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Função tireóidea após lobectomia total por bócio não tóxico / Thyroid function after total lobectomy for non-toxic goiter.Dorival de Carlucci Junior 10 January 2007 (has links)
INTRODUÇÃO: A sofisticação dos métodos de diagnóstico por imagem, em especial o ultra-som, contribuiu para que nódulos cada vez menores fossem diagnosticados com maior freqüência. Nódulos tireóideos são encontrados ao exame ultra-sonográfico, em até 17% das mulheres adultas. A lobectomia total é considerada procedimento adequado para o tratamento dos nódulos benignos laterais da tireóide. O hipotireoidismo pode ocorrer em 5% a 35% dos doentes, após esse procedimento e está relacionado tanto com a quantidade de tecido glandular remanescente, quanto com a sua qualidade funcional. Neste estudo avaliou-se a ocorrência do hipotireoidismo após lobectomia total, visando identificar os indivíduos com maior risco de desenvolver essa doença. MÉTODOS: No período de março de 1996 a julho de 2005, foram selecionados 228 indivíduos eutireóideos submetidos à lobectomia total da tireóide por bócio não tóxico, do Departamento de Cirurgia de Cabeça e Pescoço do Instituto Brasileiro de Controle do Câncer e da clínica privada do autor. Realizou-se estudo retrospectivo com 186 indivíduos passíveis de análise, considerando os níveis séricos de tireotrofina (TSH) pré e pós-operatórios e a dosagem de anticorpos antitireóideos. O volume do coto tireóideo remanescente foi determinado por exame ultrasonográfico. Os exames anatomopatológicos foram revistos e quantificaram, por meio da análise semiquantitativa, os agregados linfocitários e os folículos linfóides: graduados de 0 a IV e de 0 a III, respectivamente. O hipotireoidismo foi diagnosticado quando TSH = 5,5 mU/L em até oito semanas após a operação. RESULTADOS: Houve predomínio do sexo feminino neste estudo (88%), com a idade variando de 16 a 72 anos e com média de 45 anos. O tempo médio de seguimento foi de 29 meses, variando de seis meses a nove anos. Foi identificado TSH = 5,5 mU/L em 61 casos (32,8%). Bócio foi o diagnóstico de 82% dos hipotireóideos e 80,7% dos eutireóideos. A idade, o sexo e a quantidade de infiltrados linfocitários não apresentaram diferença estatística entre os indivíduos eutireóideos e hipotireóideos após o procedimento. Os fatores relacionados ao hipotireoidismo pósoperatório foram: valor médio de TSH pré-operatório, que registrou 2,1mU/L, entre os hipotireóideos, e 1,2 mU/L, entre os eutireóideos (p<0.001); volume médio do coto remanescente da tireóide, que indicou 3,9 cm3 no grupo com hipotireoidismo e 6,0 cm3 no grupo sem doença (p=0,003); lobectomia direita (p=0,006); positividade do anticorpo antiperoxidase (AcTPO) (p=0,009). O TSH pré-operatório > 2,0 mU/L aumentou em 7,1 vezes a possibilidade de ocorrer hipotireoidismo após lobectomia total e, quando foi considerada a lobectomia direita e o volume do coto remanescente = 4,0 cm3, a possibilidade de apresentar hipotireoidismo pós-operatório foi 7,4 vezes maior. CONCLUSÕES: O hipotireoidismo pós-operatório ocorreu em 32,8% dos indivíduos submetidos à lobectomia total por bócio não tóxico. Pequeno volume do remanescente tireóideo ao ultra-som, inferior a 4,0cm3, e a remoção do lobo direito estiveram relacionados com maior risco para o hipotireoidismo. Fatores determinantes do estado funcional da glândula, como os níveis elevados, porém ainda normais, do TSH no préoperatório e a presença AcTPO positivos também se mostraram relacionados com o risco elevado para o hipotireoidismo pós-operatório. / INTRODUCTION: Thyroid nodules, recently, have their diagnosis increased because of the improvement of imaging methods, especially ultrasound. Around 17% of these nodules may be identified in adult women by ultrasound. Total lobectomy is considered an appropriate procedure for benign thyroid nodules. Hypothyroidism may occur in 5% to 35% patients after total lobectomy and it is related to the volume of the remnant thyroid tissue and its functional quality. This study was designed to evaluate the incidence of postoperative hypothyroidism and to determine patients with high risk for this disease. METHODS: From March 1996 to July 2005, 228 euthyroid patients, from the Department of Head and Neck Surgery of the Brazilian Institute for Cancer Control (IBCC) and from the author?s private office, had a total lobectomy due to non-toxic goiter. Out of these patients, 186 were selected for this retrospectively study. Thyrotrophin (TSH) levels, antithyroid antibodies, volume of the remnant thyroid by ultrasound and a semiquantitatively review of the histological specimens considering lymphocytic infiltration were studied. Hypothyroidism was defined for TSH = 5,5 mU/L up to eight weeks postoperative. RESULTS: Women were predominant (88%) with ages varying from 16 to 72 years old and the median age of 45 years old. The average time of follow-up was 29 months, ranging from six months to nine years. TSH ³ 5,5 mU/L occurred in 61 patients (32,8%). Adenomatous goiter was the principal diagnosis in 82% of the hypothyroids patients and 80,7% of the euthyroids. Age, sex and lymphocytic infiltrate did not show any difference between the two groups. Postoperative hypothyroidism was related to: higher preoperative TSH level than the euthyroids postoperative patients (2,1 mU/L versus 1,2 mU/L, respectively) (p<0,001), smaller thyroid remnant volume, 3,9 cm3 in hypothyroid group against 6,0 cm3 in the euthyroid group (p=0,003), right lobectomy while the euthyroid patients had more left lobectomy (p=0,006) and, finally, higher positive titles of the antiperoxidase antibodies (AcTPO) (p=0,009). The risk for postoperative hypothyroidism was 7.1 times higher for those with preoperative TSH > 2,0 mU/L. When right lobectomy was analyzed with the remnant volume = 4,0 cm3, the risk for postoperative hypothyroidism was 7,4. CONCLUSIONS: Postoperative hypothyroidism occurs in 32,8% of patients who have undergone a total lobectomy for non-toxic goiter. Possible indicators for development of postoperative hypothyroidism are: preoperative TSH > 2,0 mU/L and postoperative positive AcTPO, small thyroid volume at ultrasound, and right lobectomy.
