Introduction: Subacute thyroiditis is a self-limiting inflammatory thyroid disease characterized by fever, neck pain, and thyroid dysfunction. It typically appears following an upper respiratory tract viral infection. Most cases of subacute thyroiditis are diagnosed through clinical and laboratory testing. The thyroid gland is large, painful, and tender during thyroid examination. Blood tests typically reveal elevated levels of free T4 and free T3, as well as a significantly increased sedimentation rate and C-reactive protein (CRP). Ultrasonographic findings of subacute thyroiditis are well defined.

Clinical Case: A 68-year-old male was consulted by the anesthesia department before the endoscopy and colonoscopy procedure planned to screen for malignancy. He was very worried and afraid because of the possibility of cancer and was psychologically negatively affected. He presented with night sweats and 10 kg of weight loss in the last 6 weeks. He had no history of previous disease. When a detailed history was taken, he stated that he had severe pain in his neck before his complaints started and that it went away on its own after a few weeks. On examination, he had no fever, a heart rate of 90 beats per minute, and a blood pressure of 120/80 mmHg. Neck examination showed no thyromegaly or lymphadenopathy. The general and systemic examination was unremarkable. Laboratory investigations showed hemoglobin 12.2 g/dL, WBC 8380 (x109/L), erythrocyte sedimentation rate (ESR) 78 mm/hour, CRP 50.1 mg/L, thyroid stimulating hormone 0.08 mIU/L (N = 0.55 - 4.78 mIU/L), free t4 1.4 ng/dL (N = 0.89 - 1.76 ng/dL), free t3 4.34 ng/L (N = 2.3 - 4.2 ng/L), and negative anti-thyroid peroxidase and thyroid stimulating immunglobulin. Thyroid ultrasonography was suggestive for subacute thyroiditis. He was given NSAIDS. Since his free T4 and T3 levels were normal at follow-up, endocrinological approval was given for the planned procedures. It was recommended to have a beta blocker ready during the procedure if needed. No findings in favor of cancer were detected in the detailed examinations, and the weight loss was attributed to subacute thyroiditis.

Conclusion: When elderly patients have complaints of weight loss or fatigue, it is important to exclude thyrotoxicosis and make a diagnosis by performing the necessary examinations. Subacute thyroiditis may not be severe; it is easy to diagnose with careful history-taking and simple laboratory examinations, and clinicians should keep it in mind in the differential diagnosis of weight loss.

Introduction: Primary heart tumors are uncommon with cardiac myxoma being the most frequently observed type. This tumor occurs in about 0.03% of the general population, typically appearing sporadically in adults. It can also be inherited as part of the Carney complex. While cardiac myxoma is biologically benign, it behaves functionally as a malignant tumor due to its potential to cause obstruction within the heart, embolization, and various systemic symptoms. Hashimoto’s thyroiditis (HT) is a chronic autoimmune condition characterized by lymphocytic inflammation of the thyroid gland.

Clinical Case: A 39-year-old female patient with a diagnosis of primary hypothyroidism visited our outpatient clinic 18 months postpartum. She had palpitations for the past 4 years, which had worsened over the last 2 years and were now severe enough to disturb her sleep. Additionally, she complained of hand tremors when hungry, severe headaches, extreme weakness, and drowsiness after meals. Her medical history included a diagnosis of HT 16 years ago and she was receiving levothyroxine 100 mcg daily. She has lost her mother due to a cerebrovascular event at age 45. On physical examination, her blood pressure was 120/80 mmHg, her heart rate was 88 beats per minute, she had rosacea on her face, and the rest of the examination was normal. Laboratory analysis was as follows: TSH: 1.2mU/L (0.55-4-78), fT3: 3.24ng/L(2.3-4.2), fT4: 1.26ng/dl(0.89-1.76), Hb: 12g/dL(12-15.6), ferritin: 6 microgram/L(10-291), anti thyroglobulin: 269.9IU/mL (<1.3), anti thyroid peroxidase: 389U/mL (<60), glucose: 86mg/dl(70-99). During follow-up, her levothyroxine dose was reduced due to tachycardia, and she was also treated for iron deficiency anemia. Although an echocardiogram was planned to investigate her tachycardia, she did not undergo the procedure. An echocardiogram of the patient revealed an ejection fraction of 60% and a 4.3x3.3cm, wellcircumscribed, round shaped mass in the left atrium. This mass, which was attached to the interatrial septum with a stalk and deviated the septum to the right, was consistent with a myxoma and contained areas of calcification. The patient underwent surgery for the left atrial mass, and the pathology results confirmed cardiac myxoma. In evaluations for Carney complex, cortisol was suppresse with the 1 mg dexamethasone suppression test, the glucose-growth hormone (GH) suppression test showed GH levels <0.05 μg/L, and a genetic test could not be performed.

Conclusion: Tachycardia in hypothyroid patients can occur as a side effect of levothyroxine treatment. Additionally, iron deficiency anemia can also lead to sinus tachycardia in these patients. However, if a patient presents with unusual symptoms, such as nocturnal tachycardia, it is crucial to consider the possibility of an underlying cardiac condition. When cardiac myxoma is identified, it is important to evaluate the patient for Carney Complex.

Introduction: Pituitary stalk interruption syndrome (PSIS) is a congenital abnormality of the pituitary gland responsible for GH deficiency or global pituitary insufficiency and is usually characterized by the triad of a very thin or interrupted pituitary stalk, an ectopic (or absent) posterior pituitary (EPP), and hypoplasia or aplasia of the anterior pituitary visible on magnetic resonance imaging (MRI). The etiology of this syndrome is not fully understood, and many theories, like perinatal injuries or defective organogenesis due to genetic or environmental factors during pregnancy, are proposed. In family cases of PSIS, rare mutations of HESX1, LH4, OTX3, SOX3 and PROKR2 may be the cause. In the majority of cases, no genetic cause is found. The symptoms and signs of this syndrome typically become apparent in the neonatal period and childhood. Sometimes symptoms can be overlooked, and diagnosis can be delayed.

