dei Sette Laghi, University of Insubria, Viale Borri, 57, Varese, Italy
| | - P Premoli
- Endocrine Unit, Department of Medicine and Surgery, Ospedale Di Circolo, ASST Dei Sette Laghi, University of Insubria, Viale Borri, 57, Varese, Italy
| | - C Cusini
- Endocrine Unit, Department of Medicine and Surgery, Ospedale Di Circolo, ASST Dei Sette Laghi, University of Insubria, Viale Borri, 57, Varese, Italy
| | - S Rosetti
- Endocrine Unit, Department of Medicine and Surgery, Ospedale Di Circolo, ASST Dei Sette Laghi, University of Insubria, Viale Borri, 57, Varese, Italy
| | - J Sabatino
- Endocrine Unit, Department of Medicine and Surgery, Ospedale Di Circolo, ASST Dei Sette Laghi, University of Insubria, Viale Borri, 57, Varese, Italy
| | - S Segato
- Gastroenterology and Gastrointestinal Endoscopic Unit, Department of Specialistic Medicine, ASST Dei Sette Laghi, Varese, Italy
| | - F Trimarchi
- Accademia Peloritana Dei Pericolanti, University of Messina, Messina, Italy
| | - L Bartalena
- Endocrine Unit, Department of Medicine and Surgery, Ospedale Di Circolo, ASST Dei Sette Laghi, University of Insubria, Viale Borri, 57, Varese, Italy.
| | - M L Tanda
- Endocrine Unit, Department of Medicine and Surgery, Ospedale Di Circolo, ASST Dei Sette Laghi, University of Insubria, Viale Borri, 57, Varese, Italy
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Gallo D, Rosetti S, Marcon I, Armiraglio E, Parafioriti A, Pinotti G, Perrucchini G, Patera B, Gentile L, Tanda ML, Bartalena L, Piantanida E. When primary hyperparathyroidism comes as good news. Endocrinol Diabetes Metab Case Rep 2020; 2020:EDM200046. [PMID: 32554826 PMCID: PMC7354736 DOI: 10.1530/edm-20-0046] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 05/15/2020] [Indexed: 12/14/2022] Open
Abstract
SUMMARY Brown tumors are osteoclastic, benign lesions characterized by fibrotic stroma, intense vascularization and multinucleated giant cells. They are the terminal expression of the bone remodelling process occurring in advanced hyperparathyroidism. Nowadays, due to earlier diagnosis, primary hyperparathyroidism keeps few of the classical manifestations and brown tumors are definitely unexpected. Thus, it may happen that they are misdiagnosed as primary or metastatic bone cancer. Besides bone imaging, endocrine evaluation including measurement of serum parathyroid hormone and calcium (Ca) levels supports the pathologist to address the diagnosis. Herein, a case of multiple large brown tumors misdiagnosed as a non-treatable osteosarcoma is described, with special regards to diagnostic work-up. After selective parathyroidectomy, treatment with denosumab was initiated and a regular follow-up was established. The central role of multidisciplinary approach involving pathologist, endocrinologist and oncologist in the diagnostic and therapeutic work-up is reported. In our opinion, the discussion of this case would be functional especially for clinicians and pathologists not used to the differential diagnosis in uncommon bone disorders. LEARNING POINTS Brown tumors develop during the remodelling process of bone in advanced and long-lasting primary or secondary hyperparathyroidism. Although rare, they should be considered during the challenging diagnostic work-up of giant cell lesions. Coexistence of high parathyroid hormone levels and hypercalcemia in primary hyperparathyroidism is crucial for the diagnosis. A detailed imaging study includes bone X-ray, bone scintiscan and total body CT; to rule out bone malignancy, evaluation of bone lesion biopsy should include immunostaining for neoplastic markers as H3G34W and Ki67 index. If primary hyperparathyroidism is confirmed, selective parathyroidectomy is the first-line treatment. In advanced bone disease, treatment with denosumab should be considered, ensuring a strict control of Ca levels.