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Os hormônios tireoideanos e o desenvolvimento esquelético fetal e pós-natal: estudo do padrão de expressão dos transportadores e das selenodesiodases das iodotironinas. / Thyroid hormone and skeletal development at fetal and postnatal ages: the expression pattern of iodothyronine transporters and deiodinases.Luciane Portas Capelo 09 February 2009 (has links)
Ainda não é claro o papel dos hormônios tireoideanos (HT) no desenvolvimento do esqueleto fetal. Para responder a questão, induzimos hipotireoidismo materno e fetal em camundongos prenhes através da administração de metimazol e perclorato de sódio. O esqueleto fetal apresentou discretas morfológicas até 16,5 dias de idade embrionária (E). Apenas no final da gestação, em 18,5E, foram observadas a redução significativa da zona hipertrófica, do número de condrócitos hipertróficos, desorganização e diminuição da quantidade dos condrócitos proliferativos, além da redução da expressão do colágeno I, X e osteocalcina. Os TRs, assim como LAT1, LAT2 e MCT8 foram detectados em todas as idades estudadas. A alta expressão gênica da D3, principal inativadora do hormônio tireoideano, em 14,5E e sua redução significativa durante o desenvolvimento, até atingir níveis indetectáveis no período pós-natal indicam que a D3 seja responsável por manter baixos níveis de HT no esqueletono início da gestação, garantindo um desenvolvimento ósseo normal. / Thyroid hormone (TH) plays a key role on post-natal bone development and metabolism, while its relevance during fetal bone development is uncertain. To study this, pregnant mice and fetuses were made hypothyroid. The skeleton morphology was preserved up to 16.5 embryonic days (E). Only at E18.5, the hypothyroid fetuses exhibited a reduction in femoral type I and type X collagen and osteocalcin mRNA levels, in the length and area of the proliferative and hypertrofic zones, in the number of chondrocytes per proliferative column, and in the number of hypertrophic chondrocytes. This suggests that up to E16.5, thyroid hormone signaling in bone is kept to a minimum. D3 mRNA was readily detected as early as E14.5 and its expression decreased markedly at E18.5, and even more after birth. The expression levels of D3 gene during early bone development along with the absence of a hypothyroidism-induced bone phenotype at this time suggest that its expression keeps thyroid hormone signaling in bone to very low levels at this early stage of bone development.
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L'hypothyroïdie juvénile endémique en Ubangi, ZaïreVanderpas, Jean 01 January 1994 (has links)
<p align="justify"><i>Note des Bibliothèques :la thèse du Dr Vanderpas a été défendue en 1991 mais il n'est techniquement pas possible d'indiquer cette date dans le logiciel Bictel/e.</i></p><p><p><p align="justify"><u>Première partie</u> :Fonction thyroïdienne de la naissance à 7 ans chez les enfants d’un essai clinique de supplémentation d’huile iodée versus placebo à la femme enceinte.</p><p><p><p align="justify">L’endémie goitreuse du Nord-Congo (République démocratique, ex-Zaïre) a fait l’objet d’un programme de santé publique de prévention du goitre et du crétinisme dans le cadre du Centre d’Etudes Médicales de l’Université Libre de Bruxelles pour les actions de coopération de 1974 à 1995. Le partenaire congolais était l’Institut de Recherche Scientifique et le Bureau National des Troubles dus à la Carence Iodée.</p><p><p><p align="justify">Le présente travail s’inscrit dans ce contexte et analyse plus particulièrement la fonction thyroïdienne chez l’enfant de zéro à sept ans, dans la continuité d’un suivi d’un essai clinique pharmacologique randomisé et contrôlé (RCT, Randomised Clinical Trial) de phase 2 consistant à administrer une huile iodée (Lipiodol®) à des femmes enceintes se présentant à la maternité de Karawa. Cette cohorte de femmes enceintes a été précédemment étudiée par le Professeur Claude-Hector Thilly*.</p><p><p><p align="justify">Chez les enfants nés de mères non supplémentées en iode, l’histoire fonction thyroïdienne se caractérise comme suit :<p><li>Une fonction thyroïdienne relativement stable au ours de la première année de vie par rapport aux valeurs de TSH et de T4 sériques du sang de cordon ;les moyennes de ces marqueurs biologiques sont clairement indicateurs d’un niveau de carence iodée par rapport aux normes d’une population d’enfants belges d’âge comparable (T4 sérique abaissée et TSH sérique élevée) ;</li><p><li>Une aggravation des altérations de la TSH et de la T4 sériques au cours de la deuxième année de vie, aggravation qui se poursuit jusqu’à la quatrième année ;</li><p><li>Un maintien de marqueurs biologiques de TSH et T4 sérique fortement altérés au moins jusqu’à l’âge de 7 ans (étendue d’âge étudiée).</li></p><p><p><p align="justify">Dans cette région, le manioc est connu pour son rôle goitrogène, au travers de son contenu en glucosides cyanogènes, et il avait été précédemment démontré que le thiocyanate élevé des mères passait librement la barrière placentaire. Au cours de la première année de vie, lorsque les nourrissons sont essentiellement alimentés au sein, le thiocyanate sérique diminue fortement et se rapproche de valeurs observées chez des enfants d’autres régions non exposés au manioc. La dégradation de la fonction thyroïdienne au cours de la deuxième année de vie coïncide avec l’introduction du manioc dans l’alimentation. Pour une valeur de concentration urinaire en iode stable au cours des 7 premières années de vie, la prévalence de goitre et les variations de T4 et TSH sériques suivent celles du thiocyanate sérique. Cela est confirmé au travers d’une analyse multi-variée qui met en évidence l’association entre les valeurs moyennes de TSH et T4 et les concentrations urinaires en iode et en thiocyanate.</p> <p><p><p align="justify">L’administration intra-musculaire d’huile iodée prévient les altérations de la fonction thyroïdienne chez la mère (Thilly 1978), et cette protection s’étend chez l’enfant jusqu’à 24 mois, c’est-à-dire jusqu’à ce que l’allaitement maternel reste le principal apport nutritionnel. Au-delà de 24 mois, des altérations de la fonction thyroïdienne apparaissent chez certains de ces enfants (Elévation de la TSH et abaissement de la T4), et au-delà de 4 ans, la fréquence des altérations de la fonction thyroïdienne est aussi fréquente chez les enfants de mères traitées que chez les enfants de mères non traitées.</p><p><p><p align="justify">Au vu de la fréquence fort élevée d’altérations de la fonction thyroïdienne entre 4 et 7 ans (2/3 ont une TSH anormalement élevée > 10 mU/L), seuls certains enfants présentent les stigmates d’une hypothyroïdie prolongée depuis le début de l’existence. Il apparaît qu’il y a lieu de distinguer des hypothyroïdies juvéniles de durée, de sévérité, et de timing différents. Si l’hypothyroïdie juvénile est aussi fréquente au-delà de 4 ans dans les deux groupes de l’étude, les stigmates cliniques d’hypothyroïdie persistante sont plus fréquemment observés chez les enfants nés de mères non supplémentées en iode que chez les autres. De plus, la sévérité des stigmates cliniques (degré d’arriération mentale ;importance du retard de développement statural) démontre que l’hypothyroïdie persistante s’est installée plus précocement chez ertains enfants nés de mères non supplémentées en iode que chez les autres. Dans les formes les plus sévères, l’évolution staturale et le niveau d’intelligence de ces enfants avec hypothyroïdie persistante sont compatibles avec le tableau clinique de crétinisme myxédémateux endémique décrits chez le sujet adulte par les Professeurs François Delange et Jacques Dumont.</p><p><p><p><p align="justify"><u>Deuxième partie</u>: étude du métabolisme iodé chez les enfants hypothyroïdiens et mise en évidence de la carence combinée en iode et en sélénium.</p> <p><p><p align="justify">Certains enfants hypothyroïdiens le sont depuis longtemps (depuis la naissance, éventuellement), d’autres le sont transitoirement, sans que leur hypothyroïdie passagère ne laisse de séquelles évidentes en termes de retard statural ou d’arriération mentale.