Diagnostic value of selected biochemical markers in the detection of recurrence of medullary thyroid cancer - comparison of calcitonin, procalcitonin, chromogranin A, and carcinoembryonic antigen.

INTRODUCTION: Medullary thyroid cancer (MTC) is a malignancy of the thyroid gland, which derives from parafollicular C cells. Periodic measurement of biochemical markers of MTC remains a crucial part of patient follow-up and disease monitoring. The aim of the study was to compare the diagnostic value of four selected markers - calcitonin (Ct), procalcitonin (PCT), chromogranin A (CgA), and carcinoembryonic antigen (CEA). MATERIAL AND METHODS: Patients with histopathologically confirmed MTC hospitalised in a single department between January 2015 and December 2015 were included in the study. Patients were subdivided into two groups: a remission group and an active disease group, based upon serum markers of MTC and imaging. Levels of Ct, PCT, CgA, and CEA were compared between the groups. RESULTS: Forty-four patients were included; 20 patients presented active disease and 24 were in remission. All patients with active disease had Ct exceeding the upper limit of normal range (10 pg/mL) - for that threshold the sensitivity was 100.0% and the specificity was 73.9%; for the best-fit threshold of 121.0 pg/mL the specificity was 95.8% with sensitivity 100.0%. There was significant correlation between Ct and PCT - p < 0.000001, r = 0.93. All patients with active disease exceeded the upper limit of the normal range (0.5 ng/mL) - for that threshold the sensitivity was 100.0% and the specificity was 83.3%; for the best-fit threshold of 0.95 ng/mL the specificity was 95.8% with sensitivity 100.0%. In case of CEA for the best-fit threshold of 12.66 ng/mL the specificity was 100.0% with sensitivity 57.9%; for CgA the best-fit threshold was 75.66 ng/mL with specificity 83.3% and sensitivity 75.0%. CONCLUSIONS: Our study confirms that PCT can be considered as an equivalent alternative for measurement of calcitonin. On the other hand, it is also worth noting that MTC can be a rare cause of very high levels of PTC not resulting from infectious diseases. The diagnostic value of CEA and chromogranin A is much lower and can be within the normal range even in patients with advanced, metastatic MTC. They should be used only as accessory markers.

Circulating Visfatin in Hypothyroidism Is Associated with Free Thyroid Hormones and Antithyroperoxidase Antibodies.

We hypothesized that regulation of visfatin in hypothyroidism might be altered by coexisting chronic autoimmune thyroiditis. This is a prospective case-control study of 118 subjects. The autoimmune study group (AIT) consisted of 39 patients newly diagnosed with hypothyroidism in a course of chronic autoimmune thyroiditis. The nonautoimmune study group (TT) consisted of 40 patients thyroidectomized due to the differentiated thyroid cancer staged pT1. The control group comprised 39 healthy volunteers adjusted for age, sex, and BMI with normal thyroid function and negative thyroid antibodies. Exclusion criteria consisted of other autoimmune diseases, active neoplastic disease, diabetes mellitus, and infection, which were reported to alter visfatin level. Fasting blood samples were taken for visfatin, TSH, free thyroxine (FT4), free triiodothyronine (FT3), antithyroperoxidase antibodies (TPOAb), antithyroglobulin antibodies (TgAb), glucose, and insulin levels. The highest visfatin serum concentration was in AIT group, and healthy controls had visfatin level higher than TT (p = 0.0001). Simple linear regression analysis revealed that visfatin serum concentration was significantly associated with autoimmunity (ß = 0.1014; p = 0.003), FT4 (ß = 0.05412; p = 0.048), FT3 (ß = 0.05242; p = 0.038), and TPOAb (ß = 0.0002; p = 0.0025), and the relationships were further confirmed in the multivariate regression analysis.

Diagnosis, treatment, and prognosis in patients with liver metastases from follicular thyroid carcinoma (FTC).

Follicular thyroid carcinoma (FTC) is the second most common type of thyroid cancer (TC) and accounts for approximately 10% of all TC cases. Liver metastases are a rare presentation in 0.5-1% of follicular thyroid cancers, usually occurring in the setting of widely disseminated FTC disease, and their presence is associated with poor prognosis. Until now, there have been only 30 cases of FTC liver metastases described in the literature. Herein, we review publications and describe diagnostic tools that may be used in the diagnosis and follow-up of FTC metastases to the liver, including biopsy and imaging techniques like US, CT, MRI, SPECT, PET, and radioiodine scintigraphy. We also present and discuss current methods of treatment, e.g. TSH suppressive therapy with levothyroxine, surgery, radiofrequency ablation (RFA), transarterial embolisation (TAE), liver transarterial chemoembolisation (TACE), chemotherapy with cisplatin and doxorubicin, treatment with Indium- 111-octreotide (or its analogues), and tyrosine kinase inhibitors (sorafenib, sunitinib). At the end we describe the course, results of diagnostics, and treatment in a patient with large multiple FTC metastases to the liver. (Endokrynol Pol 2016; 67 (3): 332-347).

Pyramidal lobe decreases endogenous TSH stimulation without impact on radio-iodine therapy outcome in patients with differentiated thyroid cancer.