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Affiliation(s)
- Daniela Gallo
- Department of Medicine and Surgery, Endocrine Unit, University of Insubria, Varese, Italy
| | - Sara Rosetti
- Department of Medicine and Surgery, Endocrine Unit, University of Insubria, Varese, Italy
| | - Ilaria Marcon
- Department of Oncology, ASST dei Sette Laghi, Varese, Italy
| | - Elisabetta Armiraglio
- Pathology Unit, ASST Gaetano Pini, Centro Specialistico Ortopedico Traumatologico, Gaetano Pini-CTO, Milano, Italy
| | - Antonina Parafioriti
- Pathology Unit, ASST Gaetano Pini, Centro Specialistico Ortopedico Traumatologico, Gaetano Pini-CTO, Milano, Italy
| | | | | | - Bohdan Patera
- Department of Medicine and Surgery, Endocrine Unit, University of Insubria, Varese, Italy
| | - Linda Gentile
- Department of Medicine and Surgery, Endocrine Unit, University of Insubria, Varese, Italy
| | - Maria Laura Tanda
- Department of Medicine and Surgery, Endocrine Unit, University of Insubria, Varese, Italy
| | - Luigi Bartalena
- Department of Medicine and Surgery, Endocrine Unit, University of Insubria, Varese, Italy
| | - Eliana Piantanida
- Department of Medicine and Surgery, Endocrine Unit, University of Insubria, Varese, Italy
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Trimarchi F, Martino E, Bartalena L. Cushing syndrome at the court of the infant of Spain in the eighteenth century? J Endocrinol Invest 2020; 43:871-872. [PMID: 31927746 DOI: 10.1007/s40618-020-01181-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Accepted: 01/06/2020] [Indexed: 10/25/2022]
Affiliation(s)
- F Trimarchi
- Accademia Peloritana dei Pericolanti at the University of Messina, Messina, Italy.
| | | | - L Bartalena
- Endocrine Unit, Department of Medicine and Surgery, ASST dei Sette Laghi, University of Insubria, Varese, Italy
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Piantanida E, Gallo D, Dozio E, Trotti E, Piantanida E, Frattini F, Franzi F, Sessa F, Dionigi GL, Sabatino J, Bartalena L, Tanda ML, Ippolito S. Gastric Xanthomatous Hyperplastic Polyps – Just an Incidental Endoscopic Finding? Surg Case Rep 2020. [DOI: 10.31487/j.scr.2020.05.14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Laparoscopic sleeve gastrectomy (LSG) progressively became the preferred procedure
worldwide for the treatment of morbid obesity. Occasionally, unknown gastrointestinal diseases may be
incidentally discovered during the procedure or on the histologic gastric specimen. Gastric xanthomas are
uncommon lesions of the lamina propria, composed by foamy macrophages and mixed inflammatory
infiltrate. Rarely, xanthoma cells develop within a gastric hyperplastic polyp. Although usually benign, they
may be associated with pre-malignant conditions or even gastric cancer, making advisable an appropriate
workup.
Case Presentation: A hyperplastic polyp with xanthomatous proliferation was discovered in the gastric
specimen of a young man, suffering from severe obesity and metabolic syndrome. The patient had been
treated with proton pump inhibitors for gastric discomfort for years. After the surgical procedure, the gastric
discomfort rapidly disappeared.
Conclusion: Obesity is often complicated by gastrointestinal abnormalities discovered during ultrasound
or endoscopic procedures. Incidental findings of unknown gastric lesions are common occurrences during
sleeve gastrectomy. Although xanthelasmas per se are harmless, they might coexist with pre-malignant/
malignant lesions, especially when associated with gastric polyps. Thus, prompt intra-operative recognition
and adequate work-up are mandatory. Although cases of gastric polyps or xanthomas are not a novelty, to
our knowledge, this is the first case reporting about the discovery of a gastric hyperplastic polyp with
xanthomatous proliferation on gastric histological piece. From the discussion of this case and of similar
reports in the literature, we advocated for the importance of endoscopic screening in obese patients admitted
for bariatric surgery to address the proper surgical approach and follow-up.
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Affiliation(s)
- F Trimarchi
- Accademia Peloritana dei Pericolanti at the University of Messina, Messina, Italy.
| | | | - L Bartalena
- Endocrine Unit, Department of Medicine and Surgery, University of Insubria, Varese, Italy
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Trimarchi F, Martino E, Bartalena L. The multinodular goiter of the virtuous Roman matron Lucretia by Artemisia Gentileschi. J Endocrinol Invest 2020; 43:701-702. [PMID: 31786793 DOI: 10.1007/s40618-019-01157-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2019] [Accepted: 11/27/2019] [Indexed: 11/24/2022]
Affiliation(s)
- F Trimarchi
- Accademia Peloritana dei Pericolanti at The University of Messina, Messina, Italy.
