Introduction This observational investigation aimed to assess the accuracy of a novel score in predicting the onset of overt Graves' orbitopathy (GO) in patients with Graves' disease (GD). Materials and methods A total of 156 consecutive patients with GD without GO were enrolled. As control group, 45 patients with non-autoimmune hyperthyroidism were included. At baseline, an ophthalmological evaluation was performed, including (1) visual function tests and (2) orbital ultrasound. After 24 months, the occurrence of GO was assessed in all patients. Results At baseline, a score from 0 to 3 and a score from 0 to 5 were assigned based on the results of visual function tests and the results of orbital ultrasound, respectively. The scores were combined into an overall FUnctional and MOrphological risk score (FUMO score) (0-8 points), classifying patients as low risk (score 0-2) or medium-high risk (score 3-8). After 24 months, the 2 risk groups were compared for differences in (1) presence/absence of GO and (2) GO activity and severity. Patients in the medium-high risk group developed overt GO more frequently than those in the low-risk group. Additionally, GO was more frequently active and moderate-to-severe in medium-high risk patients. Multiple logistic regression showed that TRAb levels and FUMO were the strongest independent predictors of GO, with higher FT3 and smoking habit levels also conferring increased risk. The model demonstrated good calibration and discrimination (AUC = 0.84; P < .0001), with high positive (73%) and negative (72%) predictive value. Conclusion Subclinical ocular alterations can predict the progression of GO in patients with GD. The FUMO score, particularly when combined with TRAb and FT3 levels, reliably identifies patients at risk of developing overt GO, supporting its use for early risk stratification.

OBJECTIVE:This study aimed to compare clinicopathological features of familial non-medullary thyroid cancer (FNMTC) and sporadic non-medullary thyroid cancer (sNMTC) and assess whether age at onset contributes to the different behavior of these 2 entities. DESIGN:A retrospective study including 31 patients with FNMTC, and 31 age- and sex-matched patients with sNMTC. METHODS:Histological variant, multifocality, tumor infiltration, angioinvasion, TNM stage, lymph node metastasis, BRAF and p53 expression, ATA risk stratification, and the presence of chronic lymphocytic thyroiditis (CLT) were compared between groups. Then, we identified a cutoff age to stratify patients by age of onset (≤35 vs >35 years). RESULTS:FNMTC presented at a more advanced stage at diagnosis compared to sNMTC, with a higher proportion of medium-high TNM stages. Among FNMTC, early-onset (≤35 years) cases showed higher BRAF expression, more frequent lymph node metastases, a higher proportion of medium-high TNM stages, and intermediate-to-high ATA risk compared to late-onset cases (>35 years). Medium-high TNM stage, BRAF expression, and lymph node metastases were observed more frequently in early onset FNMTC than in age-matched sNMTC. Late-onset FNMTC patients exhibited a higher prevalence of CLT than early-onset FNMTC and late-onset sNMTC patients. CONCLUSIONS:These findings underscore the relevance of age at disease onset in shaping the clinical phenotypes of FNMTC. The distinct pathological features of early-onset vs late-onset FNMTC suggest different pathophysiological mechanisms, with the former likely driven by direct genetic/oncogenic alterations, and the latter influenced by autoimmune thyroiditis-related carcinogenesis, a hypothesis that warrants further investigation in larger prospective studies.

Background/Objectives: The management of lymph node metastases of the central neck compartment (CNC) in differentiated thyroid carcinoma is debated. The intraoperative measurement of thyroglobulin (Tg) has gained attention in accurately detecting metastases, reducing unnecessary CNC dissections. Methods: A total of 37 patients underwent surgery. An intraoperative assay of thyroglobulin from fine needle aspiration (Tg-FNA) was performed on CNC lymph nodes, identified by blue dye injection in 15 patients (23 nodes, group A) and by palpation in 22 patients (35 nodes, group B). The Tg-FNA values were compared with histology to calculate the diagnostic accuracy. Results: In group A, the blue dye diffused widely, complicating lymph node identification: 2 were metastatic and 21 non-metastatic, with median Tg-FNA levels of 6236 ng/mL and 99.20 ng/mL, respectively. In group B, 8 were metastatic and 27 benign, with median Tg-FNA levels of 4063 ng/mL and 121 ng/mL (p < 0.0001), respectively. ROC analysis identified 500 ng/mL as a cutoff, achieving 100% sensitivity and 74% specificity in group B and 90% sensitivity and 70% specificity overall. Finally, among the non-metastatic lymph nodes, group A exhibited some cases of very high Tg-FNA values compared to group B, with lower accuracy for the cutoff, suggesting that colorant injection might lead to increased Tg-FNA levels. Conclusions: Blue dye injection showed low accuracy. Intraoperative Tg-FNA was reliable in detecting CNC metastases, although a higher cutoff is needed in this compartment compared to what has been reported for lateral lymph nodes. Lymphatic drainage and surgical manipulation might explain these findings. The careful interpretation of Tg-FNA in CNC should be adopted.

