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G Mercuro, S Zoncu, P Colonna, P Cherchi, S Mariotti, F Pigliaru, L Petrini, and S Iliceto

OBJECTIVE: To verify whether the accuracy of data on myocardial function provided by pulsed-wave tissue Doppler imaging (PWTDI), a new echocardiographic application that allows quantitative measurements of myocardial wall velocities, could help towards a better understanding of the natural history of acromegalic cardiomyopathy. DESIGN: Eighteen patients with active acromegaly (ten men and eight women; mean age 48.0+/-15.0 years) with no other detectable cause of heart disease underwent PWTDI. Thirteen healthy individuals matched for age and body mass index acted as a control group. METHODS: Ejection fraction (EF), transmitral early/late diastolic velocity (E/A) ratio and isovolumic relaxation time (IVRT) were measured by conventional echocardiography; systolic peak (Sv) and early (Ev) and late (Av) diastolic peak velocities, Ev/Av ratio and regional IVRT (IVRTs) were obtained by PWTDI. RESULTS: All patients showed appreciably abnormal left ventricular global diastolic function represented by prolongation of the IVRT (P<0.001). Using PWTDI we found a prolongation of IVRTs and inversion of the Ev/Av ratio. In addition, the Ev/Av ratio proved to be significantly negatively correlated with IVRT; this correlation was not present in the case of the E/A ratio. Furthermore, a decrease in Sv was detected in the basal segment of the lateral wall (P<0.01), which had the greatest degree of diastolic dysfunction. CONCLUSIONS: PWTDI confirmed the acknowledged diastolic dysfunction that accompanies acromegalic cardiomyopathy and highlighted the greater sensitivity of regional PWTDI with respect to global Doppler diastolic indexes. Furthermore, by revealing an impairment of regional systolic function in presence of a normal EF, the findings with PWTDI contradicted the largely accepted theory that systolic function remains normal for several years in patients affected by acromegalic cardiomyopathy.

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E Raspé, S Costagliola, J Ruf, S Mariotti, JE Dumont, and M Ludgate

Raspé E, Costagliola S, Ruf J, Mariotti S, Dumont JE, Ludgate M. Identification of the thyroid Na+/I cotransporter as a potential autoantigen in thyroid autoimmune disease. Eur J Endocrinol 1995;132: 399–405. ISSN 0804–4643

The thyroid gland is the target of several autoimmune diseases. Specific thyroid proteins have been identified as autoantigens associated with these diseases (e.g. thyroperoxidase, thyroglobulin and the thyrotrophin (TSH) receptor). In this paper, we report that the serum of a patient suffering from Hashimoto's thyroiditis, autoimmune gastritis and rheumatoid arthritis was able to inhibit the chronic TSH-induced I uptake of dog thyrocytes in culture, even at a 1:1000-fold dilution, without affecting their 86Rb+ uptake. This blocking activity is rare as 147 sera (from patients positive for antibodies to the thyroid microsomes and the gastric parietal cell antigen, patients with Sjögren's syndrome, patients with a high titre of microsomal antibodies and low or negative for antibodies to thyroperoxidase, and patients with a high titre of microsomal antibodies and frank hypothyroidism) were negative when tested for their ability to inhibit I uptake. Subsequently we tested 20 murine monoclonal antibodies previously obtained by immunizing mice with a crude human thyroid membrane preparation, which were all negative when tested against thyroglobulin and thyroperoxidase. One of the monoclonal antibodies displayed a 50% inhibition of the chronic TSH-induced 125I uptake of dog thyrocytes without affecting the 86Rb+ uptake of the cells. Immunoglobulins purified from the ascite fluid by affinity chromatography on a protein A cellulose column had the same characteristics. Taken together, the data suggest that thyroidal 125I uptake can be inhibited by antibodies, that autoantibodies in the patient's serum are most probably responsible for the observed inhibition and therefore that the Na+/I cotransporter is probably an autoantigen.

E Raspé, IRIBHN, School of Medicine, Free University of Brussels (ULB), 808 route de Lennik, 1070 Bruxelles, Belgium

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G. F. Del Prete, S. Mariotti, A. Tiri, M. Ricci, A. Pinchera, and S. Romagnani

Hashimoto's thyroiditis (HT) is an autoimmune disease due to the breakdown towards self thyroid antigens, resulting in the activation of as yet incompletely defined mechanisms that lead to thyroid infiltration by both T and B lymphocytes and thyroid cell destruction.

In the studies reported here we have compared the ability of B cells from peripheral blood (PB) and thyroid infiltrate of HT patients to express surface markers of activation and to secrete thyroid autoantibody in culture. Further, T lymphocytes present in HT infiltrates have been analyzed at clonal level for their phenotype, antigen-specificity and cytolytic potential.

Phenotype and function of thyroid infiltrating B cells

In respect of peripheral blood (PB), a 2- to 3-fold increase of cells belonging to the B-cell lineage has been found in HT infiltrates (McLachlan et al. 1985). In addition, it has been recently shown that a number of thyroid B cells expressed surface markers of

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F Boi, M L Lai, B Marziani, L Minerba, G Faa, and S Mariotti

Objective: We assessed the association between thyroid autoimmunity and thyroid cancer in a retrospective series of unselected thyroid nodules submitted to fine-needle aspiration cytology (FNAC) to avoid the selection bias of surgical series.