| | | | - L Bartalena
- Endocrine Unit, Department of Medicine and Surgery, University of Insubria, Varese, Italy
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Gallo D, Mortara L, Gariboldi MB, Cattaneo SAM, Rosetti S, Gentile L, Noonan DM, Premoli P, Cusini C, Tanda ML, Bartalena L, Piantanida E. Immunomodulatory effect of vitamin D and its potential role in the prevention and treatment of thyroid autoimmunity: a narrative review. J Endocrinol Invest 2020; 43:413-429. [PMID: 31584143 DOI: 10.1007/s40618-019-01123-5] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Accepted: 09/18/2019] [Indexed: 02/06/2023]
Abstract
The main role of vitamin D is to control mineral homeostasis. However, recent studies suggested the existence of a number of extraskeletal effects. Among the latter, preclinical studies provided consistent data on the involvement of vitamin D in innate and adaptive immunity and autoimmunity. Molecular biology studies showed that both vitamin D receptor and vitamin D enzymatic complexes are expressed in a large number of cells and tissues unrelated to mineral homeostasis. In contrast, only a few randomized clinical trials in humans investigated the possible role of vitamin D in the prevention or treatment of immunological disorders. In this regard, low serum vitamin D levels have been reported in observational trials in human autoimmune disorders. The aim of the present paper was to review the potential implications of vitamin D in immune modulation, with special focus on thyroid autoimmune disorders.
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Affiliation(s)
- D Gallo
- Endocrine Unit, Department of Medicine and Surgery, University of Insubria, ASST dei Sette Laghi, Viale L. Borri, 57, 21100, Varese, Italy
| | - L Mortara
- Immunology and General Pathology Laboratory, Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy
| | - M B Gariboldi
- Department of Biotechnology and Life Sciences, University of Insubria, Busto Arsizio, Italy
| | - S A M Cattaneo
- Immunohematology and Transfusion Medicine Unit, ASST dei Sette Laghi, Varese, Italy
| | - S Rosetti
- Endocrine Unit, Department of Medicine and Surgery, University of Insubria, ASST dei Sette Laghi, Viale L. Borri, 57, 21100, Varese, Italy
| | - L Gentile
- Endocrine Unit, Department of Medicine and Surgery, University of Insubria, ASST dei Sette Laghi, Viale L. Borri, 57, 21100, Varese, Italy
| | - D M Noonan
- Immunology and General Pathology Laboratory, Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy
- Vascular Biology and Angiogenesis Laboratory, Science and Technology Pole (PST), IRCCS Multimedica, Milan, Italy
| | - P Premoli
- Endocrine Unit, Department of Medicine and Surgery, University of Insubria, ASST dei Sette Laghi, Viale L. Borri, 57, 21100, Varese, Italy
| | - C Cusini
- Endocrine Unit, Department of Medicine and Surgery, University of Insubria, ASST dei Sette Laghi, Viale L. Borri, 57, 21100, Varese, Italy
| | - M L Tanda
- Endocrine Unit, Department of Medicine and Surgery, University of Insubria, ASST dei Sette Laghi, Viale L. Borri, 57, 21100, Varese, Italy
| | - L Bartalena
- Endocrine Unit, Department of Medicine and Surgery, University of Insubria, ASST dei Sette Laghi, Viale L. Borri, 57, 21100, Varese, Italy.
| | - E Piantanida
- Endocrine Unit, Department of Medicine and Surgery, University of Insubria, ASST dei Sette Laghi, Viale L. Borri, 57, 21100, Varese, Italy.
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Trimarchi F, Martino E, Bartalena L. Pituitary disorders as wonders and curiosity in XVI Century. J Endocrinol Invest 2020; 43:551-552. [PMID: 31541407 DOI: 10.1007/s40618-019-01121-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2019] [Accepted: 09/17/2019] [Indexed: 11/26/2022]
Affiliation(s)
- F Trimarchi
- Accademia Peloritana dei Pericolanti, University of Messina, Messina, Italy.
