Calcium infusion and pentagastrin injection in diagnosis of medullary thyroid carcinoma.

Calcium infusion and pentagastrin injection were compared as tests to stimulate calcitonin secretion for the detection of medullary carcinoma of the thyroid. Plasma concentrations of immunoreactive calcitonin were measured by radioimmunoassay before and during both stimulation tests in 2 persons who had been found at operation to have medullary thyroid carcinoma, 1 relative in whom a cervical lymph node biopsy had shown medullary thyroid carcinoma and 36 asymptomatic relatives. The tests were carried out on separate days by intravenous infusion of calcium gluconate for 2 hours, to provide 3.75 mg/kg of elemental calcium per hour, and rapid intravenous injection of 0.5 microgram/kg of pentagastrin. Before stimulation immunoreactive calcitonin was undetectable in the plasma of 34 of the 36 asymptomatic persons; the 2 with elevated baseline concentrations of the hormone had a positive response to both tests. Seven others showed an increase in plasma immunoreactive calcitonin concentration only after pentagastrin injection. The two persons with initially elevated values and three of the seven with increased values after pentagastrin injection were found at subsequent operation to have focal medullary carcinoma and parafollicular cell hyperplasia; after the operation immunoreactive calcitonin was undetectable in the plasma, even after stimulation. Rapid injection of pentagastrin is more reliable than slow infusion of calcium as a stimulation test for the early detection of medullary thyroid carcinoma.     

Molecular mechanisms of pulmonary fibrosis and current treatment

Pulmonary fibrosis is a common response to various insults or injuries to the lung. Although there are various initiating factors or causes, the terminal stages are characterized by proliferation and progressive accumulation of connective tissue replacing normal functional parenchyma. The pathogenesis of pulmonary fibrosis includes endothelial and epithelial cell injury, production of inflammatory cells and their mediators, and fibroblast activation. Conventional therapy consisting of glucocorticoids or cytotoxic drugs is usually ineffective in preventing progression of the disease. Further understanding of the molecular mechanisms of endothelial and epithelial cell injury, inflammatory reaction, fibroblast proliferation, collagen deposition and lung repair, should lead to the development of effective treatments against pulmonary fibrosis. Accordingly, this review summarizes recent progress made in understanding the molecular mechanisms of pulmonary fibrosis. A detailed discussion is presented regarding each of the potential new therapies which have emerged from the animal models of pulmonary fibrosis and which have been developed through advances in cellular and molecular biology.     

Molecular and biochemical screening for the diagnosis and management of medullary thyroid carcinoma in multiple endocrine neoplasia type 2A.

Patients with Multiple Endocrine Neoplasia (MEN) type 2A are at risk for early medullary thyroid carcinoma (MTC). We performed different screening tests for MTC--a recently reported biochemical screening test using omeprazole-induced calcitonin (CT) stimulation and DNA analysis--in fifteen members of two non-consanguineous Brazilian families with MEN 2A. RET proto-oncogene analysis was carried out by direct DNA sequencing of PCR-amplified products for exons 10 and 11. Family 1 showed a germline mutation (C634Y) in three individuals; a sister and a brother with symptomatic MTC; the former also presented with pheochromocytoma and hyperparathyroidism, and her son was a nine-year-old boy of previously unknown status. Family 2 showed the C634R mutation only in the index case, who presented with cutaneous lichen amyloidosis in addition to MTC, pheochromocytoma and hyperparathyroidism. Neither her parents nor her four brothers showed this genetic abnormality, suggesting a de novo RET proto-oncogene mutation in this patient. The controls and patients presented normal basal gastrin levels and a significant increase after omeprazole. Basal CT levels were elevated in patients with MTC and undetectable in control and asymptomatic family members. No subject showed any increase in CT levels after omeprazole treatment. In conclusion, the two most frequent RET proto-oncogene mutations in MEN 2A are present in Brazilian families. In addition, the specificity of basal and omeprazole-stimulated calcitonin is rather limited, and the efficacy of the omeprazole test still needs to be systematically examined. Therefore, RET proto-oncogene analysis must be the first choice for a screening procedure to identify gene carriers in MEN 2A family members and to permit early prophylactic treatment of MTC.     