This study aimed to investigate the presence of structural and functional changes in extraocular muscles (EMs) among patients with inactive Graves’ orbitopathy (GO) classified according to the Clinical Activity Score (CAS). Sixty-seven patients with Graves’ disease (GD) and inactive GO were included. The data collected included clinical parameters, thyroid function, autoantibody levels, EOM morphology via orbital ultrasound (US), and ocular motility. Patients were stratified into Red Filter Test (RFT)-positive or RFT-negative groups based on the presence or absence of latent diplopia during the RFT examination. Thirty-three patients (49.25%) exhibited latent diplopia on the RFT, despite not reporting double vision during standard ocular motility tests. Significant differences were observed between the two groups in terms of age, disease duration, intraocular pressure (IOP) elevation in up-gaze, and medial rectus muscle thickness (p < 0.05). No significant differences were found in thyroid status, TRAb and ATA levels, CASs, exophthalmos, or lateral rectus thickness between the two groups. This study revealed that in inactive GO, subclinical EM dysfunction and morphological changes may be present, which might not be apparent through routine ocular examinations. The RFT is effective in detecting latent diplopia, highlighting its utility in identifying subtle ocular motility issues and subclinical muscle involvement. Comprehensive evaluations combining functional tests like the RFT and imaging are essential for early detection of GO-related abnormalities, enabling tailored and prompt management and improving patient outcomes.

Searchable abstracts of presentations at key conferences in endocrinology ISSN 1470-3947 (print) | ISSN 1479-6848 (online)

Purpose: The FNA-CT is useful for the diagnosis of MTC. The aim of this study was to evaluate the performance of FNA-CT in TNs coexisting with CCH. Methods: This study retrospectively reviewed the records of 11 patients with TNs submitted to thyroidectomy on the basis of elevated basal and/or stimulated serum CT values, which at histology were not confirmed to be MTC. The results obtained in this group were compared with those of a previously reported group of histologically proven MTC patients submitted to an identical presurgical evaluation. All patients, negative for known mutations in the RET proto-oncogene, were preoperatively submitted to neck ultrasound, FNA-cytology, and FNA-CT. Results: Approximately 6 of 11 patients showed increased (>36 ng/mL, as established in previous studies not involving patients with CCH) FNA-CT. All these patients showed diffuse CCH at histology in the thyroid lobe submitted to FNA; 5 of them were benign at histology, while only one was malignant (papillary thyroid carcinoma, PTC). The remaining 5 of 11 patients had low FNA-CT (<36 ng/mL), and all of them showed only focal CCH in the lobe submitted to FNA; three of them were malignant (2 PTC, 1 follicular carcinoma), while two were benign. Conclusions: Employing the currently proposed cut-off values, false-positive FNA-CT results may be observed in benign/malignant TNs with coexisting diffuse CCH. FNA-CT must therefore be cautiously used in the diagnostic approach for patients with TNs and a slightly increased basal or stimulated serum CT concentration in order to avoid unnecessary surgery.

Searchable abstracts of presentations at key conferences in endocrinology ISSN 1470-3947 (print) | ISSN 1479-6848 (online)