| | | | - L Bartalena
- Endocrine Unit, Department of Medicine and Surgery, University of Insubria, Varese, Italy
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42
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Rosetti S, Tanda ML, Veronesi G, Masiello E, Premoli P, Gallo D, Cusini C, Donati S, Sabatino J, Ippolito S, Piantanida E, Bartalena L. Oral steroid prophylaxis for Graves' orbitopathy after radioactive iodine treatment for Graves' disease is not only effective, but also safe. J Endocrinol Invest 2020; 43:381-383. [PMID: 31587179 DOI: 10.1007/s40618-019-01126-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Accepted: 09/28/2019] [Indexed: 11/25/2022]
Affiliation(s)
- S Rosetti
- Department of Medicine and Surgery, Endocrine Unit, University of Insubria, ASST dei Sette Laghi, Viale Borri, 57, 21100, Varese, Italy
| | - M L Tanda
- Department of Medicine and Surgery, Endocrine Unit, University of Insubria, ASST dei Sette Laghi, Viale Borri, 57, 21100, Varese, Italy
| | - G Veronesi
- Research Centre in Epidemiology and Preventive Medicine, University of Insubria, Via Rossi, 9, 21100, Varese, Italy
| | - E Masiello
- Department of Medicine and Surgery, Endocrine Unit, University of Insubria, ASST dei Sette Laghi, Viale Borri, 57, 21100, Varese, Italy
| | - P Premoli
- Department of Medicine and Surgery, Endocrine Unit, University of Insubria, ASST dei Sette Laghi, Viale Borri, 57, 21100, Varese, Italy
| | - D Gallo
- Department of Medicine and Surgery, Endocrine Unit, University of Insubria, ASST dei Sette Laghi, Viale Borri, 57, 21100, Varese, Italy
| | - C Cusini
- Department of Medicine and Surgery, Endocrine Unit, University of Insubria, ASST dei Sette Laghi, Viale Borri, 57, 21100, Varese, Italy
| | - S Donati
- Ophthalmology Clinic, University of Insubria, ASST dei Sette Laghi, Viale Borri, 57, 21100, Varese, Italy
| | - J Sabatino
- Department of Medicine and Surgery, Endocrine Unit, University of Insubria, ASST dei Sette Laghi, Viale Borri, 57, 21100, Varese, Italy
| | - S Ippolito
- Department of Medicine and Surgery, Endocrine Unit, University of Insubria, ASST dei Sette Laghi, Viale Borri, 57, 21100, Varese, Italy
| | - E Piantanida
- Department of Medicine and Surgery, Endocrine Unit, University of Insubria, ASST dei Sette Laghi, Viale Borri, 57, 21100, Varese, Italy
| | - L Bartalena
- Department of Medicine and Surgery, Endocrine Unit, University of Insubria, ASST dei Sette Laghi, Viale Borri, 57, 21100, Varese, Italy.
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43
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Tonacchera M, Chiovato L, Bartalena L, Cavaliere AF, Vitti P. Treatment of Graves' hyperthyroidism with thionamides: a position paper on indications and safety in pregnancy. J Endocrinol Invest 2020; 43:257-265. [PMID: 31784912 DOI: 10.1007/s40618-019-01148-w] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Accepted: 11/17/2019] [Indexed: 01/01/2023]
Abstract
CONTEXT Graves' disease affects 3% of women and 0.5% of men in the general population. The first line treatment of Graves' hyperthyroidism is based on the administration of antithyroid drugs (ATD), propylthiouracil (PTU), methimazole (MMI) and carbimazole. A recent warning from the Italian Drug Agency (Agenzia Italiana del Farmaco AIFA) reported the risk of MMI-induced acute pancreatitis. In addition, AIFA highlighted the possible association of MMI treatment during the first trimester of pregnancy with congenital malformations, thus recommending the use of effective contraceptive methods in women of childbearing age treated with MMI. METHODS AND RESULTS Revision of literature reported less than ten cases of the alleged MMI pancreatitis, allowing the inclusion of MMI in class III drug regarding the relative risk for drug-induced pancreatitis. Data available on the effect of hyperthyroidism per se on the risk of fetal malformations, although scanty, are sufficient to recommend treatment with ATD of the hyperthyroid pregnant woman. Case reports and population studies either suggesting or not suggesting MMI-induced fetal malformations do not allow unquestionable conclusions on this matter. CONCLUSIONS This consensus by experts from Italian Endocrine and Gynecologic Scientific Societies has edited recommendations derived form the available data and published guidelines of International Scientific Societies.