Clinical Case: A 22-year-old male presented in our clinic with hypothyroidism and growth hormone deficiency. He had previously received growth hormone (GH) treatment for 6 years until he was 15 years old. He was receiving levothyroxine therapy for hypothyroidism. Complete blood count, serum electrolytes, erythrocyte sedimentation rate, urinalysis, and thyroid function tests were normal. Hormonal analysis showed FSH: 11.9 U/L (N = 1.4-18.1 U/L), LH: 4.1 U/L (N = 1.5-9.3 U/L), prolactin: 9.1 μg/L (N = 5.4-15.4 μg/L), ACTH: 24.5 pg/mL (N = <46), fasting morning cortisol: 17.2 μg/dL (N = 5.2-22.4 μg/dL), total testosterone: 4.03 μg/L (N = 1.64-7.53 μg/L), free testosterone: 6.39 pg/mL (N = 5.4-40 pg/mL), IGF-1: 114 μg/dL (N = 161-384 μg/dL). Brain MRI revealed slightly hypoplastic sella turcica and adenohypophysis measuring 4.2 mm in height, thin infundibulum, and ectopic posterior pituitary located posterior to the infundibulum in the suprasellar cistern. The diagnosis of pituitary stalk interruption syndrome is mainly based on its clinical manifestations, laboratory tests, and imaging examinations.

Conclusion: PSIS is a rare congenital malformation that presents with significant growth and developmental challenges in children. The symptoms can be disregarded, and the diagnosis will therefore be delayed. Early diagnosis and treatment are crucial for improving growth outcomes and overall quality of life. It must be considered in the presence of combined or isolated hypopituitarism. MRI is the imaging modality of choice for the diagnosis of this condition. Regular monitoring and supportive care are essential components of effective management for these patients.

Purpose: In previous studies, magnesium (Mg) was found to be lower in cases with more severe primary hyperparathyroidism (PHPT) and higher calcium (Ca) levels. This study evaluated the relationship between serum Mg and serum Ca and phosphorus (P) levels in PHPT and their utility in discriminating osteoporosis and nephrolithiasis.

Methods Patients: who were followed up with PHPT between March 2019 and March 2023 were analyzed retrospectively. Biochemical data, renal ultrasonography results, dual-energy x-ray absorptiometry reports, and technetium 99m sestamibi parathyroid scintigraphy reports were obtained. MgxP, Mg/P, Ca/P, and corrected Ca (cCa)/P values were calculated. The relationships between biochemical parameters and clinical outcomes were evaluated statistically.

Results: A total of 543 patients were included in the study. For Ca/Mg, a cut-off value of 5.47 had a sensitivity of 74% and a specificity of 73% for the presence of nephrolithiasis. The cut-off value for cCa/Mg that can be used to predict nephrolithiasis was 5.24, with a sensitivity of 73.3% and a specificity of 73%. No statistically significant correlation existed between the Mg/P, MgxP, cCa/Mg, Ca/Mg values, and DEXA results.

Conclusion: Ca/Mg and cCa/Mg ratios especially seem more valuable in discriminating nephrolithiasis than the currently used 24-hour urine Ca measurement. Unlike urinary Ca measurements, they are cheaper, more practical, and more accessible.

Crooke cell corticotroph adenomas are a rare subtype of corticotroph adenomas. It can be detected in less than 1% of all pituitary adenomas. They are usually noticed as invasive macroadenomas on preoperative imaging. They are expected to have a more aggressive course and more frequent recurrences during their clinical course. We present a case series of 11 patients who were followed up with Cushing’s Disease in our clinic and were diagnosed with Crooke cell adenoma after surgery. Nine patients were female(81.8%), and 2(18.2%) were male. The average age of the patients was 41.0(19.0-71.0) years. There were macroadenomas in 6 patients(54.5%) and microadenomas in 5 patients(45.5%). The average largest tumor diameter was 14.00 (4.50-35.00) mm. Pituitary adenoma invaded surrounding tissues in 3 patients(27.3%). Optic chiasm compression was observed in 2 patients(18.2%). Preoperative hypopituitarism was present in 6 patients(54.5%). In this group of patients, macroadenoma was detected in 5 patients, and microadenoma was detected in 1. The patients’ preoperative laboratory parameters and clinical findings are given in Table 1 and Table 2, respectively. A 1-milligram dexamethasone suppression test was performed in all patients in the preoperative period, and it was found to be high in all patients. 24- hour urinary cortisol was measured in 8 patients and was high in 5. In the postoperative period, two patients could not be evaluated for remission because they continued their follow-up in another center. Biochemical remission was achieved in 4 of the other nine patients(44.4%), and biochemical remission was not achieved in 5(55.6%). Postoperative follow-up periods of patients in biochemical remission have been 33, 39, 56, and 62 months; no recurrence was observed in any patient during this period.

Table 1. Laboratory parameters of patients with Crooke cell corticotroph adenoma

Table 2. Clinical findings of patients with Crooke cell corticotroph adenoma

The co-occurrence of congenital adrenal hyperplasia and type 1 diabetes mellitus (T1DM) is a rare phenomenon in existing literature. The primary cause of congenital adrenal hyperplasia (CAH) is often 21-hydroxylase deficiency (21OHD), a condition associated with the CYP21A2 gene located on chromosome 6p21.3 within the major human leukocyte antigen (HLA) histocompatibility locus. Various gene polymorphisms, particularly in HLADQalpha, DQbeta, and DR genes on chromosome 6p21.32, are known to influence the risk of type 1 diabetes. Although the genetic loci for T1DM and 21- OH CAH are close, these conditions typically manifest independently, we present a case involving a man in his 20s who visited the emergency department with symptoms such as nausea, vomiting, headache, fatigue, and excessive sleepiness. This individual had a history of both classic salt-wasting congenital adrenal hyperplasia and type 1 diabetes mellitus. Over the past decade, the patient had experienced recurrent hospitalizations for diabetic ketoacidosis, with recent complications arising from the malfunction of an insulin pump due to technical issues. Initial treatment included insulin infusion, intravenous hydration, and an increased hydrocortisone dose. Once acidosis resolved, the patient transitioned to basal-bolus therapy and resumed insulin pump use. Carb counting was introduced, and dietary adjustments were made. An abdominal computed tomography scan revealed bilaterally thickened adrenal glands, and scrotal ultrasound detected an adrenal rest tumor. The patient was discharged with oral hydrocortisone (30 mg once daily), oral fludrocortisone (0.2 mg once daily), and continued use of an insulin pump. Repeated ketoacidosis episodes were potentially linked to hydrocortisone use, prompting consideration of a connection between T1DM and 21OHD, necessitating further investigation through additional studies