Purpose It is well known that interferon-α (IFN-α), used for long time as the main therapy for HCV-related disease, induces thyroid alterations, but the impact of the new direct-acting antivirals (DAAs) on thyroid is not established. Aim of this prospective study was to evaluate if DAAs therapy may induce thyroid alterations. Methods A total of 113 HCV patients, subdivided at the time of the enrollment in naïve group ( n = 64) and in IFN-α group ( n = 49) previously treated with pegylated interferon-α and ribavirin, were evaluated for thyroid function and autoimmunity before and after 20–32 weeks of DAAs. Results Before starting DAAs, a total of 8/113 (7.1%) patients showed Hashimoto's thyroiditis (HT) all belonging to IFN-α group (8/49, 16.3%), while no HT cases were found in the naïve group. Overall, 7/113 (6.2%) patients were hypothyroid: 3/64 (4.7%) belonging to naïve group and 4/49 (8.2%) to IFN-α group. Furthermore, a total of 8/113 patients (7.1%) showed subclinical hyperthyroidism: 2/64 (3.1%) were from naïve group and 6/49 (12.2%) from IFN-α group. Interestingly, after DAAs therapy, no new cases of HT, hypothyroidism and hyperthyroidism was found in all series, while 6/11 (54.5%) patients with non-autoimmune subclinical thyroid dysfunction became euthyroid. Finally, the only association between viral genotypes and thyroid alterations was genotype 1 and hypothyroidism. Conclusions This study supports evidence that DAAs have a limited or missing influence on thyroid in patients with HCV-related diseases. Moreover, it provides preliminary evidence that subclinical non-autoimmune thyroid dysfunction may improve after HCV infection resolution obtained by DAAs.

Papillary thyroid cancer (PTC) often co-occurs with Hashimoto’s thyroiditis, an association that has long been reported in clinical studies, remaining controversial. Experimental evidence has recently shown that pre-existing thyroiditis has a beneficial effect on PTC growth and progression by a distinctive expansion of effector memory CD8 T cells. Although the link between inflammation and PTC might involve different components of the immune system, a deep characterization of them which includes T cells, B cells and tertiary lymphoid structures, Mye-loid cells, Neutrophils, NK cells and dendritic cells will be desirable. The present review article considers the role of the adaptive and innate immune response surrounding PTC in the context of Hashimoto’s thyroiditis. This review will focus on the current knowledge by in vivo and in vitro studies specifically performed on animals’ models; thyroid cancer cells and human samples including (i) the dual role of tumor-infiltrating lymphocytes; (ii) the emerging role of B cells and tertiary lymphoid structures; (iii) the role of myeloid cells, dendritic cells, and natural killer cells; (iv) the current knowledge of the molecular biomarkers implicated in the complex link between thyroiditis and PTC and the potential implication of cancer immunotherapy in PTC patients in the context of thyroiditis.

Simona De Angelis1 · Daniela Rotondi1 · Enzo Gilardi1 · Paolo Stacchini2 · Augusto Alberto Pastorelli2 · Angela Sorbo2 · Marilena D’Amato2 · Anna Chiara Turco2 · Emanuela Medda3 · Roberto Da Cas4 · Sebastiano Andò5 · Daniela Bonofiglio5 · Marcello Bagnasco6 · Maurizio Gasperi7 · Domenico Meringolo8 · Caterina Mian9 · Efisio Puxeddu10 · Concetto Regalbuto11 · Mariacarla Moleti12 · Augusto Taccaliti13 · Salvatore Ulisse14 · Massimo Tonacchera15 · Maria Laura Tanda16 · Francesco Boi17 · Valeria Ruggiero17 · Stefano Mariotti17 · Carlo Corbetta18 · Renzo Ciatti19 · Elisabetta Tarsi19 · Vera Stoppioni19 · Nicola Perrotti20 · Onorina Marasco21 · Giovanna Scozzafava21 · Marta Camilot22 · Francesca Teofoli22 · Francesca Righetti23 · Antonio Dimida15 · Giuseppe Plutino24 · Elena Carrano24 · Roberto Copparoni24 · Marco Gabbianelli1 · Paolo Vitti15 · Antonella Olivieri1

Purpose Thyroid alterations including de novo appearance of thyroid autoimmunity are adverse effects of tyrosine kinase inhibitors, used in solid and hematologic cancer therapy, but the relationship between thyroid alterations during this treatment and the outcome of chronic myeloid leukemia remains unclear. Aim of this study was to investigate whether the presence of thyroid alterations may affect the clinical outcome of chronic myeloid leukemia on tyrosine kinase inhibitors. Methods We evaluated thyroid function and autoimmunity in 69 chronic myeloid leukemia patients on long-term therapy looking at the association between thyroid abnormalities and disease molecular response. Results Overall, 24 of 69 (34.8%) had one or more thyroid abnormalities during therapy. A high percentage of patients (21/69, 30.4%) showed thyroid autoimmunity (positive thyroid autoantibodies with ultrasound hypoechogenicity), while clinical and subclinical hypothyroidism and subclinical hyperthyroidism were, respectively, found in 4 of 69 (5.8%) and 3 of 69 (4.3%) of cases. Second-generation tyrosine kinase inhibitors resulted significantly associated (14/32, 43.7%) with Hashimoto’s thyroiditis, compared to first generation (7/37, 18.9%; p = 0.03). Interestingly, we also found a significant association between euthyroid (14/26, 53.8%) and hypothyroid Hashimoto’s thyroiditis (4/26, 15.4%) in patients with deep molecular response, as compared to euthyroid (3/43, 7%; p = 0.0001) and hypothyroid (0/43, 0%; p = 0.02) Hashimoto’s thyroiditis patients with major molecular response. Conclusions Our study confirms and extends our knowledge on the tyrosine kinase inhibitors effects on thyroid, showing that thyroid autoimmunity is frequently observed in chronic myeloid leukemia patients on long-term therapy and is associated with a better oncological response.