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Affiliation(s)
- M Tonacchera
- Department of Clinical and Experimental Medicine, Endocrinology Unit, University of Pisa, For Associazione Italiana della Tiroide (AIT), Via Paradisa 2, 56124, Pisa, Cisanello, Italy.
| | - L Chiovato
- Istituti Clinici Scientifici Maugeri IRCCS and Department of Internal Medicine and Therapeutics, University of Pavia for Associazione Italiana della Tiroide (AIT), Pavia, Italy
| | - L Bartalena
- Department of Medicine and Surgery, University of Insubria, Varese for Associazione Italiana della Tiroide (AIT), Varese, Italy
| | - A F Cavaliere
- Fondazione Policlinico Universitario A. Gemelli, IRCCS Roma for Società Italiana di Ginecologia e Ostetricia (SIGO), Rome, Italy
| | - P Vitti
- Department of Clinical and Experimental Medicine, Endocrinology Unit, University of Pisa, For Società Italiana Endocrinologia (SIE), Pisa, Italy
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44
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Gallo D, Piantanida E, Gallazzi M, Bartalena L, Tanda ML, Bruno A, Mortara L. Immunological Drivers in Graves' Disease: NK Cells as a Master Switcher. Front Endocrinol (Lausanne) 2020; 11:406. [PMID: 32765422 PMCID: PMC7379480 DOI: 10.3389/fendo.2020.00406] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Accepted: 05/20/2020] [Indexed: 12/18/2022] Open
Abstract
Graves' disease (GD) is a common autoimmune cause of hyperthyroidism, which is eventually related to the generation of IgG antibodies stimulating the thyrotropin receptor. Clinical manifestations of the disease reflect hyperstimulation of the gland, causing thyrocyte hyperplasia (goiter) and excessive thyroid hormone synthesis (hyperthyroidism). The above clinical manifestations are preceded by still partially unraveled pathogenic actions governed by the induction of aberrant phenotype/functions of immune cells. In this review article we investigated the potential contribution of natural killer (NK) cells, based on literature analysis, to discuss the bidirectional interplay with thyroid hormones (TH) in GD progression. We analyzed cellular and molecular NK-cell associated mechanisms potentially impacting on GD, in a view of identification of the main NK-cell subset with highest immunoregulatory role.
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Affiliation(s)
- Daniela Gallo
- Endocrine Unit, Department of Medicine and Surgery, University of Insubria, ASST dei Sette Laghi, Varese, Italy
| | - Eliana Piantanida
- Endocrine Unit, Department of Medicine and Surgery, University of Insubria, ASST dei Sette Laghi, Varese, Italy
| | - Matteo Gallazzi
- Immunology and General Pathology Laboratory, Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy
| | - Luigi Bartalena
- Endocrine Unit, Department of Medicine and Surgery, University of Insubria, ASST dei Sette Laghi, Varese, Italy
| | - Maria Laura Tanda
- Endocrine Unit, Department of Medicine and Surgery, University of Insubria, ASST dei Sette Laghi, Varese, Italy
| | | | - Lorenzo Mortara
- Immunology and General Pathology Laboratory, Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy
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45
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Premoli P, Tanda ML, Piantanida E, Veronesi G, Gallo D, Masiello E, Rosetti S, Cusini C, Boi F, Bulla J, Rodia R, Mariotti S, Capelli V, Rotondi M, Magri F, Chiovato L, Rocchi R, Campopiano MC, Elisei R, Vitti P, Barbato F, Pilli T, Castagna MG, Pacini F, Bartalena L. Features and outcome of differentiated thyroid carcinoma associated with Graves' disease: results of a large, retrospective, multicenter study. J Endocrinol Invest 2020; 43:109-116. [PMID: 31327128 DOI: 10.1007/s40618-019-01088-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Accepted: 07/17/2019] [Indexed: 02/05/2023]
Abstract