Inheritable forms of medullary thyroid carcinoma

Medullary thyroid carcinoma (MTC) arises from parafollicular or C cells of the thyroid that produce calcitonin. It accounts for 5-10% of all thyroid cancers. Hereditary MTC represents 20-30% of all MTCs. It can be transmitted with an autosomal dominant pattern, either as a single entity, familial MTC, or it can arise as part of a multiple endocrine neoplasia (MEN) syndrome type 2A or 2B. The identification of hereditary MTC has been facilitated in recent years by the direct analysis of the ret proto-oncogene.     

Oncogene expression in a medullary thyroid carcinoma

We report the expression of Ha-ras, fos, c-myc and N-myc mRNA in a human medullary carcinoma of the thyroid gland, both in primary tumor and lymph node metastasis, as demonstrated by in situ hybridization and Northern blot analysis. A significant difference in the oncogene expression in the primary tumor and the metastasis was not observed. Tumor tissue revealed a significant overexpression of Ha-ras, c-myc and N-myc mRNA as compared to the normal thyroid gland. The amount of fos mRNA expression in non tumorous thyroid gland did not significantly differ from tumor tissue, sis, fms and abl mRNA expression was not detectable in tumor tissue and non tumorous thyroid gland. We conclude, that the (over)expression of the oncogenes Ha-ras, c-myc and N-myc may be associated with initiation and progression of medullary thyroid carcinoma. Similar studies on additional cases of human medullary thyroid carcinoma will be necessary to reveal further information.     

Roles of circulating carcinoembryonic antigen and calcitonin in diagnosis of medullary thyroid carcinoma: a comparative study.

Carcinoembryonic antigen (CEA) and calcitonin (CT) were simultaneously determined in sera and tumor tissues from 15 patients with medullary carcinoma of the thyroid (MCT). Serum CEA was increased in all but one patient, and CT did in all of them. Both levels were significantly related to the weight of excised tumor, but not to the presence of metastasis. Furthermore, a significant correlation was noted between the basal levels of CT and CEA. Both levels fell to normal after a radical operation had been performed. Tissue concentrations of CEA and CT in the MCT were more than 100 times those in hyperthyroidism, and the ratios of tissue over serum levels averaged 770 in CEA and 1000 in CT. In the calcium infusion test, CEA levels were not significantly changed in contrast with a distinct increase in CT levels. The results indicate that CEA and CT represent separate activities of the tumor cells, and that circulating CEA together with CT is a useful indicator in the diagnosis and follow-up of the disease.     

The ultrastructure of the thyroid medullary carcinoma

The ultrastructure and the morphometrical pattern of secretory granules were studied in six cases of thyroid medullary carcinoma. The tumor cells were fusiform or polyhedral with irregular, mostly elongated nuclei. Phagolysosomes containing a crystalloid material, probably degraded lipoprotein complexes, degeneratively changed mitochondria, moderately developed rough endoplasmic reticulum and Golgi complexes were commonly found. Amyloid occurred as small fibrils in intercellular spaces. Marked dystrophic lesions of tumor cells surrounding amyloid fibrils were found. Numerous roundshaped electron-dense secretory granules were noticed in tumor cell cytoplasms. The morphometrical analysis showed that the size of granules oscillated between 60 and 450 nm with mean values ranging from 171.4 +/- 31.8 to 227.7 +/- 28.1 nm. Frequency distribution curves showed at least two peaks varying with the investigated case at different intervals. In two cases two distinct groups of granules were found within the same cells: one group of electron-dense, compact, smaller sized granules and another group of larger, finely granulated, less dense granules. In the other four cases the granule sizes were more homogeneous. These results might indicate that the granule size depends on the maturation degree and functional activity or that there are several kinds of granules specialized in the secretion of various substances.     