</p><p><p><p align="justify">Ceux qui sont en hypothyroïdie persistante au-delà de 4 ans ont une fonction thyroïdienne altérée :lorsqu’on leur administre de l’iode, leur glande ne répond pas à cette correction de carence iodée, et ils demeurent profondément hypothyroïdiens. Ce phénomène de non réponse à la correction de la carence iodée n’estpas observé chez les enfants hypothyroïdiens plus jeunes :cela démontre qu’il y a, chez certains enfants, une perte progressive de la capacité fonctionnelle de la thyroïde à répondre à la supplémentation iodée. Ces sujets développent le tableau clinique de crétin myxédémateux endémique.</p><p><p><p align="justify">On constate que l’hypothyroïdie juvénile recouvre un vaste spectre depuis les cas d’hypothyroïdie transitoire jusqu’aux cas d’hypothyroïdie irréversible, même après correction de la carence iodée.</p><p><p><p align="justify">Sur base d’hypothèse physiopathologique de cette perte de capacité fonctionnelle de la thyroïde chez certains jeunes enfants, il a été proposé qu’une carence combinée en iode et en sélénium pourrait expliquer ce processus. Une telle carence combinée a été décrite dans notre travail dans la région goitreuse du Nord-Congo, et pas dans d’autres régions non goitreuses du même pays ou dans d’autres endémies goitreuses avec peu de crétinisme myxédémateux endémique (Soudan, Sénégal).</p> <p><p><p align="justify"><FONT size=1>*Thilly Claude-Hector, Delange François, Lagasse Raphael, Bourdoux Pierre, Ramioul L, Berquist Helen, Ermans André-Marie. Fetal hypothyroidism and maternal thyroid status in severe endemic goiter. Journal of Clinical Endocrinology and Metabolism.</FONT></P><p><p> / Agrégation de l'enseignement supérieur, Orientation médecine / info:eu-repo/semantics/nonPublished
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Morphogenèse de la thyroïde : de l'humain au poisson-zèbreLarrivée Vanier, Stéphanie 11 1900 (has links)
L’hypothyroïdie congénitale (HC), qui se traduit par une insuffisance d’hormone thyroïdienne (HT) à la naissance, est la maladie endocrinienne congénitale la plus fréquente avec une prévalence d’un cas sur 2,500 naissances vivantes. Non-traitée, cette insuffisance peut entrainer un retard de développement sévère, surtout au niveau cognitif. L’HC est le plus souvent due à un défaut lors du développement de la thyroïde (dysgénésie thyroïdienne (DT)) ou lors de la production des hormones thyroïdiennes (dyshormonogenèse (D)). La majorité des cas d’HC par dysgénésie thyroïdienne (HCDT) ont une ectopie, soit une glande mal positionnée. Contrairement aux dyshormonogenèses, qui s’expliquent fréquemment par des mutations dans les gènes responsables de la production des HT, selon un modèle autosomique récessif, les causes de l’HCDT demeurent largement inconnues. Certains arguments sont en faveur d’une prédisposition génétique (le risque relatif chez les parents de premier degré est de 40 fois supérieur à celui de la population générale) mais l’HCDT ne suit pas un modèle Mendélien: 98 % des cas sont sporadiques et 92 % des jumeaux monozygotiques sont discordants pour l’HCDT. De ce fait, nous avons suggéré une hypothèse de double-hit pour expliquer les HCDT, hypothèse combinant une prédisposition germinale (héritée ou de novo) à un évènement somatique (génétique ou épigénétique). Par le passé, nous avons étudié l’évènement somatique, mais nous n’avions pas encore étudié la prédisposition germinale. Le séquençage d’exome complet peut permettre d’identifier la cause génétique dans des formes familiales d’HC, mais aussi déterminer si les cas avec une HCDT isolée sont enrichis en variants délétères, tel qu’observé chez des patients avec une malformation cardiaque congénitale, patients qui partagent des caractéristiques similaires avec ceux atteints d’HCDT. De plus, cette technique pourrait permettre d’identifier de nouveaux gènes de prédisposition associés à l’HCDT.
D’une part, nous avons séquencé l’exome d’un trio (parent-enfant) afin d’identifier la cause de l’HC dans une famille avec plusieurs enfants sévèrement atteints d’HC. D’autre part, nous avons comparé les données d’exome d’une cohorte de cas avec une HCDT isolée (HCDT non syndromique, HCDT-NS) à celles d’une cohorte contrôle, à l’aide d’une approche biaisée (gene-based burden) et non biaisée (gènes candidats). Finalement, nous avons développé le modèle de poisson-zèbre afin de pouvoir valider, in vivo, l’implication de potentiels gènes candidats, dans le développement thyroïdien.
L’analyse de l’exome du trio a révélé un variant dans le gène TSHR qui co-ségrégait parfaitement avec le phénotype, et les études de minigène ont permis de montrer que ce variant intronique loin des sites d’épissage traditionnels introduisait un pseudo-exon dans la séquence du TSHR, créant ainsi un récepteur tronqué et inactif. L’analyse par comparaison de cohorte (cas-contrôle) a montré que les cas avec une HCDT-NS n’ont pas davantage de variants rares délétères comparé aux contrôles. De plus, après correction, le gene-based burden n’a pas identifié de gène candidat. Par contre, des variants rares pathogéniques ou probablement pathogéniques dans des gènes liés à l’hypothyroïdie congénitale ont été identifiés chez 42% des cas. Les études réalisées chez le poisson-zèbre sur un gène candidat, IKBKE, identifié par une analyse préliminaire de l’exome dans la cohorte de cas, confirme que les vaisseaux sanguins sont importants pour le bon positionnement de la glande thyroïde chez le poisson-zèbre, mais ne permet pas d’établir le rôle d’IKBKE dans la migration thyroïdienne.
Nous avons d’abord montré que l’exome est une bonne technique pour identifier la cause de l’HC dans une famille avec plusieurs enfants atteints. Toutefois, une connaissance approfondie de la maladie et des isoformes du gène d’intérêt s’est avérée essentielle afin de bien analyser les données d’exome. Ensuite, nos résultats suggèrent que les cas avec une HCDT-NS n’ont pas davantage de variants délétères que les contrôles et que l’exome complet n’est pas suffisant pour identifier des gènes de prédisposition. Le séquençage du génome est peut-être nécessaire pour trouver une prédisposition génétique à l’HCDT-NS. Par contre, il est aussi possible que la génétique ne joue pas un rôle majeur dans les dysgénésies thyroïdiennes. Finalement, nous avons validé que le poisson-zèbre est un bon modèle pour étudier le développement de la thyroïde. / Congenital hypothyroidism (CH) is a disorder with a prevalence of one in 2,500 live births. CH can lead to severe intellectual disability if left untreated. It is most commonly caused by a defect during thyroid development (thyroid dysgenesis), which results in an ectopic gland in the majority of cases. A defect in thyroid hormone production (dyshormonogenesis) is the second most common cause of CH. In contrast to dyshormonogenesis, which generally has an identified cause and follows a Mendelian mode of inheritance, the cause of CHTD remains mostly unknown. CHTD is generally sporadic (98%) and has a high discordance rate (92%) between monozygotic twins. However, first-degree relatives are affected more often than by chance alone (40x) and there is an ethnic and female predominance. We thus hypothesized that CHTD is a disorder caused by two events, one germinal (a necessary but not sufficient predisposing factor) becoming pathogenic only if a second genetic or epigenetic event occurs at the somatic level. Whole exome sequencing (WES) can allow for identification of the genetic cause of CHTD in familial forms, but may also reveal if non-syndromic CHTD (NS-CHTD) cases are enriched in rare protein-altering variant, as seen in congenital heart malformations, a developmental defect that shares several characteristics with CHTD. Moreover, it might also identify new predisposing genes.
First, we performed WES on a trio (parent-child) in a family with several siblings affected with severe CH. Second, we compared WES data of a NS-CHTD cohort with data from a control cohort, using a gene-based burden (unbiased) approach and a candidate gene (biased) approach to evaluate whether WES analysis allows to identify new predisposing genes in a well-characterized cohort. Finally, we developed the zebrafish model to test the roles of candidate genes, that will be identified by WES, in thyroid development.