BACKGROUND Whether differentiated thyroid cancer (DTC) occurring concomitantly with Graves' disease (GD) is more aggressive and bound to a less favorable outcome is controversial. OBJECTIVE Aim of this multicenter retrospective study was to compare baseline features and outcome of DTC patients with GD (DTC/GD+) or without GD (DTC/GD-). PATIENTS Enrolled in this study were 579 patients referred to five endocrine units (Cagliari, Pavia, Pisa, Siena, and Varese) between 2005 and 2014: 193 patients had DTC/GD+ , 386 DTC/GD-. Patients were matched for age, gender and tumor size. They underwent surgery because of malignancy, large goiter size, or relapse of hyperthyroidism in GD. RESULTS Baseline DTC features (histology, lymph node metastases, extrathyroidal extension) did not differ in the two groups, except for multifocality which was significantly more frequent in DTC/GD+ (27.5% vs. 7.5%, p < 0.0001). At the end of follow-up (median 7.5 years), 86% of DTC/GD+ and 89.6% DTC/GD- patients were free of disease. Patients with persistent or recurrent disease (PRD) had "biochemical disease" in the majority of cases. Microcarcinomas were more frequent in the DTC/GD+ group (60% vs. 37%, p < 0.0001) and had an excellent outcome, with no difference in PRD between groups. However, in carcinomas ≥ 1 cm, PRD was significantly more common in DTC/GD+ (24.4% vs. 11.5%; p = 0.005). In the whole group, univariate and multivariate analyses showed that GD+ , lymph node involvement, extrathyroidal invasion, multifocality and tall cell histotype were associated with a worse outcome. Female gender and microcarcinomas were favorable features. No association was found between baseline TSH-receptor antibody levels and outcome. Graves' orbitopathy (GO) seemed to be associated with a better outcome of DTC, possibly because patients with GO may early undergo surgery for hyperthyroidism. CONCLUSIONS GD may be associated with a worse outcome of coexisting DTC only if cancer is ≥ 1 cm, whereas clinical outcome of microcarcinomas is not related to the presence/absence of GD.
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Affiliation(s)
- P Premoli
- Department of Medicine and Surgery, University of Insubria, Endocrine Unit, Ospedale di Circolo, ASST dei Sette Laghi, Viale Borri, 57, 21100, Varese, Italy
| | - M L Tanda
- Department of Medicine and Surgery, University of Insubria, Endocrine Unit, Ospedale di Circolo, ASST dei Sette Laghi, Viale Borri, 57, 21100, Varese, Italy
| | - E Piantanida
- Department of Medicine and Surgery, University of Insubria, Endocrine Unit, Ospedale di Circolo, ASST dei Sette Laghi, Viale Borri, 57, 21100, Varese, Italy
| | - G Veronesi
- Research Centre in Epidemiology and Preventive Medicine, University of Insubria, Varese, Italy
| | - D Gallo
- Department of Medicine and Surgery, University of Insubria, Endocrine Unit, Ospedale di Circolo, ASST dei Sette Laghi, Viale Borri, 57, 21100, Varese, Italy
| | - E Masiello
- Department of Medicine and Surgery, University of Insubria, Endocrine Unit, Ospedale di Circolo, ASST dei Sette Laghi, Viale Borri, 57, 21100, Varese, Italy
| | - S Rosetti
- Department of Medicine and Surgery, University of Insubria, Endocrine Unit, Ospedale di Circolo, ASST dei Sette Laghi, Viale Borri, 57, 21100, Varese, Italy
| | - C Cusini
- Department of Medicine and Surgery, University of Insubria, Endocrine Unit, Ospedale di Circolo, ASST dei Sette Laghi, Viale Borri, 57, 21100, Varese, Italy
| | - F Boi
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - J Bulla
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - R Rodia
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - S Mariotti
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - V Capelli
- Unit of Internal Medicine and Endocrinology, Istituti Clinici Scientifici Maugeri, Department of Internal Medicine and Therapeutics, University of Pavia, Pavia, Italy
| | - M Rotondi
- Unit of Internal Medicine and Endocrinology, Istituti Clinici Scientifici Maugeri, Department of Internal Medicine and Therapeutics, University of Pavia, Pavia, Italy
| | - F Magri
- Unit of Internal Medicine and Endocrinology, Istituti Clinici Scientifici Maugeri, Department of Internal Medicine and Therapeutics, University of Pavia, Pavia, Italy
| | - L Chiovato
- Unit of Internal Medicine and Endocrinology, Istituti Clinici Scientifici Maugeri, Department of Internal Medicine and Therapeutics, University of Pavia, Pavia, Italy
| | - R Rocchi
- Endocrinology Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - M C Campopiano
- Endocrinology Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - R Elisei
- Endocrinology Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - P Vitti
- Endocrinology Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - F Barbato
- Endocrinology Unit, University of Siena, Siena, Italy
| | - T Pilli
- Endocrinology Unit, University of Siena, Siena, Italy
| | - M G Castagna
- Endocrinology Unit, University of Siena, Siena, Italy
| | - F Pacini
- Endocrinology Unit, University of Siena, Siena, Italy
| | - L Bartalena
- Department of Medicine and Surgery, University of Insubria, Endocrine Unit, Ospedale di Circolo, ASST dei Sette Laghi, Viale Borri, 57, 21100, Varese, Italy.