Subjects and methods: Ultrasound (US)-guided FNACs were obtained from 590 unselected consecutive patients with single thyroid nodules and positive (ATA + , n = 197) or negative (ATA − , n = 393) serum anti-thyroid antibody (ATA). Cytological results were classified in three classes of increased risk of malignancy: low risk or benign (class II); indeterminate risk (class III); and suspect or malignant (class IV).

Results: A higher prevalence of class III (28.9% vs 21.4%, P < 0.05) and class IV (18.8% vs 9.2%, P < 0.001) and lower prevalence of class II (52.3% vs 69.5%, P < 0.001) were found in ATA + vs ATA − nodules respectively. By multivariate logistic regression analysis ATA + conferred a significant risk (odds ratio (OR): 2.29 (95% confidence interval (CI): 1.39–3.76)) for class IV cytology independently from age and sex. In 106 patients where thyroidectomy was carried out, thyroid cancer was found in 54/61 (88.5%) patients with class IV nodules (with similar positive predictive value for cancer in ATA + (96.4%) and ATA– (81.8%) nodules), in 6/31 (19.3%) of class III nodules (all ATA − ) and in none of 14 class II nodules. Non-specific cytological atypias from hyperplastic nodules in lymphocytic thyroiditis probably accounted for the different prevalence of cancer in class III ATA + and ATA − nodules. Histologically proven thyroid cancer (mostly papillary) was then observed in a higher proportion (27/197 = 13.7%) of ATA + , when compared with ATA − nodules (33/393 = 8.4%, P = 0.044), but the significance of this finding is limited by the low number of class II nodules operated on.

Conclusions: The presence of ATA + confers an increased risk of suspicious or malignant cytology in unselected thyroid nodules. Since ATA + is not responsible for increased false- positive class IV FNAC, our study provides indirect evidence supporting a significant association between thyroid carcinoma and thyroid autoimmunity, although further studies with a different design are needed for a definitive histological proof.

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M Piga, M C Cocco, A Serra, F Boi, M Loy, and S Mariotti


Amiodarone-induced thyrotoxicosis (AIT) is caused by excessive hormone synthesis and release (AIT I) or a destructive process (AIT II). This differentiation has important therapeutic implications.


To evaluate 99mTc-sestaMIBI (MIBI) thyroid scintigraphy in addition to other diagnostic tools in the diagnosis and management of AIT.

Subjects and methods

Thyroid and 99mTc-MIBI scintigraphies were performed in 20 consecutive AIT patients, along with a series of biochemical and instrumental investigations (measurement of thyrotrophin, free thyroid hormones and thyroid autoantibodies; thyroid colour-flow Doppler sonography (CFDS) and thyroid radioiodine uptake (RAIU)).


On the basis of instrumental and laboratory data (excluding thyroid 99mTc-MIBI scintigraphy) and follow-up, AIT patients could be subdivided into six with AIT I, ten with AIT II and four with indefinite forms of AIT (AIT Ind). 99mTc-MIBI uptake results were normal/increased in all the six patients with AIT I and absent in all the ten patients with AIT II. The remaining four patients with AIT Ind showed low, patchy and persistent uptake in two cases and in the other two evident MIBI uptake followed by a rapid washout. MIBI scintigraphy was superior to all other diagnostic tools, including CFDS (suggestive of AIT I in three patients with AIT II and of AIT II in three with AIT Ind) and RAIU, which was measurable in all patients with AIT I, and also in four out of the ten with AIT II.


Thyroid MIBI scintigraphy may be proposed as an easy and highly effective tool for the differential diagnosis of different forms of AIT.

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F Boi, ML Lai, C Deias, M Piga, A Serra, A Uccheddu, G Faa, and S Mariotti

OBJECTIVE: To assess the relevance of (99m)Tc-SestaMIBI (MIBI) scan in the diagnostic evaluation of thyroid nodules with oncocytic cytology. SUBJECTS AND METHODS: Twenty-four patients with a single (or prevalent) 'cold' solid nodule with Hurthle cells (HC) at fine needle aspiration cytology (FNAC) were studied. Cytological diagnosis of oncocytic metaplasia (OM) or HC tumor (HCT) was made when HC on the smear were comprised 10-75%, or >75%. Nodules concentrating MIBI at early and late (2 h after washout) stages were considered MIBI-positive. In all cases histological findings were obtained after total thyroidectomy. RESULTS: FNAC was malignant or suspect for malignancy in 16 cases (six HCT and 10 OM) and not suspect in eight (two HCT and six OM). Histological examination revealed 14 malignant tumors (11 HCT and three OM), and 10 benign thyroid lesions (three HCT and seven OM). Sensitivity of FNAC for malignancy was 92.8% and specificity was 70.0%; HCT were identified by FNAC in only 35.7% and OM in 70.0% of cases. No significant difference in MIBI positivity was found between malignant and benign thyroid nodules. The highest percentage of MIBI positivity was found in HCT (78.5%), but MIBI-positive nodules were also observed in thyroid lesions with HC metaplasia (40.0%). CONCLUSIONS: MIBI scintiscan has no value in differentiating malignant from benign HC thyroid neoplasias. Most HCT are MIBI-positive, but this scan is not sufficiently specific to differentiate true HC neoplasias from other thyroid lesions showing HC at FNAC, although an MIBI-negative scan strongly supports the absence of true HCT.