Plasma carcinoembryonic antigen versus plasma calcitonin in the diagnosis of medullary carcinoma of the thyroid

Summary The value of carcinoembryonic antigen (CEA) assay for diagnosis and follow-up in patients suffering from medullary carcinoma of the thyroid (MCT) was investigated in a large sample (106 cases). High levels of CEA were found in 84% of patients suffering from either the sporadic or the familial form of the disease. Levels of CEA and calcitonin (CT) are significantly and positively correlated. Removal of tumoral tissue is followed by a decrease in both CEA and CT levels. High levels of CEA were also observed in the parents of patients suffering from the familial form of MCT. These patients were operated on and MCT was confirmed histologically. The limitations of the use of CEA assay in the diagnosis of MCT are discussed.     

Molecular mechanisms of thyroid dysgenesis

Thyroid dysgenesis (TD) is the most prevalent form of congenital hypothyroidism. Ttf-1, Ttf-2, Pax8 and the Tshr are expressed at early stages of thyroid development and are implicated in thyroid ontogeny. Mutations in these genes have been found in some cases of TD. The prevalence of familial forms of TD is significantly higher than expected if the disease was only sporadic, allowing to postulate a genetic basis of the disease. Linkage analysis and mutational screening of the four above-mentioned genes in familial forms of TD showed their exclusion as contributors to the disease in some families, implicating genetic heterogeneity and involving other genetic mechanisms. Strategies to uncover new genes involved in TD are therefore needed. We underscore differences in the temporal expression patterns during the human thyroid development with those in animal models. Further, the extrathyroid expression of these genes during human development enables to define the gene-specific malformations that may be present in patients bearing mutations. The data gathered on molecular thyroid development enable precise genetic counselling of affected families. By increasing our knowledge of thyroid development, we hope to uncover new perspectives of genetic screening and eventually of early in utero treatment.     

Melanin-producing medullary thyroid carcinoma with glandular differentiation

A rare case is reported of melanin-producing medullary thyroid carcinoma in a 62-year-old man. Intraoperative imprints of the thyroid tumor revealed numerous detached tumor cells containing large amounts of brown pigment. The Fontana-Masson argentaffin reaction with bleach confirmed that those granules were melanin. Histologically, the tumor was composed of two different components--a medullary area with hyalinized stroma and a follicular area. Melanin was scattered in both areas. The tumor cells in both areas were immunoreactive to carcinoembryonic antigen, calcitonin, gastrin-releasing peptide, somatostatin, met.-enkephalin, neuron-specific enolase, chromogranin and neurofilaments, and negative for thyroglobulin and S-100 protein. The histologic diagnosis was melanin-producing medullary thyroid carcinoma with glandular differentiation. Although various kinds of peptides and amines have been reported to be produced in medullary thyroid carcinoma, melanin production is quite rare; this appears to be only the third reported case.     

Cytologic diagnosis of a medullary carcinoma of the thyroid by Sevier-Munger silver staining and calcitonin immunocytochemistry

A medullary carcinoma of the thyroid was preoperatively diagnosed on ultrasonically guided fine needle aspiration biopsies. After cytocentrifugation, the tumor cells displayed a dense cytoplasmic silver granulation with the Sevier-Munger technique when applied to air-dried or acetone-ethanol-fixed samples and an obvious calcitonin immunoreactivity after fixation in Bouin's fluid. These methods may prove useful in the identification of nonpalpable metastases and recurrences of medullary carcinomas of the thyroid, especially since the cytologic typing of medullary thyroid carcinoma cells may be difficult with routine stainings.     

Imaging and uptake mechanism of 131I-meta-iodobenzylguanidine in medullary thyroid carcinoma

131I-meta-iodobenzylguanidine (131I-MIBG) was also taken up by medullary thyroid carcinoma (MTC) as well as by pheochromocytoma in two patients with Sipple's syndrome. However, the mechanism of 131I-MIBG uptake by MTC has not been clarified yet. We measured tissue catecholamine levels in three MTC, since MTC can produce several active substances. Catecholamines were detected in various amounts in all MTC, but not in normal thyroid tissues. These findings suggest that MTC can produce catecholamines and therefore, 131I-MIBG is taken up and stored in catecholamine vesicles of MTC, like pheochromocytoma and neuroblastoma. We conclude that 131I-MIBG may be applied not only to diagnosis but also for the treatment of patients with MTC.