Radioactive iodine therapy (RAI) is a treatment method used to in cases of Graves’ disease(GD), toxic multinodular guatr and solitary toxic nodu¨le and residual tissue after thyroidectomy or in the treatment of metastases capable of capturing iodine. The biological basis of the treatment is the inhibition of follicle cell functions. Side effects such as thyroid swelling, radiation thyroiditis and sialadenitis are rare. Radiation thyroiditis tends to occur within two weeks after RAI administration and is generally asymptomatic in most patients. Approximately % 1-5 of patients with GD develop radiation thyroiditis after RAI treatment. Radiation causes ınflammation that develops as a result of exposure of a large residual tissue to a high radiation dose may cause tenderness in the thyroid tissue or neck, erythema and edema, pain when swallowing, rarely airway obstruction, and in some patients, a thyrotoxic state. Symptoms generally begin 1- 10 days after treatment. Pain and tenderness in the thyroid and neck area are mild and disappear within 3-7 days. There may be a temporary hyperthyroidism attack at this time. Mild symptoms are usually relieved with non-steroidal antiinflammatory drugs. In more severe cases, corticosteroid treatment (30 mg/day prednisone) provides rapid relief of symptoms. In case of thyroid storm, symptoms can be controlled with corticosteroids, if severe adrenergic symptoms are accompanied by beta blockers and if necessary antithyroid drugs. Here we will present a case of radiation tyroditis developing after Graves Diseaes(GD). A 71- year-old patient with a diagnosis of Graves’ disease was treated with 20 mcı radioactive iodine due to elevated liver function tests under antithyroid drug therapy. 1 week after radioactive iodine treatment, she was admitted to our outpatient clinic with complaints of pain in the throat and difficulty swallowing. Thyrotoxicosis was detected in the tests. Oral cavity looked natural and sensivity was detected in the neck area. No respiratory distress was detected. Newyl developed tracheal stenosis was detected on the cervical graphy. Color doppler pattern 3 and edema in the thyroid gland was detected on the ultrasonography. The patient ‘s complaıns were primarily evaluated as thyroiditis secondary to radıoactive iodine treatment. The patient was started on oral methylprednisolone sodıum succinate, non-steroidal anti-inflamatory and betablocker treatment. The patient’s complaints regressed under treatment. In conclusion, radiation thyroiditis is a complication of RAI for the treatment of GD and may cause morbidity. Radiation thyroiditis should be suspected as the etiology of patients presenting with neck pain and difficulty swallowing immediately after RAI

Aim: In patients with papillary thyroid carcinoma (PTC), the incidence of subacute thyroiditis (SAT) is thought to be more frequent than estimated. The incidence of thyroid cancer is between 2.3% and 21.1% in Graves’ Disease (GD).

Case: A 31-year-old female patient applied with complaints of amenorrhea and hair loss in the 10th postpartum month. There was no history of COVID-19 infection, but Biontech vaccine were administered two years ago. Her family history revealed GD in her sister. On physical examination, blood pressure was 120/1 mm/Hg, pulse rate was 83 beats/min. Laboratory values were TSH:!0.1 mU/l (0.55-4.78), freeT4:2.1 ng/dl (0.89-1.76), freeT3:11.1 ng/l (2.3-4.2), antithyroglobulin:2.7 IU/ml (!13), antithyroidperoxidase: 10235 U/ml (!60), thyroid stimulating immunglobulin: 6.34 IU/l (0.1-0.55), TSH receptor antibody: 3.63 IU/l (!1.5). The patient refused thyroid scintigraphy because of breastfeeding. She admitted with severe pain over the right thyroid lobe the next day. There was tenderness in the right thyroid area and the body temperature was 37.58. Thyroid US revealed hypoechoic heterogeneous areas in the superior anterior and the inferior anterior regions of the right lobe, a 16x24x1 mm isoechoic nodule with areas of cystic degeneration in the superior region and a 22x38x1 mm conglomerated isoechoic nodule with areas of cystic degeneration in the inferior region of left lobe. In laboratory analysis, TSH:!0.1 mU/l, freeT4:2.1 ng/dl (0.89-1.76), freeT3:15.1 ng/l (2.3-4.2), sedimentation rate: 1 mm/hour(0-20), CRP:8.1 mg/l (0-5). Her pain regressed and CRP values returned to normal after one week with NSAID treatment. However, since thyrotoxicosis did not resolve (TSH:!0.1 mU/l (0.55- 4.78), free T4:3.05nd/dl(0.89-1.76), free T3: 18.1 ng/l (2.3-4.2), methimazole treatment was started. On the control thyroid US, heterogeneous hypoechoic areas have resolved. The thyroid FNAB cytology result of the dominant nodule in the left lobe was suspecious for follicular neoplasia and hurtle cell type. The patient underwent bilateral total thyroidectomy, and an infiltrative follicular subtype PTC 0.1 cm in diameter was observed in the right lobe in addition to hyperplastic colloidal nodules in non-tumor thyroid tissue.