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F Boi, M Loy, M Piga, A Serra, F Atzeni, and S Mariotti

OBJECTIVE: To assess the potential role of conventional sonography and colour flow Doppler (CFD) sonography (CFDS) in the differential diagnosis of toxic multinodular goitres. SUBJECTS AND METHODS: We investigated 55 patients with untreated hyperthyroidism (24 with typical toxic diffuse goitre of Graves' disease (Group A); 26 with multinodular goitre (Group B); and five with single toxic adenoma (Group C); 22 euthyroid subjects (12 with non-toxic multinodular goitre (Group D) and ten normal subjects (Group E)) were included as controls. In all cases free thyroxine, free tri-iodothyronine, TSH, TSH receptor antibodies (TRAb), anti-thyroperoxidase antibody, anti-thyroglobulin antibodies and anti-thyroid microsomal antibodies were determined and a [(99m)Tc]pertechnetate thyroid scan was performed. RESULTS: Patients with toxic multinodular goitre displayed two different CFDS patterns: 18 patients (Group B-1) had nodules with normal vascularity surrounded by diffuse parenchymal hypoechogenicity with markedly increased CFD signal and maximal peak systolic velocity (PSV) (a pattern similar to Group A patients with Graves' disease); eight patients (Group B-2) had increased intra- and perinodular CFD signal and PSV with normal extranodular vascularity (a pattern similar to that found in Group C patients with single toxic adenoma). Patients of Group B-1 showed a proportion of clinically evident thyroid ophthalmopathy, positive TRAb and other thyroid autoantibodies similar to that observed in Group A patients, while no evidence of thyroid autoimmunity was found in Group B-2. Sixteen out of 18 (89%) patients from Group B-1 displayed a scintiscan pattern of diffuse uneven radionuclide distribution, while seven out of eight (87.5%) of those from Group B-2 had localized uptake in multiple discrete nodules. Taken together, these data strongly suggest that Group B-1 mostly represents patients with the multinodular variant of Graves' disease, while Group B-2 represents patients with non-autoimmune toxic multinodular goitre. CONCLUSIONS: This study shows that combined conventional sonography and CFDS may easily distinguish nodular variants of Graves' disease from non-autoimmune forms of toxic multinodular goitre and confirms the clinical usefulness of this technique in the first-line evaluation of hyperthyroid patients.

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A. Pinchera, S. Mariotti, L. Chiovato, P. Vitti, G. Lopez, A. Lombardi, S. Anelli, R. Bechi, and P. Carayon

Abstract. Evidence has been accumulated that human thyroid microsomal/microvillar autoantigen (M) is expressed both in the cytoplasm and on the surface of thyroid follicular cells. The availability of this autoantigen to the immune system, possibly associated with abnormally expressed HLA-DR antigens may be relevant both to the triggering and to maintenance of thyroid autoimmune reactions. Preliminary biochemical characterization of M suggested that it was a glycoprotein with a mol. wt. of about 100–110 kD. recent studies carried out in our laboratories taking advantage of monoclonal antibodies provided evidence that the structure presently referred as M-Ag is represented by thyroid peroxidase (TPO). The identity between TPO and M is further supported by four-layer immunofluorescence analysis showing a complete overlap of the two antigens both in the surface and in the cytoplasm of thyroid cells and by the observation that the expression of M and TPO is similarly modulated by TSH, possibly through a cAMP-dependent mechanism.

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E. Martino, L. Bartalena, S. Mariotti, F. Aghini-Lombardi, C. Ceccarelli, F. Lippi, M. Piga, A. Loviselli, L. Braverman, M. Safran, and A. Pinchera

Abstract. Amiodarone, an iodine-rich drug, represents at the present, at least in Europe, one of the most common sources of iodine-induced thyroid dysfunction. The drug may induce both hypothyroidism and thyrotoxicosis. In spite of the large iodine intake occurring during amiodarone therapy, 131I thyroid uptake is detectable in patients with amiodarone-iodine-induced hypothyroidism, irrespective of the presence or absence of underlying thyroid disease. In contrast, in patients with amiodarone-iodine-induced thyrotoxicosis, 131I thyroid uptake is normal or even elevated in those with co-existent underlying thyroid disorders, whereas it is very low in those with an apparently normal thyroid gland. Perchlorate discharge test was performed in 8 patients with hypothyroidism and in 5 patients with hyperthyroidism induced by amiodarone: a positive test was found in all hypothyroid patients and a negative test in all hyperthyroid patients.