OBJECTIVES:The thymus plays a central role in immune tolerance, which prevents autoimmunity. Myasthenia gravis (MG) is commonly associated with thymoma or thymus hyperplasia, and it can coexist with autoimmune thyroid diseases. However, the role of the thymus in thyroid autoimmunity remains to be clarified, which we investigated here.STUDY DESIGN:The study design entailed the inclusion of consecutive MG patients and the measurement of anti-thyroid autoantibodies at baseline and, limited to autoantibody-positive patients, also at 24 and 48 weeks. One hundred and seven MG patients were studied. The main outcome measure was the behaviour of anti-thyroglobulin autoantibodies (TgAbs) and anti-thyroperoxidase autoantibodies (TPOAbs) over time in relation to thymectomy.RESULTS:Serum TgAbs and/or TPOAbs were detected in ∼20% of patients in the absence of thyroid dysfunction. The prevalence of positive serum TgAbs and/or TPOAbs decreased significantly (p = 0.002) over the follow-up period in patients who underwent thymectomy, but not in patients who were not thymectomized. When the analysis was restricted to TgAbs or TPOAbs, findings were similar. On the same line, there was a general trend towards a reduction in the serum concentrations of anti-thyroid autoantibodies in patients who underwent thymectomy, which was significant for TPOAbs (p = 0.009).CONCLUSIONS:Our findings suggest a role of the thymus in the maintenance of humoral thyroid autoimmunity.

Adequate iodine intake is necessary for normal thyroid function. Iodine deficiency is associated with serious complications, but also iodine excess can lead to thyroid dysfunction, and iodine supplementation aimed to prevent iodine deficiency disorders has been associated with development of thyroid autoimmunity. The epidemiology of thyroid diseases has undergone profound changes since the implementation of iodoprophylaxis, notably by means of iodine-enriched salt, specifically resulting in decreased prevalence of goiter and neonatal hypothyroidism, improved cognitive function development in infancy, and reduced incidence of more aggressive forms of thyroid cancer. The main question we address with this review is the clinical relevance of the possible effect on autoimmunity exerted by the use of iodine-enriched salt to correct iodine deficiency. In animal models, exogenous iodine is able to trigger or exacerbate thyroid autoimmunity, but it is still not clear whether the observed immunological changes are due to a direct effect of iodine on immune response, or whether they represent a secondary response to a toxic effect of iodine on thyroid tissue. Previous iodine status of a population seems to influence the functional thyroid response to increased iodine intake and possibly the development of thyroid autoimmunity. Moreover, the prevalence of thyroid antibodies, regarded as hallmark of autoimmune thyroid disease, varies between populations under the influence of genetic and environmental factors, and the presence of thyroid antibodies does not always coincide with the presence of thyroid disease or its future development. In addition, the incidence of autoimmune diseases shows a general increasing trend in the last decades. For all these reasons, available data are quite heterogeneous and difficult to analyze and compare. In conclusion, available data from long-term population surveys show that a higher than adequate population iodine intake due to a poorly controlled program of iodine prophylaxis could induce thyroid dysfunction, including thyroid autoimmunity mostly represented by euthyroid or subclinical hypothyroid autoimmune thyroiditis. Close monitoring iodine prophylaxis is therefore advised to ensure that effects of both iodine deficiency and iodine excess are avoided.