Conclusion: SAT can be seen rarely in patients with PTC. In the literature, there are cases diagnosed with GD after SAT, cases of SAT concurrent with GD, and cases of concurrent GD and SAT after COVID-19 infection. Considering that the incidence of combinations of these three diseases is very rare, our patient is the first case in the literature with all three diagnoses

Aim: In patients with papillary thyroid carcinoma (PTC), the incidence of subacute thyroiditis (SAT) is thought to be more frequent than estimated. The incidence of thyroid cancer is between 2.3% and 21.1% in Graves’ Disease (GD).

Case: A 31-year-old female patient applied with complaints of amenorrhea and hair loss in the 10th postpartum month. There was no history of COVID-19 infection, but Biontech vaccine were administered two years ago. Her family history revealed GD in her sister. On physical examination, blood pressure was 120/1 mm/Hg, pulse rate was 83 beats/min. Laboratory values were TSH:!0.1 mU/l (0.55-4.78), freeT4:2.1 ng/dl (0.89-1.76), freeT3:11.1 ng/l (2.3-4.2), antithyroglobulin:2.7 IU/ml (!13), antithyroidperoxidase: 10235 U/ml (!60), thyroid stimulating immunglobulin: 6.34 IU/l (0.1-0.55), TSH receptor antibody: 3.63 IU/l (!1.5). The patient refused thyroid scintigraphy because of breastfeeding. She admitted with severe pain over the right thyroid lobe the next day. There was tenderness in the right thyroid area and the body temperature was 37.58. Thyroid US revealed hypoechoic heterogeneous areas in the superior anterior and the inferior anterior regions of the right lobe, a 16x24x1 mm isoechoic nodule with areas of cystic degeneration in the superior region and a 22x38x1 mm conglomerated isoechoic nodule with areas of cystic degeneration in the inferior region of left lobe. In laboratory analysis, TSH:!0.1 mU/l, freeT4:2.1 ng/dl (0.89-1.76), freeT3:15.1 ng/l (2.3-4.2), sedimentation rate: 1 mm/hour(0-20), CRP:8.1 mg/l (0-5). Her pain regressed and CRP values returned to normal after one week with NSAID treatment. However, since thyrotoxicosis did not resolve (TSH:!0.1 mU/l (0.55- 4.78), free T4:3.05nd/dl(0.89-1.76), free T3: 18.1 ng/l (2.3-4.2), methimazole treatment was started. On the control thyroid US, heterogeneous hypoechoic areas have resolved. The thyroid FNAB cytology result of the dominant nodule in the left lobe was suspecious for follicular neoplasia and hurtle cell type. The patient underwent bilateral total thyroidectomy, and an infiltrative follicular subtype PTC 0.1 cm in diameter was observed in the right lobe in addition to hyperplastic colloidal nodules in non-tumor thyroid tissue.

Conclusion: SAT can be seen rarely in patients with PTC. In the literature, there are cases diagnosed with GD after SAT, cases of SAT concurrent with GD, and cases of concurrent GD and SAT after COVID-19 infection. Considering that the incidence of combinations of these three diseases is very rare, our patient is the first case in the literature with all three diagnoses

Objective: Gonadotroph adenomas are the most common subtype of pituitary adenomas. Rarely, clinical findings may occur due to the secretion of high amounts of biologically active gonadotropins. It may affect platelet activity if there is an excessive increase in the release of estrogen and testosterone or if it is used in pharmacological doses. In this study, we aimed to investigate whether platelet activity indices and coagulation parameters were affected in silent gonadotroph adenomas.

Methods: Patients who operated for a pituitary adenoma in our center between March 2019 and July 2023 were recruited for the study. Presence of thromboembolic disease history, preoperative and postoperative (after the first month) follicle-stimulating hormone (FSH), luteinizing hormone (LH), total testosterone, free testosterone, estradiol (E2), platelet count, mean platelet volume (MPV), platelet distribution width (PDW), international normalized ratio (INR) and activated partial thromboplastin time (aPTT) levels of the patients were recorded.

Results: 25 female patients and 32 male patients were included in the study. We found no statistically significant difference between FSH, LH, testosterone, and E2 levels in both genders’ preoperative and postoperative periods. No statistically significant difference was observed in MPV, PDW, INR, and aPTT in both genders. None of the patients in the study had a history of thromboembolic events. No thromboembolic event was observed in any patient within the first year of the postoperative period.

Conclusion: Silent gonadotroph adenomas do not affect platelet activity in male and female patients

Introduction: Medullary thyroid cancer (MTC) is characterized by elevated calcitonin levels, stemming from genetic factors or occurring sporadically. Carcinoid syndrome involves symptoms triggered by substances released by tumors, such as hormones and amines. This case report details a patient who developed carcinoid syndrome linked to medullary thyroid cancer.

Case: A 77-year-old male presented with flushing, diarrhea, and dizziness. No other health issues or medication use were reported, except for flushing and hypotension during a hemorrhoid operation a year ago. While routine tests showed normal results, neck CT revealed calcified nodules in the thyroid and pathological lymph nodes. Calcitonin was elevated at 11312 pg/ml, CEA at 126 ng/ml. Thyroid ultrasound displayed a 19.1!21!35.9 mm calcified nodule with pathological cervical lymph nodes. Ga-68-DOTA-PET confirmed thyroid and cervical involvement. Fine needle aspiration biopsy confirmed medullary carcinoma. Catecholamine and 5-HIAA levels were normal. Chromogranin was normal. Surgery was planned for MTC, involving bilateral total thyroidectomy and lymph node dissection. Sandostatin infusion was initiated for carsinoid symptoms 24 hours before surgery, continuing intraoperatively and 48 hours postoperatively, gradually decreasing over a week. Postoperatively, calcitonin was 639 pg/ml, CEA 110 ng/ml on day one. Three months later, similar symptoms recurred, with calcitonin at 2600 pg/ml . Re-operation confirmed MTC, with a 5 cm retrosternal mass in the right lobe. Postoperatively, calcitonin decreased to 312 pg/ml . Two months later, a patient with similar complaints had a calcitonin level of 261 pg/ml, and residual tissue? was observed in the right lobe on thyroid ultrasonography. A spherical lymph node with the largest size of 10 cm was identified in the right level IV. Biopsy results were non-diognastic, and calcitonin washouts results of 4.9 pg/ml and 15.2 pg/ml, respectively. Due to ongoing symptoms, the patient was readmitted with a preliminary diagnosis of carcinoid syndrome, and short-acting sandostatin was initiated. After the post-operative follow-up Ga-68 DOTA-PET, as regression and the absence of new metastases were observed, tyrosine kinase inhibitors were not considered. The patient was discharged with lanreotide 120 mg/month, and no attacks were observed following the treatment.