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Cappellani D, Papini P, Pingitore A, Tomisti L, Mantuano M, Di Certo AM, Manetti L, Marconcini G, Scattina I, Urbani C, Morganti R, Marcocci C, Materazzi G, Iervasi G, Martino E, Bartalena L, Bogazzi F. Comparison Between Total Thyroidectomy and Medical Therapy for Amiodarone-Induced Thyrotoxicosis. J Clin Endocrinol Metab 2020; 105:5572853. [PMID: 31545358 DOI: 10.1210/clinem/dgz041] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Accepted: 09/20/2019] [Indexed: 11/19/2022]
Abstract
CONTEXT It is not known whether total thyroidectomy is more favorable than medical therapy for patients with amiodarone-induced thyrotoxicosis (AIT). OBJECTIVE To compare total thyroidectomy with medical therapy on survival and cardiac function in AIT patients. METHODS Observational longitudinal cohort study involving 207 AIT patients that had received total thyroidectomy (surgery group, n = 51) or medical therapy (medical therapy group, n = 156) over a 20-year period. AIT types and left ventricular ejection fraction (LVEF) classes were determined at diagnosis of AIT. Cardiac and thyroid function were reevaluated during the study period. Survival was estimated using the Kaplan-Meier method. RESULTS Overall mortality and cardiac-specific mortality at 10 and 5 years, respectively, were lower in the surgery group than in the medical therapy group (P = 0.04 and P = 0.01, respectively). The lower mortality rate of the surgery group was due to patients with moderate to severely compromised LVEF (P = 0.005 vs medical therapy group). In contrast, mortality of patients with normal or mildly reduced LVEF did not differ between the 2 groups (P = 0.281 and P = 0.135, respectively). Death of patients with moderate to severe LV systolic dysfunction in the medical therapy group occurred after 82 days (interquartile range, 56-99), a period longer than that necessary to restore euthyroidism in the surgery group (26 days; interquartile range, 15-95; P = 0.038). Risk factors for mortality were age (hazard ratio [HR] = 1.036) and LVEF (HR = 0.964), whereas total thyroidectomy was shown to be a protective factor (HR = 0.210). LVEF increased in both groups after restoration of euthyroidism, above all in the most compromised patients in the surgery group. CONCLUSIONS Total thyroidectomy could be considered the therapeutic choice for AIT patients with severe systolic dysfunction, whereas it is not superior to medical therapy in those with normal or mildly reduced LVEF.
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Affiliation(s)
- Daniele Cappellani
- Unit of Endocrinology, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Piermarco Papini
- Unit of Endocrine Surgery, Department of Surgical, Medical, Molecular Pathology and Critical Area, University of Pisa, Pisa, Italy
| | - Alessandro Pingitore
- Clinical Physiology Institute, Consiglio Nazionale delle Ricerche (CNR), Pisa, Italy
| | - Luca Tomisti
- Unit of Endocrinology, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Michele Mantuano
- Unit of Endocrinology, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Agostino M Di Certo
- Unit of Endocrinology, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Luca Manetti
- Unit of Endocrinology, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Giulia Marconcini
- Unit of Endocrinology, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Ilaria Scattina
- Unit of Endocrinology, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Claudio Urbani
- Unit of Endocrinology, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | | | - Claudio Marcocci
- Unit of Endocrinology, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Gabriele Materazzi
- Unit of Endocrine Surgery, Department of Surgical, Medical, Molecular Pathology and Critical Area, University of Pisa, Pisa, Italy
| | - Giorgio Iervasi
- Clinical Physiology Institute, Consiglio Nazionale delle Ricerche (CNR), Pisa, Italy
| | - Enio Martino
- Unit of Endocrinology, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Luigi Bartalena
- Department of Medicine and Surgery, University of Insubria, 21100 Varese, Italy
| | - Fausto Bogazzi
- Unit of Endocrinology, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
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Bartalena L, Piantanida E, Gallo D, Lai A, Tanda ML. Epidemiology, Natural History, Risk Factors, and Prevention of Graves' Orbitopathy. Front Endocrinol (Lausanne) 2020; 11:615993. [PMID: 33329408 PMCID: PMC7734282 DOI: 10.3389/fendo.2020.615993] [Citation(s) in RCA: 109] [Impact Index Per Article: 27.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Accepted: 10/26/2020] [Indexed: 12/13/2022] Open
Abstract