We first identified a variant in TSHR that segregated perfectly with the phenotype in the family with CHTD and a mini gene assay showed that this deep intronic variant induced a pseudo-exon, leading to a truncated protein missing the transmembrane domain, thus an inactive TSH receptor. Next, we found that NS-CHTD cases are not enriched in rare protein-altering variants and gene-base burden analysis did not identify novel candidate genes. However, WES data revealed pathogenic or likely pathogenic variants in CH-related genes in 42% of the NS-CHTD cases. Finally, zebrafish is a good model to study thyroid development and our results on IKBKE confirm the importance of vessels in thyroid positioning, but not its role in thyroid migration.
First, we showed that WES analysis is a good tool to identify the causative variant in a family with several siblings affected by CH. However, the interpretation of the exome analysis required knowledge of the expression of the relevant isoforms and of the biology of the disease. Second, while a gene-based burden test, using WES data from a well-characterised NS-CHTD cohort, did not identified new predisposing genes, it identified pathogenic or likely pathogenic variants in 42% of the NS-CHTD cases. Whole genome sequencing might be required to identify the genetic causes in NS-CHTD. However, our result may indicate that genetics does not play a major role in thyroid dysgenesis. Finally, we have established that zebrafish is a good model to study thyroid development and may help, in the future, identify pathways implicated in this process.
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Molecular determinants of congenital hypothyroidism due to thyroid dysgenesisAbu-Khudir, Rasha 04 1900 (has links)
L’hypothyroïdie congénitale par dysgénésie thyroïdienne (HCDT) est la condition endocrinienne néonatale la plus fréquemment rencontrée, avec une incidence d’un cas sur 4000 naissances vivantes. L’HCDT comprend toutes les anomalies du développement de la thyroïde. Parmi ces anomalies, le diagnostic le plus fréquent est l’ectopie thyroïdienne (~ 50% des cas). L’HCDT est fréquemment associée à un déficit sévère en hormones thyroïdiennes (hypothyroïdisme) pouvant conduire à un retard mental sévère si non traitée. Le programme de dépistage néonatal assure un diagnostic et un traitement précoce par hormones thyroïdiennes. Cependant, même avec un traitement précoce (en moyenne à 9 jours de vie), un retard de développement est toujours observé, surtout dans les cas les plus sévères (c.-à-d., perte de 10 points de QI).
Bien que des cas familiaux soient rapportés (2% des cas), l’HCTD est essentiellement considérée comme une entité sporadique. De plus, plus de 92% des jumeaux monozygotiques sont discordants pour les dysgénésies thyroïdiennes et une prédominance féminine est rapportée (spécialement dans le cas d’ectopies thyroïdiennes), ces deux observations étant clairement incompatible avec un mode de transmission héréditaire mendélien. Il est donc cohérent de constater que des mutations germinales dans les facteurs de transcription thyroïdiens connus (NKX2.1, PAX8, FOXE1, and NKX2.5) ont été identifiées dans seulement 3% des cas sporadiques testés et furent, de plus, exclues lors d’analyse d’association dans certaines familles multiplex. Collectivement, ces données suggèrent que des mécanismes non mendéliens sont à l’origine de la majorité des cas de dysgénésie thyroïdienne. Parmi ces mécanismes, nous devons considérer des modifications épigénétiques, des mutations somatiques précoces (au stade du bourgeon thyroïdien lors des premiers stades de l’embryogenèse) ou des défauts développementaux stochastiques (c.-à-d., accumulation aléatoire de mutations germinales ou somatiques). Voilà pourquoi nous proposons un modèle «2 hits » combinant des mutations (épi)génétiques germinales et somatiques; ce modèle étant compatible avec le manque de transmission familial observé dans la majorité des cas d’HCDT.
Dans cette thèse, nous avons déterminé si des variations somatiques (épi)génétiques sont associées à l’HCTD via une approche génomique et une approche gène candidat. Notre approche génomique a révélé que les thyroïdes ectopiques ont un profil d’expression différent des thyroïdes eutopiques (contrôles) et que ce profil d’expression est enrichi en gènes de la voie de signalisation Wnt. La voie des Wnt est cruciale pour la migration cellulaire et pour le développement de plusieurs organes dérivés de l’endoderme (p.ex. le pancréas). De plus, le rôle de la voie des Wnt dans la morphogénèse thyroïdienne est supporté par de récentes études sur le poisson-zèbre qui montrent des anomalies du développement thyroïdien lors de la perturbation de la voie des Wnt durant différentes étapes de l’organogénèse. Par conséquent, l’implication de la voie des Wnt dans l’étiologie de la dysgénésie thyroïdienne est biologiquement plausible.
Une trouvaille inattendue de notre approche génomique fut de constater que la calcitonine était exprimée autant dans les thyroïdes ectopiques que dans les thyroïdes eutopiques (contrôles). Cette trouvaille remet en doute un dogme de l’embryologie de la thyroïde voulant que les cellules sécrétant la calcitonine (cellules C) proviennent exclusivement d’une structure extrathyroïdienne (les corps ultimobranchiaux) fusionnant seulement avec la thyroïde en fin de développement, lorsque la thyroïde a atteint son emplacement anatomique définitif.
Notre approche gène candidat ne démontra aucune différence épigénétique (c.-à-d. de profil de méthylation) entre thyroïdes ectopiques et eutopiques, mais elle révéla la présence d’une région différentiellement méthylée (RDM) entre thyroïdes et leucocytes dans le promoteur de FOXE1. Le rôle crucial de FOXE1 dans la migration thyroïdienne lors du développement est connu et démontré dans le modèle murin. Nous avons démontré in vivo et in vitro que le statut de méthylation de cette RDM est corrélé avec l’expression de FOXE1 dans les tissus non tumoraux (c.-à-d., thyroïdes et leucocytes). Fort de ces résultats et sachant que les RDMs sont de potentiels points chauds de variations (épi)génétiques, nous avons lancé une étude cas-contrôles afin de déterminer si des variants génétiques rares localisés dans cette RDM sont associés à la dysgénésie thyroïdienne.
Tous ces résultats générés lors de mes études doctorales ont dévoilé de nouveaux mécanismes pouvant expliquer la pathogenèse de la dysgénésie thyroïdienne, condition dont l’étiologie reste toujours une énigme. Ces résultats ouvrent aussi plusieurs champs de recherche prometteurs et vont aider à mieux comprendre tant les causes des dysgénésies thyroïdiennes que le développement embryonnaire normal de la thyroïde chez l’homme. / Congenital hypothyroidism from thyroid dysgenesis (CHTD) is the most common congenital endocrine disorder with an incidence of 1 in 4,000 live births. CHTD includes multiple abnormalities in thyroid gland development. Among them, the most common diagnostic category is thyroid ectopy (~ 50 % of cases). CHTD is frequently associated with a severe deficiency in thyroid hormones (hypothyroidism), which can lead to severe mental retardation if left untreated. The newborn biochemical screening program insures the rapid institution of thyroid hormone replacement therapy. Even with early treatment (on average at 9 d), subtle developmental delay is still be observed in severe cases (i.e., IQ loss of 10 points).