Conclusion: MTC can manifest with flushing in carcinoid syndrome. When diagnosing flushing, consider MTC, pheochromocytoma, pancreatic tumors, hyperthyroidism, and male hypogonadism. Treating carcinoid syndrome involves addressing the underlying disease, and also sandostatin relieves symptoms in these patients. Keep MTC in mind when patients present with flushing or carcinoid syndrome.

Introduction: Targeted therapies and monoclonal antibodies are known to trigger thyroid autoimmunity. No case of autoimmune thyroid disease with mepolizumab, an anti-IL-5 monoclonal antibody, is reported in the literature. In this case report, we present a case of Graves’ disease that recurred after Mepolizumab treatment.

Case: A 74-year-old male patient was referred to the endocrinology outpatient clinic upon detection of hyperthyroidism on 11/2021. The patient, who had known aortic valve replacement, allergic asthma, and benign prostatic hyperplasia, was using warfarin 1!5 mg, atorvastatin 1!20 mg, inhaler salmeterol, 1!5 mg levocetirizine and 1!8 mg silodesin. In the patient’s examinations, TSH !0.008 mU/l, free T4:3.94 ng/dl, free T3:11.99 ng/l, anti-tg:2.4 IU/ml, and TSH receptor antibody (TRAB):6.77 IU/l (!1.5 IU). /l) was seen. On electrocardiography, his pulse was 98 beats/minute, and his rhythm was normal sinus rhythm. While no nodule was detected in the patient’s thyroid ultrasonography, bilateral parenchymal heterogeneous and sparse patchy hypoechoic areas were observed. Color flow doppler pattern was observed as 2 in thyroid doppler. The patient, who had no history of recent contrast exposure or amiodarone use, was evaluated as having Graves’ disease, and methimazole 3x5 mg and propranolol 2x20 mg were started. No signs of ophthalmopathy were detected in the eye examination performed at the time of diagnosis. After one month, propranolol was discontinued, and methimazole dosage was adjusted, and periodic checks were scheduled. On 05/2023, in the 19th month of treatment, while receiving methimazole 1!2.5 mg treatment, TSH was measured:2.4 mU/l, free T4:1.04 ng/dl, free T3:3.62 ng/l, thyroid stimulating immunoglobulin was 0.52 IU/l (0.1- 0.55 IU/l). The treatment was discontinued at this point. In the follow-ups performed one month and two months later, it was observed that the patient was euthyroid. On 07/2023, as the patient’s complaints about allergic asthma increased, the pulmonologist started Mepolizumab to be administered 100 mg subcutaneously once a month. On 09/2023, after the patient received two doses of mepolizumab, TSH:0.02 mU/l, free T4:1.86, and free T3:4.68 ng/l were observed in the controls performed in our outpatient clinic, and the patient was started on methimazole 1!5 mg again. The patient, who was evaluated as having a relapse of Graves disease, was assessed in a multidisciplinary council, and radioactive iodine treatment was planned.

Conclusion: Thyroid autoimmunity may be triggered after Mepolizumab, an anti-IL-5 monoclonal antibody. Patients receiving this treatment should also be followed in this respect.

Aim: Dry eye syndrome(DES) is a common finding in patients with thyroid orbitopathy. There are few studies on DES in patients with papillary thyroid cancer (PTC). Retinal pathology may develop in case of vitamin E deficiency, which has antioxidant, anti-inflammatory and anti-apoptotic properties.

Materials and Methods: In our study, 29 patients who received radioactive iodine (RAI) treatment (Group 1) and 22 patients who did not receive RAI treatment (Group 2) with a diagnosis of PTC were included. 26 healthy individuals without PTC were determined as the control group (Group 3). Exclusion criteria were diabetes mellitus, rheumatologic diseases, keratoconus, glaucoma, history of contact lens use, previous eye surgery. Ocular surface disease index, meibomian gland secretion quality, lid margin score, noninvasive tear breakup time were evauated with sirius device and meibomagraphy in all patients. Thyrotropin (TSH), free thyroxine, free triiodothyronine, and vitamin E levels were measured.

Results: TSH levels were significantly lower in Group 1 and 2 compared to Group 3 (P!0.001, P!0.001, respectively). There was no significant difference between the groups in terms of vitamin E levels (PZ0.599). The proportion of those with normal noninvasive tear breakup time (O17) was similar in Group 1, Group 2 and Group 3 (30.8%, 27.3%, and 44.6%, respectively, PZ0.145). The proportion of those with an upper lid margin score of R1 was significantly higher in Group 1 and Group 2 than in the control group (64.9%, 56.8% and 17.9%; respectively, PZ0.025). Lower meibomian gland expressivity was O1 in 34.5% of the patients in Group 1, 22.7% in Group 2, and 7.1% in Group 3 (PZ0.002). The proportion of patients with lower meibomiagraphy values of R1 was significantly higher in Group 1 and Group 2 compared to the control group (61.1%, 52.5%, and 29.5%, respectively, PZ0.007). There was no significant difference between the groups in terms of lower lid margin score, Oxford values, upper meibomian gland expressibility, and upper meibomiagraphy grades (PZ0.485, PZ0.064, PZ0.256 and PZ0.069, respectively). OSDI (survey questioning eye-related irritation symptoms) values were 6.25 in Group 1 and 8.12 in Group 2 and were significantly higher than the control group (2.27) (PZ0.034).