GO is the most frequent extrathyroidal manifestation of Graves' disease, although it may rarely occur in euthyroid/hypothyroid patients with chronic autoimmune thyroiditis. It is a relatively infrequent disorder, and men tend to have more severe ocular involvement at an older age. The prevalence of GO is lower than in the past among patients with recent onset Graves' hyperthyroidism, and moderate-to-severe forms requiring aggressive treatments are no more than 5-6% of all cases of GO. After an initial inflammatory (active) phase and a phase of stabilization (plateau phase), GO tends to improve and eventually inactivates (inactive or burnt-out phase). Minimal-to-mild GO often remits spontaneously, but complete restitutio ad integrum almost never occurs when GO is more than mild. Several risk factors contribute to its development on a yet undefined genetic background. Cigarette smoking is the most important of them. Early diagnosis, control and removal of modifiable risk factors, early treatment of mild forms of GO may effectively limit the risk of progression to more severe forms, which have a profound and dramatic impact on the quality of life of affected individuals, and remain a therapeutic challenge, often requiring long-lasting and multiple medical and surgical therapies.
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Affiliation(s)
- Luigi Bartalena
- *Correspondence: Luigi Bartalena, , orcid.org/0000000184475449
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Affiliation(s)
- F Trimarchi
- Accademia Peloritana dei Pericolanti at the University of Messina, Messina, Italy.
| | | | - L Bartalena
- Endocrine Unit, Department of Medicine and Surgery, University of Insubria, Varese, Italy
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Smith TJ, Bartalena L. Will biological agents supplant systemic glucocorticoids as the first-line treatment for thyroid-associated ophthalmopathy? Eur J Endocrinol 2019; 181:D27-D43. [PMID: 31370005 PMCID: PMC7398270 DOI: 10.1530/eje-19-0389] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Accepted: 07/30/2019] [Indexed: 12/14/2022]
Abstract
In this article, the two authors present their opposing points of view concerning the likelihood that glucocorticoids will be replaced by newly developed biological agents in the treatment of active, moderate-to-severe thyroid-associated ophthalmopathy (TAO). TAO is a vexing, disfiguring and potentially blinding autoimmune manifestation of thyroid autoimmunity. One author expresses the opinion that steroids are nonspecific, frequently fail to improve the disease and can cause sometimes serious side effects. He suggests that glucocorticoids should be replaced as soon as possible by more specific and safer drugs, once they become available. The most promising of these are biological agents. The other author argues that glucocorticoids are proven effective and are unlikely to be replaced by biologicals. He reasons that while they may not uniformly result in optimal benefit, they have been proven effective in many reports. He remains open minded about alternative therapies such as biologicals but remains skeptical that they will replace steroids as the first-line therapy for active, moderate-to-severe TAO without head-to-head comparative clinical trials demonstrating superiority. Despite these very different points of view, both authors are optimistic about the availability of improved medical therapies for TAO, either as single agents or in combination. Further, both agree that better treatment options are needed to improve the care of our patients with active moderate-to-severe TAO.
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Affiliation(s)
- Terry J. Smith
- Department of Ophthalmology and Visual Sciences, Division of metabolism, Endocrinology and Diabetes, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI 48105, USA
| | - Luigi Bartalena
- Department of Medicine & Surgery,University of Insubria, Endocrine Unit, ASST dei Sette Laghi, Viale Borri, 57, 21100 Varese, Italy
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50
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Trimarchi F, Martino E, Bartalena L. The clinical enigma of the "Flea catcher" by Georges de La Tour: a pregnant sinner with pre-eclampsia or a hypothyroid girl? J Endocrinol Invest 2019; 42:995-996. [PMID: 30730039 DOI: 10.1007/s40618-019-01017-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Accepted: 02/04/2019] [Indexed: 11/27/2022]
Affiliation(s)
- F Trimarchi
- Accademia Peloritana dei Pericolanti at the University of Messina, Messina, Italy.
| | | | - L Bartalena
- Endocrine Unit, Department of Medicine and Surgery, University of Insubria, Varese, Italy
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