Although there have been some reports of familial occurrence (in 2% of the cases), CHTD is mainly considered as a sporadic entity. Furthermore, monozygotic (MZ) twins show a high discordance rate (92%) for thyroid dysgenesis and female predominance is observed in thyroid dysgenesis (especially thyroid ectopy), these two observations being incompatible with simple Mendelian inheritance. In addition, germline mutations in the thyroid related transcription factors NKX2.1, PAX8, FOXE1, and NKX2.5 have been identified in only 3% of sporadic cases and linkage analysis has excluded these genes in some multiplex families with CHTD. Collectively, these data point to the involvement of non-Mendelian mechanisms in the etiology of the majority of cases of thyroid dysgenesis. Among the plausible mechanisms are epigenetic modifications, somatic mutations occurring in the thyroid bud early during embryogenesis, or stochastic developmental events. Hence, we proposed a two-hit model combining germline and somatic (epi)genetic variations that can explain the lack of clear familial transmission of CTHD.
In this present thesis, we assessed the role of somatic (epi)genetic variations in the pathogenesis of thyroid dysgenesis via a genome-wide as well as a candidate gene approach. Our genome wide approach revealed that ectopic thyroids show a differential gene expression compared to that of normal thyroids, with enrichment for the Wnt signalling pathway. The Wnt signalling pathway is crucial for cell migration and for the development of several endoderm-derived organs (e.g., pancreas). Moreover, a role of Wnt signalling in thyroid organogenesis was further supported by recent zebrafish studies which showed thyroid abnormalities resulting from the disruption of the Wnt pathway during different steps of organogenesis. Thus, Wnt pathway involvement in the etiology of thyroid ectopy is biologically plausible.
An unexpected finding of our genome-wide gene expression analysis of ectopic thyroids was that they express calcitonin similar to normally located (orthotopic) thyroids. Such a finding, although in contradiction with our current knowledge of the embryological development of the thyroid attributes C cell origins to extrathyroidal structures (ultimobrachial bodies) upon fusion with a fully-formed, normally situated gland.
Using a candidate gene approach, we were unable to demonstrate any differences in the methylation profile between ectopic and eutopic thyroids, but nevertheless we documented the presence of a differentially methylated region (DMR) between thyroids and leukocytes in the promoter of FOXE1, a gene encoding the only thyroid related transcription factor known to play a crucial role in regulating the migration of the thyroid precursors during development as shown by animal studies. We demonstrated by in vivo and in vitro studies that the methylation status of this DMR is correlated with differential expression of FOXE1 in non-tumoral tissues (thyroids and leukocytes). Knowing that DMRs are hotspots for epi(genetic) variations, its screening among CTHD patients is justifiable in our search for a molecular basis of thyroid dysgenesis, currently underway in a case-control study.
The results generated during my graduate studies represent unique and novel mechanisms underlying the pathogenesis of CHTD, the etiology of which is still an enigma. They also paved the way for many future studies that will aid in better understanding both the normal and pathogenic development of the thyroid gland.
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Pacientes com carcinoma papilífero de tireoide tratados com tireoidectomia total e não submetidos a dose ablativa com iodo radioativo: evolução da captação cervical do iodo radioativo e da tireoglobulina / Evolution of cervical radioactive iodine uptake and serum thyroglobulin after total thyroidectomy for the treatment of papillary thyroid carcinoma without radioiodine remnant ablationCardoso, Cesar Augusto 06 August 2013 (has links)
INTRODUÇÃO: O tratamento e o seguimento do carcinoma papilífero de tireoide (CPT) são individualizados pelos riscos de recorrência e mortalidade. A indicação do iodo radioativo (iodo-131) para ablação de remanescente tireóideo captante é controversa em casos classificados como de baixo risco. Por diminuir a massa tireóidea remanescente, a dose ablativa com iodo-131 (DAIR) facilita o seguimento pós-operatório, mas tem riscos e onera o tratamento. Não se encontrou na literatura estudo demonstrando a evolução da captação cervical do iodo-131 e da concentração sérica de tireoglobulina (TG) em pacientes submetidos à tireoidectomia total por CPT de riscos muito baixo e baixo, sem DAIR. OBJETIVO: Avaliar a evolução da captação cervical do iodo-131 e da concentração sérica de TG em pacientes com CPT de baixo e muito baixo risco, após tireoidectomia total e não submetidos a DAIR. MÉTODOS: Foi realizado estudo prospectivo não randomizado em pacientes com CPT de baixo e muito baixo risco submetidos a tireoidectomia total, atendidos no Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo no período setembro de 2008 novembro de 2011. Após a tireoidectomia foi ministrada levotiroxina na dose necessária para manter a concentração de hormônio tireo-estimulante (TSH) entre 0,5 e 1,0 U/ml. Dosagem sérica de TG, pesquisa de corpo inteiro com iodo-131 (PCI) e dosagem de iodo urinário foram realizadas sob estímulo de TSH endógeno elevado por interrupção da reposição hormonal com levotiroxina, por 30 dias, e dieta pobre em iodo por 15 dias. Foram realizadas ultrassonografias cervicais três e 12 meses após a tireoidectomia. As concentrações séricas de TSH e tiroxina livre sem supressão do TSH foram realizadas seis, nove e 12 meses após a tireoidectomia. RESULTADOS: Dos 26 pacientes incluídos, 22 eram do sexo feminino (84,6%), e quatro, do masculino (15,4%), com idade variando de 27 a 45 anos (média de 38,5 anos e mediana de 39,5 anos). Onze pacientes (42,3%) foram estratificados como de muito baixo risco, e 15 (57,7%), como de baixo risco. Todos os pacientes estavam em hipotireoidismo, no momento da avaliação inicial e final (TSH > 30?U/ml), e os exames realizados seis, nove e 12 meses após a operação, com ingestão de levotiroxina, mostraram as medianas da concentração de TSH de 3,4 ?U/mL, 0,3 ?U/mL e 1,5 ?U/mL, respectivamente. A média da captação de iodo-131 caiu de 1,9% na avaliação inicial para 0,5% na final, e a média da concentração sérica de TG estimulada caiu de 3,1 ng/mL para 1,9 ng/ml. CONCLUSÃO: Houve diminuição estatisticamente significativa da captação cervical do iodo-131 e da concentração sérica de TG sem DAIR nos pacientes submetidos a tireoidectomia total por CPT de baixo e muito baixo risco, sem supressão do TSH / INTRODUCTION: The treatment and follow-up of papillary thyroid carcinoma (PTC) are individualized according to the risk of recurrence and mortality. Radioiodine ablation of thyroid remnant is controversial in low-risk patients. By reducing the thyroid remnant, ablation with radioiodine facilitates the follow-up, but it adds risks and increases the cost of the treatment. We found no published study showing the outcome of cervical uptake of radioactive iodine and the serum concentration of thyroglobulin (TG) in patients undergoing total thyroidectomy for PTC classified as very low risk and low risk who did not undertake ablative dose of radioactive iodine. OBJECTIVE: The aim of this study was to document changes in the cervical uptake of radioiodine and changes in TG concentrations in low-risk and very low-risk PTC patients not submitted