Conclusion: Meibomian gland dysfunction is observed in patients with PTC who received and did not receive RAI. This may be related to TSH suppression. It is important to question these patients for a dry eye because it might affect their daily living activities

Aim: Papillary thyroid cancer (PTC) accounts for 85% of thyroid cancers. Classical PTC has a 10 year survival rate of over 95%. Although the histopathological diagnosis of thyroid tumors, which started in the 1950s, has improved significantly in the last few decades, the effect of aggressive subtypes on survival has not been fully clarified. In our study, we investigated the effect of aggressive cytologic subtypes on behavior and prognosis in patients followed up with a diagnosis of PTC.

Method: Our retrospective study included 484 patients who underwent bilateral total thyroidectomy and were diagnosed with PTC. There were 11 patients with aggressive subtype (columnar cell, tall cell, diffuse sclerosing, solid, hobnail PTC), 382 patients with nonaggressive subtype (papillary, follicular PTC), and 91 patients with mixed subtype. 36 month follow-up results were analyzed. Demographicall findings, imaging and laboratory results, histopathological features (tumor diameter, capsule invasion, vascular invasion, extrathyroidal invasion, lymphatic invasion, distant metastasis), radioactive iodine (RAI) treatment were noted from the records. Dynamic risk scoring (excellent response, biochemical incomplete response, structural incomplete response, indeterminate response) was performed.

Results: The mean age at diagnosis was lower in the aggressive subtypes (44.36G10.63) than in the nonaggressive and mixed subtypes (46.14G12.82 and 47.71G13.24, respectively) (PZ0.501). Tumor size was significantly larger in the aggressive subtypes (1.83G2.27 cm) than in the nonaggressive and mixed subtypes (1.21G 1.1 cm and 1.60G1.1 cm, respectively) (PZ0.019). According to the American Thyroid Association (ATA) risk classification, the proportions of those identified as intermediate and high risk were higher in the aggressive and mixed subtypes (72.7% and 68.1%, respectively) than in the nonaggressive subtypes (23.9%) and the difference was statistically significant (P!0.001). Remission, persistence, recurrence and metastasis rates during follow-up did not differ significantly between groups (PZ0.926, PZ0.903, PZ0.776 and PZ0.920, respectively). There was no significant difference in treatment responses according to dynamic risk scoring after initial treatment 6-12 months, 12-18 months, 18-24 months, 24- 36 months (PZ0.931, PZ0.961, PZ0.892, PZ0.698, respectively).

Conclusion: In our study, we found that tumor size was larger in the aggressive subtype, and those with intermediate and high risk, according to the ATA risk classification, were more common in the aggressive and mixed subtypes. In patients with PTC, aggressive and mixed subtypes in the initial treatment phase may create differences in approach, and further studies are needed.

Introduction: Malabsorption of levothyroxine is an important clinical problem. Changes in gastric pH due to various medical conditions might cause challenges in maintaning normal TSH values. Case: A forty-nine years old female who has been followed up with a diagnosis of primary hypothyroidism for 12 years admitted to our outpatient clinic with a complaint of unachievement of euthyroidism despite increasing the levothyroxine dose up to 200 mg. He did not have any other chronic disease and was not using any other medication. In laboratory examination, free T3 was 1.14 ng/l (2.3 - 4.2), free T4 was 0.32 ng/dl (0.89 - 1.76) and TSH was 129 mU/l (0.55 - 4.78). Thyroid autoantibodies were markedly high (antithyroglobulin O1000 IU/ml and antithyroid peroxidase antibody O13000 U/ml) and thyroglobulin was !0.20 mg/l Tthyroid ultrasonography showed heterogeneous parenchyma with widespread patchy hypoechoic areas and thin-thick fibrous bands. Free T4 was was measured just before and after the administration of oral levothyroxine 200 mg. Basal, first hour and second hour free T4 were 0.23 ng/dl, 0.29 ng/dl and 0.29 ng/dl, respectively. A malabsorption test was performed with 500 mg levothyroxine. Accordingly, free T4 was 0.40 ng/dl at basal state, 0.41 ng/dl in the first hour, 0.50 ng/dl in the second hour and 0.47 ng/dl in the fourth hour. Thus, free T4 level increased by a maximum of 25%. The patient’s celiac and anti-pariatel cell antibodies were negative. Helicobacter Pylori antigen tested in the stool was detected positive. The patient’s upper gastrointestinal endoscopy revealed antral gastritis and colonoscopy revealed Grade 1 internal hemorrhoids, He was given 1000 mg/day vitamin C. At the third day of vitamin C, serial free T4 levels were measured after ingestion of 250 mg levothyroxine. While basal TSH was 112 mU/l and free T4 was 0.5 ng/dl, free T4 increased to 0.71 ng/dl at the first, 0.80 ng/dl at the second and 0.80 ng/dl at the fourth hour. A maximum increase of 60% in free T4 value was detected.

Conclusion: There are publications in the literature showing that vitamin C corrects abnormalities in serum free T4, T3 and TSH in patients with hypothyroidism and gastrointestinal pathology. Although the mechanism was not explained clearly, it was suggested that decreasing pH via vitamin C might increase the absorption of the drug. Co-administration of vitamin C with L-T4 may be useful in the treatment of patients with high TSH values despite high doses of L-T4.