OBJECTIVES: The aim of the study was to assess the frequency of pyramidal lobe (PL) detected in iodine-131 (I-131) scans of thyroid bed in patients after thyroidectomy for differentiated thyroid cancer (DTC) and to investigate influence of PL on endogenous thyrotropin (TSH) stimulation as well as on the effects of the radio-iodine ablation in one-year follow-up. PATIENTS AND METHODS: This study was designed as a retrospective analysis of 302 radio-iodine neck scans of patients thyroidectomized due to DTC. The study population was selected from patients with PL detected in thyroid bed scintigraphy. Patients without PL were included to the control group. The study and the control groups did not differ in age, sex of patients, histological type and stage of the DTC. RESULTS: Pyramidal lobes were found in 30.5% of all patients. Patients in the study group underwent repeat surgery more often than controls without PL. Preablative TSH level in patients with PL was statistically lower than in the control group, in contrast to free thyroid hormones, which were higher in patients with PL. Preablative and postablative TSH-stimulated thyroglobulin (Tg) and antibodies against thyroglobulin (TgAbs) were measured in both groups, and comparison did not reveal differences. Moreover, for the per-patient analysis, sites of uptake in whole body scintigraphy performed 1 year after radio-iodine remnant ablation (RRA) did not differ between the study and the control groups. CONCLUSION: Pyramidal lobe decreases endogenous TSH stimulation without impact on radio-iodine therapy outcome in patients with DTC.

Struma ovarii maligna.

INTRODUCTION: Malignant struma ovarii is a rare ovarian neoplasm composed predominantly of mature thyroid tissue. CASE REPORT: A right ovarian tumor was discovered at ultrasound examination in a 20-year-old woman. Complete right ovariectomy was done - histopathological examination revealed papillary thyroid carcinoma arising in struma ovarii (malignant struma ovarii). Patient underwent subsequent total thyroidectomy - the thyroid was found to be without any pathological lesions. After operations the patient received ablative radioiodine treatment (200 mCi 131I). An 131I posttherapeutic whole-body radioiodine scintigraphy was performed and showed uptake in bone metastases. L-thyroxine TSH suppresive doses followed radioiodine ablation and thyroglobulin level is monitored. Next doses of radioiodine has been scheduled. DISCUSSION: Authors suggest that the management of malignant struma ovarii should be the same as differentiated thyroid cancer, so after surgical excision of ovarian neoplasm, we recommend thyroidectomy, radiotherapy with 131I and levothyroxine suppressive therapy. Long-term follow-up for the detection of metastases or tumor recurrence by serial serum thyroglobulin measurements and 131I scan may be required in patients with this rare tumor.

Combined octreotide and peptide receptor radionuclide therapy ((90)Y-DOTA-TATE) in case of malignant insulinoma.

BACKGROUND: Insulinomas are the most common functioning neuroendocrine tumours of the pancreas. Hypoglycemia due to excessive production of insulin is a main feature of this disease. Usually these neoplasms are benign and single with surgical excision as a treatment of choice. About 10% are malignant with tendency to form metastases especially to the liver then therapy requires various medical technics. CASE REPORT: 43 years old female with reccurent syncopies in course of hypoglycemia was admitted to the hospital to be diagnosed. Having suspected pathology within the pancreas the abdominal MRI was performed. It showed presence of numerous metastatic changes in the liver with no any other deviations in the abdomen including pancreas. Subsequent 18FDG PET-CT revealed metastases to the regional lymph nodes and the liver and suggested the presence of a primary lesion in the tail of the pancreas which was confirmed in EUS. Surgical excision of the tail of the pancreas was done. Pathological result: pancreatic neuroendocrine well differetiated cancer. Due to the recurrence of hypoglycemia patient was admitted to Department of Endocrinology where somatostatin analogue scintigraphy showed the presence of tracer accumulation foci in the liver. Combined long-acting somatostatin analogue (octreotide) and peptide radionuclide receptor ((90)Y-DOTA-TATE) therapy were introduced. Stable blood glucose levels with no tendency to hypoglycemia and partial regression (PR) of liver lesions according to RECIST citeria were observed in course of the treatment.

Lack of TSH stimulation in patients with differentiated thyroid cancer - possible causes.

Differentiated thyroid cancer is one of the most common endocrine cancers. Typical standard treatment includes total thyroidectomy with partial lymphadenectomy, then depending on the indications, treatment with iodine isotope 131-I. A prerequisite to conduct the therapy is to obtain endogenic thyroid-stimulating hormone (TSH) stimulation (TSH > 30 µU/ml). We describe two patients with differentiated thyroid carcinoma in whom no rise in serum TSH was observed after withdrawal of thyroxine. In one patient TSH deficiency was due to partial hypopituitarism secondary to a tumor of the pituitary gland. In the second patient the TSH level was suppressed by metabolically active thyroid tissue within bilateral ovarian teratomas. The problems with TSH growth after withdrawal of thyroxine requires additional studies to identify the cause. Above two possible reasons for the lack of TSH stimulation after withdrawal of thyroxine were presented. In the case of non-TSH stimulation due to hypopituitarism both control tests and isotope treatment should be carried out using stimulation by recombinant human TSH (rhTSH).