to radioiodine remnant ablation (RRA). METHODS: We conducted a prospective non-randomized study in patients with PTC classified as low risk and very low risk undergoing total thyroidectomy at the General Hospital of the University of Sao Paulo, School of Medicine, from September 2008 to November 2011. Levothyroxine was administered after thyroidectomy at a dose required to maintain the concentration of thyroid stimulating hormone (TSH) between 0.5 and 1.0 ?U/ml. Serum thyroglobulin, whole body scan with iodine-131 and urinary iodine were evaluated under high endogenous TSH stimulation after 30 days levothyroxine withdrawal and iodine-poor diet for 15 days. Neck ultrasounds were performed three and 12 months after thyroidectomy. The concentration of serum TSH and free thyroxine without TSH suppression were measured six, nine and 12 months after thyroidectomy. RESULTS: Of the 26 patients included, 22 were female (84.6%) and four were male (15.4%), aged ranged from 27 to 45 years (mean 38.5 years, median 39.5 years). Eleven patients (42.3%) were classified as very low risk and 15 (57.7%) as low risk. All subjects were hypothyroidism at the time of the initial and final evaluations (TSH> 30 ?U/ml). Tests performed six, nine and 12 months after the operation with levothyroxine showed the median concentration of TSH 3.4 ?U/ml, 0.3 U/ml and 1.5 ?U/ml, respectively. The average uptake of iodine-131 dropped 1.9% at baseline to the end of 1.5% and higher mean serum thyroglobulin fell from 3.1 ng/mL to 1.9 ng/ml. CONCLUSION: There was a statistically significant reduction in cervical radioiodine uptake and in stimulated TG level over one year\'s observation of low-risk and very low-risk papillary thyroid carcinoma patients who were not treated with RRA, even in the absence of TSH suppression
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Etude métabolomique par résonance magnétique nucléaire de pathologies associées à la signalisation thyroïdienne chez la souris / The application of metabolomics by high field nuclear magnetic resonance to study thyroid signalisation pathologies in miceBoumaza, Houda 08 March 2019 (has links)
La métabolomique par résonance magnétique nucléaire (RMN) permet d’étudier laréponse métabolique globale d’un système biologique à un stimulus ou un événementphysiopathologique (maladie, manipulation génétique, etc.). Cette discipline connaît un essorimportant dans la recherche clinique et biologique, et constitue ainsi un outil à fort potentielpour la découverte de biomarqueurs de maladies, et l’étude de la fonction des gènes.Cette thèse est dédiée à l’application de la métabolomique par RMN à hauts champspour l’étude des pathologies associées à la signalisation thyroïdienne chez la souris. L’objectifglobal est d’identifier des biomarqueurs spécifiques liés aux différentes maladies hormonales :l’hypothyroïdie et la maladie génétique émergente résistance à l’hormone thyroïdienne due àune mutation au niveau du récepteur TRα1 (RTHα). Cette dernière est particulièrementdifficile à diagnostiquer à cause du manque de marqueurs biochimiques et de symptômesspécifiques à cette maladie. De plus, elle présente des similitudes avec l’hypothyroïdie auniveau symptomatique. Des modèles murins de RTHα et de l’hypothyroïdie ont été analysés,et l’investigation a été menée sur l’urine et le plasma sanguin dans le but de différenciermétaboliquement ces maladies et d’identifier des biomarqueurs spécifiques à RTHα. Dessignatures métaboliques liées à chaque maladie ont été identifiées dans l’urine et le plasmasanguin. Cinq métabolites qui varient de façon significative ont été identifiés dans l’urinecomme étant liés à la maladie RTHα : trimethylamine, dimethylamine, isovalerylglycine, Nacetylglucosamineet la choline. Dans le sang, ce sont les lipides insaturés qui varient de façonsignificative chez les souris mimant la maladie RTHα. / Metabolomics by nuclear magnetic resonance (NMR) allows studying the metabolicresponse of a global biological system to a stimuli or a physiopathological even (diseases,genetic modifications, etc.). This discipline is growing especially in the clinical and biologicalfields, and represents a strong potential tool to identify biomarkers related to diseases, andstudy the function of genes.This thesis is dedicated to the application of metabolomics by high field NMR to studythyroid signalisation pathologies in mice. The main goal is to identify biomarkers related tothe emerging genetic disease called resistance to thyroid hormone due to a mutation in thyroidhormone receptor TRα1 (RTHα). This disease is particularly difficult to diagnose because ofthe lack of biochemical markers and specific symptoms. In addition, it presents commonfeatures with hypothyroidism in term of symptoms. Mice models of RTHα andhypothyroidism were analysed, and the investigation were driven on urine and blood plasmain order to differentiate metabolically theses diseases and identify biomarkers related toRTHα. Metabolic fingerprints related to each disease were identified in both urine and bloodplasma. Five metabolites vary significantly in the urine of RTHα mice: trimethylamine,dimethylamine, isovalerylglycine, N-acetylglucosamine and choline. Unsaturated lipids varysignificantly in the blood plasma of RTHα mice.The impact of thyroid hormones (TH) and the thyroid hormone receptor TRβ on theliver metabolism were also studied in the present manuscript through NMR-basedmetabolomics. A mouse model, with a specific knock-out of TRβ gene in hepatocytes (LTRβ-KO), were used to study this question. To understand the function of TH mediated by TRβ,the liver metabolic response to TH, obtained from liver aqueous extracts and intact livertissues, TRβKO and wild-type mice were compared. The results suggest the presence ofdirect and indirect effects of thyroid hormones on the liver metabolism.
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Influência do hipotireoidismo gestacional experimental no comportamento ingestivo e perfil metabólico da prole de ratas / Influence of experimental gestational hypothyroidism on the biology of ingestive behavior and metabolic profile in offspring of ratsGaujac, Danielle Pereira 25 July 2013 (has links)
Recent experimental approaches attribute value to events occurring during intrauterine life as crucial in the onset of several diseases during postnatal life. Thyroid hormones (TH) are critical to the physiology of metabolism and body development. The aim of this study was to investigate the repercussions of lack of TH during pregnancy on body mass gain, metabolic profile, ingestive behavior of food, sodium (0.3M NaCl) and water in rat offspring at different postnatal ages. The experimental gestational hypothyroidism (EGH) was induced by the administration of 0.02% methimazole (MMI) in ad libitum drinking water from day 9 of gestation until delivery. Offspring (males and females) from MMI-treated dams (OMTD) were compared to their corresponding control offspring (i.e. male and female offspring from water-treated dams; OWTD). Insulin tolerance test (ITT) and glucose tolerance test (GTT) were also performed. Two- or three-way ANOVA followed by Bonferroni post-test were performed when necessary. OMTD showed lower body weight on PND 23 and 30 (p<0.0001). Similar profile was observed when the offspring were separated by gender, at least during the experimental period (PND 60, 90 and 120; p<0.0001 for both genders). However, there was no difference in the amount of food intake when males of OMTD (m-OMTD) were compared to OWTD (m-OWTD). Female of OMTD (f-OMTD) had lower ability to