Insulin autoimmune syndrome is a condition characterized by production of autoantibodies against insulin. Drugs are one of the ethiological factors, especially when they contain the sulfydryl group such as methimazole and alpha lipoic acid. Herein we present a case report of insulin autoimmune syndrome due to alpha lipoic acid. A 77 year-old female patient presented to emergency department with syncope because of hypoglycemia. She was diagnosed with type 2 diabetes mellitus a year ago. Metformin and gliclazide was prescribed. During her follow-up, she had complaints of neuropathy, so alpha lipoic acid was added to her treatment. She also had autoimmune thyroid disease but didnot need for levothyroxine replacement. When she was questioned it was learned that she hadnot been taking metformin and gliclazide aproximately for 2 weeks, but she continued to take alpha lipoic acid. During a hypoglycemic episode insulin and c-peptide levels were examined and was compatible with hyperinsulinemic hypoglycemia. Anti-insulin antibody titer was high. She was considered to have insulin autoimmune syndrome due to alpha lipoic acid. Alpha lipoic acid was stopped, afterwards hypoglycemia was ceased, anti-insulin antibody titer decreased accordingly. There are several case reports of insulin autoimmune syndrome presented in literature due to intake of alpha lipoic acid. All of the cases had autoantibodies against insulin at presentation, cessation of hypoglycemia and deacrease of anti-insulin antibody titer after discontinuation of alpha lipoic acid. There are certain HLA allels which causes predisposition to this syndrome. Also these patients have higher incidance of other autoimmune diseases. If a patient who takes a drug containing sulfydryl group and has any of the autoimmune diseases presents with hyperinsulinemic hypoglycemia, insulin autoimmune syndrome must be considered.

Introduction: Fibrodysplasia ossificans progressiva (FOP), also known as stone man disease, is a rare connective tissue disorder with a prevalence of 1 in 2 million. It is caused by a mutation in ACVR1 gene, usually sporadic and sometimes with autosomal dominant (AD) inheritance. These patients are normal at birth except for the short great toes and hallux valgus. Over time soft tissues such as ligaments, skeletal muscles or tendons ossify. Diaphragm, tongue, extraocular and cardiac muscles are spared.

Clinical case: A 32-year-old female with severe bone pain and hip contracture applied to our clinic. In her history, at age 8 she was admitted to hospital due to lump on her back. The biopsy result of the lesion was reported as fibrotic fat tissue and she was discharged. Two years later at age 10 she was admitted to hospital again due to protrusion and pain in the area where the biopsy was taken. The second biopsy taken from the left thoracic wall was reported as heterotopic endochondral ossification. Further examination of the case for FOP was recommended. Genetic testing could not be done due to the family’s financial difficulties. Over the years, painful swellings continued to develop in various regions. When the patient’s daughter was 5 years old, the same painful swellings began to occur. This time genetic testing was done on both. Mutation was detected positive for ACVR1 gene for both. (NM_001105.5, c.617GOA (p.R206H) (p.Arg206Pro) (Heterozygote)). During our examination, many painful ossification areas were detected in different regions such as the back, dorsum of foot and chest wall. In addition, contracture of the left hip joint occurred in external rotation and abduction. She also had short big toes and hallux valgus. No abnormalities were detected in laboratory tests. In plain radiographs, pseudoexostoses were seen in various parts such as left sided thoracic wall, left iliopsoas muscle and adductor magnus muscle. Also, monophalangic great toes were noted (Figure 1). Since there was no treatment to prevent the progression of the disease, we administered ibuprofen for symptomatic treatment and glucocorticoid to use during painful flare-ups.

Conclusion: FOP is a rare disease that reduces quality and duration of life. Where heterotopic ossification is detected clinically or radiologically, FOP should be kept in mind. Since it can be inherited AD, genetic testing and counseling should be provided in case of clinical suspicion

Patient is a 43 years old female without any known additional disease. A pituitary mass was seen in the cranial MRI taken due to the complaint of forgetfulness. Pituitary MRI of the patient revealed a ’large intrasellar mass of 3.2x3x2.3 cm, which expanded the sella and pressed the optic chiasm’. The patient didn’t describe any symptoms other than forgetfulness. She didn’t have galactorrhea, cushingoid or acromegaloid appearance. Patients laboratuary evaluation can be seen in Table 1. The patient was started on levothyroxine for central hypothyroidism and it was thought that the patient had a non-functional pituitary adenoma. In the follow-up of the patient who underwent transsphenoidal surgery, no hypopituitarism or central diabetes insipidus was detected. In the immunohistochemical and histological examination of the patient’s surgical material:’Tumor cells showed diffuse staining with ACTH. GH, PRL, TSH, FSH, LH are negative. The Ki-67 proliferation index was 3-4%.’These findings, patient’s pre-operative examinations and clinically situation were evaluated and it was determined that the patient had a ’silent corticotroph adenoma’. The patient had no complaints in the post-operative first month. Her anterior pituitary hormones were observed(Table 2). Due to the tendency of silent corticotroph adenomas to progress aggressively, pituitary MRI control was planned at the postop 3rd month. Silent corticotroph adenomas constitutes 4.8-6.8% of all pituitary adenomas and 19% of non-functioning pituitary adenomas. It has a highly aggressive and invasive course. It often recurs after treatment and is resistant to treatment. In the studies,0.5 mg DST performed with a cut-off value of 3.0µg/dl in the screening of Cushing’s syndrome. That has been shown to have higher sensitivity and specificity than the classical 1 milligram DST. In our case, both screening tests were applied.

Table 1 Biochemistry and pre-operative anterior pituitary hormone examination results

Table 2 Biochemistry and anterior pituitary hormone test results in post-operative first month

Background: Micro vascular complications are the major outcome of Type 2 Diabetes Mellitus progression, which reduces the quality of life and increases diabetic morbidity & mortality. As the incidence of type 2 diabetes is growing day by day; our search for its aetiology and pathogenesis is also ever growing to predict its risk factors and early screening for better care and prevention of its complications. Many studies have tried to link susceptibility of type 2 diabetes with ABO blood group though results have been inconsistent. The present study aims to analyse association of micro vascular complication with different blood groups if any.

Methods: The study included the paitents with diabetes who were hospitalized and followed up in our clinic form Dec. 2019 to April 2022. Information such as age, sex, and family history of diabetes was scanned from medical records. The blood group was determined by standard serological methods. Screening of microvascular complications done by appropriate clinical examinations and laboratory investigations.

