We have demonstrated that T₃ increases the expression of ZAKI-4α, an endogenous calcineurin inhibitor. In this study we characterized a T₃-dependent signaling cascade leading to ZAKI-4α expression in human skin fibroblasts. We found that T₃-dependent increase in ZAKI-4α was greatly attenuated by rapamycin, a specific inhibitor of a protein kinase, mammalian target of rapamycin (mTOR), suggesting the requirement of mTOR activation by T₃. Indeed, T₃ activated mTOR rapidly through S2448 phosphorylation, leading to the phosphorylation of p70^S6K, a substrate of mTOR. This mTOR activation is mediated through phosphatidylinositol 3-kinase (PI3K)-Akt/protein kinase B (PKB) signaling cascade because T₃ induced Akt/PKB phosphorylation more rapidly than that of mTOR, and these T₃-dependent phosphorylations were blocked by both PI3K inhibitors and by expression of a dominant negative PI3K (Δp85α). Furthermore, the association between thyroid hormone receptor β1 (TRβ1) and PI3K-regulatory subunit p85α, and the inhibition of T₃-induced PI3K activation and mTOR phosphorylation by a dominant negative TR (G345R) demonstrated the involvement of TR in this T₃ action. The liganded TR induces the activation of PI3K and Akt/PKB, leading to the nuclear translocation of the latter, which subsequently phosphorylates nuclear mTOR. The rapid activation of PI3K-Akt/PKB-mTOR-p70^S6K cascade by T₃ provides a new molecular mechanism for thyroid hormone action.

Preventive medicine has been dramatically improved by cancer genetics. The identification of susceptibility genes for hereditary forms of cancers in the past decades opened avenues for detection of second primary and recurrent tumors. Once a given germline mutation is detected, newly identified carriers are clinically investigated, and thus the diagnosis of tumors in an asymptomatic stage in the relatives of carriers becomes possible. Pheochromocytoma, paraganglioma, and associated inherited diseases served in this direction as important pacesetters. The susceptibility genes—including RET as causing multiple endocrine neoplasia type 2 (RefSeq NM_020975.4); VHL for von Hippel-Lindau disease (RefSeq NM_000551.3); SDHD, SDHC, and SDHB (succinate dehydrogenase subunits D [RefSeq NM_003002.3], C [RefSeq NM_003001.3], and B [RefSeq NM_003000.2]) for paraganglioma syndromes types 1, 3, and 4; and NF1 for neurofibromatosis type 1 (RefSeq NM_000267.3), herein summarized as classic susceptibility genes—have served as effective molecular tools for preventive medicine studies and practice in this field in the first years of the new millenium.^1-8 These studies led to the end of the 10% rule for the frequency of hereditary pheochromocytoma and instead pointed to at least a 24% hereditary fraction.^6,9 By 2010 and 2011, additional susceptibility genes for pheochromocytomas and paragangliomas were reported, including SDHA (succinate dehydrogenase subunit A [RefSeq NM_004168.3]), TMEM127 (transmembrane protein 127 [RefSeq NM_017849.3]), MAX (Myc-associated factor X [RefSeq NM_002382.4]), and SDHAF2 (succinate dehydrogenase complex assembly factor 2 [RefSeq NM_017841.2]).^10-13 In contrast to the classic susceptibility genes, recommendations of the last International Symposium for Pheochromocytoma (2014) do not provide clinical management guidelines for those with mutations in the susceptibility genes analyzed and characterized herein.¹⁴ The main reasons are the limited number of sufficiently large registries, leading to limited clinical data associated with mutations of these genes. The much-needed and important process of returning to the clinical roots is a labor-intensive one. Thus, our comprehensive genetic and clinical characterization study intends to close the gap between finding a mutation in 1 of these 4 new susceptibility genes and the associated clinical data so that gene-informed risk assessment, counseling, and management can be performed.

Thyroid hormones (THs) may play a role in diseases other than hyper- and hypothyroidism. Several lines of evidence suggest tumor-promoting effects of TH and TH receptors. They are possibly mediated by phosphatidylinositol-3-kinase and MAPK and involve among others stimulation of angiogenesis via αvβ3. Thus, an increased risk for colon, lung, prostate, and breast cancer with lower TSH has been demonstrated in epidemiological studies, even suggesting a TH dose effect on cancer occurrence. Furthermore, higher TH levels were associated with an advanced clinical stage of breast and prostate cancer. In rodent models, TH stimulated growth and metastasis of tumor transplants, whereas hypothyroidism had opposite effects. In clinical studies of glioblastoma and head and neck cancer, hypothyroid patients showed longer survival than euthyroid patients. Also, patients with renal cell cancer that were treated with the tyrosine kinase inhibitor sunitinib and developed hypothyroidism in due course showed significantly longer survival than patients that remained euthyroid. Development of hypothyroidism was an independent predictor for survival in two studies. Yet, it is still possible that hypothyroidism is only a surrogate marker for treatment efficacy and does not positively influence treatment outcome by itself. Future cancer treatment studies, especially with substances that can induce hypothyroidism, should therefore be designed in a way that allows for an analysis of thyroid function status and its contribution on treatment outcome.

Current literature makes a distinction between two pathways for thyroid hormone signaling: genomic and nongenomic. However, this classification is a source of confusion. We propose a clarification in the nomenclature that may help to avoid unproductive controversies and favor progress in this field of research. Four types of thyroid hormone signaling are defined, and the experimental criteria for classification are discussed.