reduce glucose plasma level at ITT (p = 0.0224), otherwise, no change in GTT (p = 0.1313) was observed. At PND 60, glucose plasma level was higher in f-OMTD than in f-OWTD (p = 0.013). In m-OMTD, plasma cholesterol was higher in PND 60 and lower on PND 120 (p <0.0001), when compared to m-OWTD. In f-OMTD, cholesterol was lower only at PND 120 (p = 0.035). The high density lipoprotein (HDL) cholesterol was lower in OMTD on PND 15 and 30 (p = 0.04) and remained lower only in f-OMTD on PND 120 (p = 0.024). Moreover, EGH induced an increased in plasma triglycerides (TGL), as well as, in serum level of very low density lipoprotein (VLDL) cholesterol in offspring at DPN 15 (p = 0.039) and also after puberty (at DPN 60), but only the m-OMTD (p < 0.0001). The serum urea was lower in OMTD on PND 15 and 30. Interestingly, serum urea was inverted at DPN 60 in both, m- and f-OMTD (p = 0.006, and p = 0.003, respectively), when compared to their respective control groups. At PND 120, retroperitoneal fat weight was lower both in m- (p = 0.05) and f-OMTD (p = 0.009). Additionally, at all studied ages, relative kidney and liver mass was lower in m- (p = 0.001) and f-OMTD (p = 0.008). In conclusion, we demonstrated, for the first time, that maternal TH are critical to the ontogenetic development of systems that regulate energy metabolism throughout the life of the offspring, resulting in a reduction in body mass, biochemical instability throughout the life, lower sensitivity to insulin in females, and, a delay in the development of critical organs for the metabolism of macronutrients. / Recentes abordagens experimentais têm imputado valor aos eventos ocorridos durante a vida intrauterina como cruciais no aparecimento de doenças na vida pós-natal. Os hormônios tireoidianos (HTs) são críticos para fisiologia do metabolismo e desenvolvimento corporal. O objetivo do presente estudo foi investigar as repercussões da carência dos HTs em ratas prenhes na evolução ponderal da massa corporal, perfil bioquímico, comportamento ingestivo de ração, água e sódio (NaCl 0,3M) da prole em diferentes idades pós-natais. O hipotireoidismo gestacional experimental (HGE) foi induzido através da adicão de metimazol 0,02% na água de beber a partir do dia 9 de gestação até o parto. O grupo de prole (machos e fêmeas) de mães hipotireoideanas (PMH) foi comparado ao grupo controle de mães eutireoideanas (PME). Realizou-se o teste de tolerância à insulina (TTI) e o teste de tolerância à glicose (TTG). Os dados foram submetidos ao teste de ANOVA de duas ou três vias, quando necessário, seguidos do pós-teste de Bonferroni. De acordo com os resultados obtidos, observou-se que a PMH apresentou massa corporal menor aos 23 e 30 dias pós-natal (DPN) (p<0,0001). Padrão similar foi encontrado quando as proles foram separadas por gênero, aos 60, 90 e 120 DPN (p<0,0001, para ambos os gêneros). No entanto, não houve diferença significativa na ingestão de ração entre os machos PMH e PME. As fêmeas da prole de mães hipotireoideanas (f-PMH) apresentaram menor capacidade de reduzir a glicemia no TTI (p=0,0224) sem alteração no TTG. Aos 60 DPN, a concentração sérica de glicose foi maior nas f-PMH (p = 0,013) que nas f-PME. Nos machos prole de mães hipotireoideanas (m-PMH) o colesterol plasmático foi elevado aos 60 DPN e reduziu aos 120 DPN (p<0,0001), quando comparado aos machos prole de mães eutireoideanas (m-PME). Nas f-PMH o colesterol sérico foi menor somente aos 120 DPN (p=0,035). O HDL sérico foi menor na PMH aos 15 e 30 DPN (p=0,04), e continuou menor nas f-PMH aos 60, 90 e 120 DPN (p=0,024). Entretanto, o HGE elevou as concentrações séricas de TGL, bem como de VLDL, na PMH aos 15 DPN, e após a puberdade (aos 60 DPN), somente nos m-PMH (p<0,0001). A concentração sérica de ureia foi menor na PMH aos 15 e 30 DPN. Interessantemente, a ureia sérica foi invertida aos 60 DPN, se apresentando elevada tanto em m- (p=0,006) como em f-PMH (p=0,003), quando comparados aos respectivos grupos controle. Aos 120 DPN, a massa da gordura retroperitoneal foi menor tanto em m- (p=0,05) como em f-PMH (p=0,009). Adicionalmente, em todas idades estudadas, as massas relativas dos rins e do fígado foram menores tanto em m- (p=0,001) como em f- da PMH (p=0,008). Em conclusão, demonstrou-se, pela primeira vez, que os HTs maternos são críticos para o desenvolvimento ontogênico de sistemas que regulam o metabolismo de energia ao longo da vida da prole, resultando numa redução da massa corporal, instabilidade bioquímica ao longo da vida, menor sensibilidade à insulina em fêmeas, e um atraso no desenvolvimento de órgãos críticos para o metabolismo de macronutrientes.
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Pacientes com carcinoma papilífero de tireoide tratados com tireoidectomia total e não submetidos a dose ablativa com iodo radioativo: evolução da captação cervical do iodo radioativo e da tireoglobulina / Evolution of cervical radioactive iodine uptake and serum thyroglobulin after total thyroidectomy for the treatment of papillary thyroid carcinoma without radioiodine remnant ablationCesar Augusto Cardoso 06 August 2013 (has links)
INTRODUÇÃO: O tratamento e o seguimento do carcinoma papilífero de tireoide (CPT) são individualizados pelos riscos de recorrência e mortalidade. A indicação do iodo radioativo (iodo-131) para ablação de remanescente tireóideo captante é controversa em casos classificados como de baixo risco. Por diminuir a massa tireóidea remanescente, a dose ablativa com iodo-131 (DAIR) facilita o seguimento pós-operatório, mas tem riscos e onera o tratamento. Não se encontrou na literatura estudo demonstrando a evolução da captação cervical do iodo-131 e da concentração sérica de tireoglobulina (TG) em pacientes submetidos à tireoidectomia total por CPT de riscos muito baixo e baixo, sem DAIR. OBJETIVO: Avaliar a evolução da captação cervical do iodo-131 e da concentração sérica de TG em pacientes com CPT de baixo e muito baixo risco, após tireoidectomia total e não submetidos a DAIR. MÉTODOS: Foi realizado estudo prospectivo não randomizado em pacientes com CPT de baixo e muito baixo risco submetidos a tireoidectomia total, atendidos no Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo no período setembro de 2008 novembro de 2011. Após a tireoidectomia foi ministrada levotiroxina na dose necessária para manter a concentração de hormônio tireo-estimulante (TSH) entre 0,5 e 1,0 U/ml. Dosagem sérica de TG, pesquisa de corpo inteiro com iodo-131 (PCI) e dosagem de iodo urinário foram realizadas sob estímulo de TSH endógeno elevado por interrupção da reposição hormonal com levotiroxina, por 30 dias, e dieta pobre em iodo por 15 dias. Foram realizadas ultrassonografias cervicais três e 12 meses após a tireoidectomia. As concentrações séricas de TSH e tiroxina livre sem supressão do TSH foram realizadas seis, nove e 12 meses após a tireoidectomia. RESULTADOS: Dos 26 pacientes incluídos, 22 eram do sexo feminino (84,6%), e quatro, do masculino (15,4%), com idade variando de 27 a 45 anos (média de 38,5 anos e mediana de 39,5 anos). Onze pacientes (42,3%) foram estratificados como de muito baixo risco, e 15 (57,7%), como de baixo risco. Todos os pacientes estavam em hipotireoidismo, no momento da avaliação inicial e final (TSH > 30?U/ml), e os exames realizados seis, nove e 12 meses após a operação, com ingestão de levotiroxina, mostraram as medianas da concentração de TSH de 3,4 ?U/mL, 0,3 ?U/mL e 1,5 ?U/mL, respectivamente. A média da captação de iodo-131 caiu de 1,9% na avaliação inicial para 0,5% na final, e a média da concentração sérica de TG estimulada