The extent to which mononuclear cells and TSH-receptor autoantibodies (TRAb) contribute to Graves’ orbitopathy (GO) is not completely defined. Here we investigated the relationship between the immunohistochemical phenotype of orbital infiltrating cells and GO features in a large number of patients. We conducted an observational cohort study in 76 consecutive patients with GO (16 men and 60 women) who underwent orbital decompression over a period of 18 consecutive months. An ophthalmological evaluation was performed in all patients, as well as immunohistochemistry for CD3, CD4, CD8, CD56 (T-cell markers), CD25 (T and B-cell marker), CD20, CD19 (B-cell markers), and CD138 (plasmacell marker) in specimens collected at decompressive surgery. Having established cutoff values for each marker, cell infiltrates were found in 60 patients (78.9%; CD3: 39.4%, CD4 55.2%, CD8 50%, CD56: 0%, CD25: 28.9%, CD20: 51.3%, CD19: 25%, CD138: 26.3%). Eleven (14.4%) stained exclusively for CD138 (plasmacells). Patients with CD4-positive mononuclear cells had a significantly greater GO clinical activity score (CAS) (mean difference 1.07, 95% CI − 0.33 to − 1.82, P = 0.004 by univariate, P = 0.05 by multivariate analysis). CAS as well as the remaining GO features were not affected significantly by the mononuclear cell subpopulations in multivariate analyses. Mononuclear cell infiltrates are present in the majority of GO patients, with a small percentage represented exclusively by plasmacells. CD4 cells exert a major role on GO activity. These findings may represent a further advancement in the comprehension of GO pathogenesis.

Papillary thyroid cancer (PTC) often co-occurs with Hashimoto's thyroiditis, an association that has long been reported in clinical studies yet remains controversial. Some studies, in fact, have suggested a protective effect of thyroiditis while others have not. We generated a mouse model where PTC and thyroiditis develop in a predictable manner, combining the oncogenic drive of the BRAF(v600E) mutation (inducible by tamoxifen) to the thyroiditis susceptibility of the NOD.H2(h4) strain (inducible by iodine). A total of 113 NOD.H2(h4)_TPO-CRE-ER_BRAF(V600E) mice (50 followed throughout lifetime and 63 sacrificed at 16 weeks post tamoxifen) were used to determine whether the PTC phenotype differs when thyroiditis precedes or coincides with the onset of PTC. Mice with pre-existing thyroiditis lived longer (median survival of 28.2 weeks post tamoxifen) than those with concomitant (25.6 weeks) or no (24.5 weeks) thyroiditis (P < 0.01 by Laplace regression). PTC developed less frequently (33%) in the pre-existing thyroiditis group than the concomitant (100%) or no (100%) thyroiditis groups (P < 0.001 by chi-squared) and showed less aggressive histopathological features. The intratumoral mononuclear cell infiltration was more prominent in mice with pre-existing thyroiditis (P = 0.002 vs the other groups) and sustained by a significant expansion of effector memory CD8 + T cells and CD19 + B cells. These findings shed light on the controversial PTC-thyroiditis association and emphasize the contribution of intratumoral T and B lymphocytes to the evolution of PTC.

The serum metabolic changes occurring during the transition from hypothyroidism to euthyroidism are not known. This study aimed to determine the metabolomic profile in hypothyroid patients before (HypoT0) and after (HypoT1) euthyroidism achieved through levothyroxine (L-T4) treatment. Eighteen patients with overt primary hypothyroidism were recruited for the study. All patients were treated with L-T4 to achieve euthyroidism. Thyrotropin (TSH), free thyroxine (FT4), free triiodothyronine (FT3) and metabolomics profiles were measured before and after 3 months of treatment. The euthyroid control group consisted of 28 healthy volunteers. Metabolomics analysis was performed using Nuclear Magnetic Resonance (NMR) spectroscopy. 1H NMR-based metabolomics profiling of patients with newly diagnosed hypothyroidism (HypoT0) showed significantly higher levels of citrate, creatinine, glycerol, myo-inositol and serine, and lower levels of proline and taurine compared to controls. Interestingly, some metabolic changes were persistent three months after pharmacological treatments, despite normal serum TSH and thyroid hormone concentrations (HypoT1). When an Orthogonal Partial Least Squares Discriminant Analysis (OPLS-DA) model was built to evaluate possible differences in the metabolic profile between HypoT0 and HypoT1, the data obtained were not significantly different. These results suggest that metabolic changes in the patients with hypothyroidism may persist after normalization of serum levels of FT3, FT4, and TSH, which currently represent the gold standard in laboratory testing for diagnosis and evaluation of thyroid pathology. So, the metabolomics approach may contribute to integrate classical hormone assays and to determine the euthyroid status achievement with greater efficacy.