caiu de 3,1 ng/mL para 1,9 ng/ml. CONCLUSÃO: Houve diminuição estatisticamente significativa da captação cervical do iodo-131 e da concentração sérica de TG sem DAIR nos pacientes submetidos a tireoidectomia total por CPT de baixo e muito baixo risco, sem supressão do TSH / INTRODUCTION: The treatment and follow-up of papillary thyroid carcinoma (PTC) are individualized according to the risk of recurrence and mortality. Radioiodine ablation of thyroid remnant is controversial in low-risk patients. By reducing the thyroid remnant, ablation with radioiodine facilitates the follow-up, but it adds risks and increases the cost of the treatment. We found no published study showing the outcome of cervical uptake of radioactive iodine and the serum concentration of thyroglobulin (TG) in patients undergoing total thyroidectomy for PTC classified as very low risk and low risk who did not undertake ablative dose of radioactive iodine. OBJECTIVE: The aim of this study was to document changes in the cervical uptake of radioiodine and changes in TG concentrations in low-risk and very low-risk PTC patients not submitted to radioiodine remnant ablation (RRA). METHODS: We conducted a prospective non-randomized study in patients with PTC classified as low risk and very low risk undergoing total thyroidectomy at the General Hospital of the University of Sao Paulo, School of Medicine, from September 2008 to November 2011. Levothyroxine was administered after thyroidectomy at a dose required to maintain the concentration of thyroid stimulating hormone (TSH) between 0.5 and 1.0 ?U/ml. Serum thyroglobulin, whole body scan with iodine-131 and urinary iodine were evaluated under high endogenous TSH stimulation after 30 days levothyroxine withdrawal and iodine-poor diet for 15 days. Neck ultrasounds were performed three and 12 months after thyroidectomy. The concentration of serum TSH and free thyroxine without TSH suppression were measured six, nine and 12 months after thyroidectomy. RESULTS: Of the 26 patients included, 22 were female (84.6%) and four were male (15.4%), aged ranged from 27 to 45 years (mean 38.5 years, median 39.5 years). Eleven patients (42.3%) were classified as very low risk and 15 (57.7%) as low risk. All subjects were hypothyroidism at the time of the initial and final evaluations (TSH> 30 ?U/ml). Tests performed six, nine and 12 months after the operation with levothyroxine showed the median concentration of TSH 3.4 ?U/ml, 0.3 U/ml and 1.5 ?U/ml, respectively. The average uptake of iodine-131 dropped 1.9% at baseline to the end of 1.5% and higher mean serum thyroglobulin fell from 3.1 ng/mL to 1.9 ng/ml. CONCLUSION: There was a statistically significant reduction in cervical radioiodine uptake and in stimulated TG level over one year\'s observation of low-risk and very low-risk papillary thyroid carcinoma patients who were not treated with RRA, even in the absence of TSH suppression
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Oral lichen planus – etiopathogenesis and managementSiponen, M. (Maria) 18 January 2017 (has links)
Abstract
Oral lichen planus (OLP) is a chronic immune-mediated mucosal disease with unknown etiology. According to the current view, the pathogenesis of OLP involves activation of T-cell mediated immunity against the epithelial keratinocytes. A proportion of OLP patients are affected by painful symptoms, and the risk of oral cancer is increased in OLP. There is no curative treatment for OLP. Topical corticosteroids are used most commonly in the management of OLP. However, the evidence base for the effectiveness of any therapy is weak.
The objective of this thesis was to study novel aspects of OLP etiopathogenesis and management. An epidemiologic, retrospective case-control study was conducted to determine whether systemic diseases, in particular thyroid diseases, are associated with OLP. In addition, a randomized controlled trial comparing the effectiveness of topical tacrolimus, triamcinolone acetonide and placebo in symptomatic OLP was carried out. Furthermore, immunohistochemical expression of toll-like receptors 4 and 9, hyaluronan and its principal receptor CD44 antigen, hyaluronan synthases 1-3, hyaluronidases 1-2 and cathepsin K was studied in OLP tissue samples and in healthy oral mucosa. The effect of topical tacrolimus on the expression of these molecules in OLP was also studied.
The results of the present study showed that a history of hypothyroidism was associated with an approximately twofold risk of having OLP. Furthermore, both tacrolimus and triamcinolone acetonide were more efficient than placebo in reducing the signs and symptoms of OLP. No statistically significant differences were noted in the efficacy between tacrolimus and triamcinolone acetonide. In addition, the expression of the studied molecules was altered in the epithelium or stroma in OLP compared to healthy oral mucosa. Tacrolimus treatment decreased the expression of CD44 antigen in the stroma and the expression of cathepsin K in the epithelium in OLP.
In conclusion, the present study extends our knowledge about systemic associated factors and management of OLP. In addition, the results improve our understanding of molecular level changes that occur in OLP. / Tiivistelmä
Suun punajäkälä on krooninen immuunivälitteinen limakalvotauti, jonka etiologia on tuntematon. Taudin syntymekanismiin liittyy tämän hetkisen näkemyksen mukaan T-soluvälitteisen immuniteetin aktivoituminen epiteelin keratinosyyttejä vastaan. Suun punajäkälä aiheuttaa osalle potilaista kivuliaita oireita ja lisää suusyövän riskiä. Parantavaa hoitoa tautiin ei ole. Yleisimmin suun punajäkälän oireiden hoidossa käytetään paikallisia kortikosteroidivalmisteita. Kuitenkin eri hoitomuotojen tehosta on vain heikkoa näyttöä.
Tämän väitöskirjatyön tarkoituksena oli tutkia uusia näkökohtia liittyen suun punajäkälän etiopatogeneesiin ja hoitoon. Epidemiologisessa tapaus-verrokkitutkimuksessa selvitettiin, liittyvätkö yleissairaudet, erityisesti kilpirauhassairaudet, suun punajäkälään. Lisäksi satunnaistetussa kontrolloidussa tutkimuksessa verrattiin paikallisen takrolimuusin, triamsinoloniasetonidin ja lumelääkkeen tehoa oireisesta suun punajäkälästä kärsivillä potilailla. Tutkimuksessa selvitettiin myös tollin kaltaisten reseptorien 4 ja 9, hyaluronaanin ja sen pääasiallisen reseptorin CD44-antigeenin, hyaluronaanisyntaasien 1–3, hyaluronidaasien 1–2 sekä katepsiini K:n immunohistokemiallista ilmentymistä suun punajäkälänäytteissä ja terveessä suun limakalvossa. Lisäksi tutkittiin takrolimuusihoidon vaikutusta näiden molekyylien ilmentymiseen suun punajäkälässä.
Tämän tutkimuksen tulokset osoittivat, että kilpirauhasen vajaatoimintaan liittyi noin kaksinkertainen riski sairastaa suun punajäkälää. Lisäksi havaittiin, että suun punajäkälässä sekä takrolimuusi että triamsinoloniasetonidi ovat tehokkaampia kuin lumelääke oireiden ja kliinisen taudinkuvan lievittämisessä. Takrolimuusin ja triamsinoloniasetonidin tehossa ei todettu tilastollisesti merkitseviä eroja. Lisäksi suun punajäkälänäytteissä tutkittujen molekyylien ilmentyminen oli muuttunut joko epiteelissä tai stroomassa verrattuna terveeseen limakalvoon. Takrolimuusihoito vähensi CD44-antigeenin ilmentymistä stroomassa ja katepsiini K:n ilmentymistä epiteelissä suun punajäkälässä.
Yhteenvetona voidaan todeta, että tämä tutkimus lisää tietoa suun punajäkälään liittyvistä systeemisistä tekijöistä ja suun punajäkälän hoidosta. Lisäksi löydökset lisäävät ymmärtämystä suun punajäkälässä tapahtuvista molekyylitason muutoksista.
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