Results: There was 348 patients with type 2 diabetes in this study, the average age of the patients was 59.3±12.8, male to female ratio was 142(40.8%)/204 (59.8%) respectively. 246 (70.68%) patients had one or the other complications. Diabetic nephropathy, rethinopathy and neuropathy ratio was 31.3%, 35.20% ve %52.0% respectively. None of the type of micro vascular complication was found to be significantly associated with different blood groups. In addition we found that Rh (K) group had significantly low Diabetic nephropathy, rethinopathy compare to Rh (C) group (P=0.044 ve P 0.041).

Conclusions: Although we didn’t finde a relationship between ABO blood group and diabetic microvascular complications, Rh (C) was found to be a risk factor for developing nephropathy and retinopathy.

Background: Micro vascular complications are the major outcome of Type 2 Diabetes Mellitus progression, which reduces the quality of life and increases diabetic morbidity & mortality. As the incidence of type 2 diabetes is growing day by day; our search for its aetiology and pathogenesis is also ever growing to predict its risk factors and early screening for better care and prevention of its complications. Many studies have tried to link susceptibility of type 2 diabetes with ABO blood group though results have been inconsistent. The present study aims to analyse association of micro vascular complication with different blood groups if any.

Methods: The study included the patients with diabetes who were hospitalized and followed up in our clinic form Dec. 2019 to April 2022. Information such as age, sex, and family history of diabetes was scanned from medical records. The blood group was determined by standard serological methods. Screening of microvascular complications done by appropriate clinical examinations and laboratory investigations.

Results: There was 348 patients with type 2 diabetes in this study, the average age of the patients was 59.3±12.8, male to female ratio was 142(40.8%)/204 (59.8%) respectively. 246 (70.68%) patients had one or the other complications. Diabetic nephropathy, rethinopathy and neuropathy ratio was 31.3%, 35.20% ve %52.0% respectively. None of the type of micro vascular complication was found to be significantly associated with different blood groups. In addition we found that Rh (K) group had significantly low Diabetic nephropathy, rethinopathy compare to Rh (C) group (P=0.044 ve P 0.041).

Conclusions: Although we didn’t finde a relationship between ABO blood group and diabetic microvascular complications, Rh (C) was found to be a risk factor for developing nephropathy and retinopathy.

Introduction: Metformin is widely used as the first-line therapy for patients with type 2 diabetes,

and its most common adverse effects are gastrointestinal. Metformin-associated lactic acidosis (MALA) is a rare but serious adverse effect in patients with type 2 diabetes or patients who attempt suicide with metformin overdose. Here, we report the case of a 22-year-old woman who developed severe lactic acidosis after high-dose metformin was taken for a suicide attempt.

Case: A 22-year-old woman with anxiety disorder and depression developed lifethreatening lactic acidosis after taking high doses of metformin to attempt suicide. The patient received approximately 30 g of metformin. She applied to the emergency department with slurred speech and nausea. In her initial laboratory findings, arterial blood gas pH was 7.41, bicarbonate 14 mmol/l, anion gap 13 mmol/l, lactate 7.5 mmol/l, and creatinine of 1.44 mg/dl. Then she deteriorated and arterial blood gas pH became 6.96, bicarbonate 5.8 mmol/l, anion gap 33 mmol/l, lactate 23.9 mmol/l, and creatinine of 1.99 mg/dl. Renal replacement therapy was initiated. After one dialysis session, her severe acidemia resolved over time. She was discharged from the hospital without any complications. A Naranjo assessment score of 9 was obtained, indicating a probable relationship between the patient’s lactic acidosis and her use of the suspect drug.

Conclusion: MALA is a well-known and life-threatening complication of metformin. Vomiting and diarrhea are the first signs of MALA. Even if severe lactic acidosis may not be apparent at first as in our case clinicians should be aware that lactic acidosis may develop. Severe lactic acidosis can be treated with renal replacement therapy because metformin is dialysable.

Objective: Thyroid nodules are one of themost common thyroid diseases. Ultrasonography is an

reliable and the most commonly used imaging method in the evaluation of thyroid nodules with a high sensitivity (Sn) and specificity (Sp). The prevelance of obesity, especially severe obesity, is increasing at an alarming rate in the worldwide. Although obesity and thyroid disorders are related to each other, the pathological relationship between those is not clear. Several studies have revealed that thyroid nodules are associated with adiposity which is assessed by body mass index (BMI). In this study we aimed to evaluate the morphological structure of the thyroid gland and thyroid nodules in obese patients according to the degree of the obesity.

Methods: 273 patients with BMI>30 kg/m² and applied to our endocrinology outpatient clinic between 2019 and 2022 years for obesity or any other reason and also requested thyroid ultrasonography and thyroid function tests were analyzed retrospectively. The demographic data of the patients (sex, age), thyroid function tests, thyroid ultrasonography features (thyroid gland size, volume, parenchyma structure, and, if any, nodule and nodule features) and also if there is thyroid nodule cytology, were evaluated. According the body mass index patients were divided as

class I (BMI;30-34.9 kg/m²), class II (BMI; 35-39.9 kg/m²) or class III (BMI;R40 kg/m²) obesity.

Results: Total of the 273 patients, 53 (19.4%) were male, 220 (80.6%) were female. 19 (7%) , 60 (22%), and 194 (71%) of the 273 patients had class I, II, and class III obesity, respectively. Ultrasonographically, the thyroid parenchyma was heterogeneous in 221 (92.9%) of the patients. But there was no statistically significant thyroid gland heterogeneity between the groups. Anti thyroglobulin antibody positivity was significantly higher in class III obese patients (P=0.047), but no significant difference was found in antiTPO antibody positivity and thyroid function tests between obesity classes. Also there was no significant difference between obesity classes and thyroid nodule features including; echogenicity, structure, halo sign, border regularity, presence of calcification and also thyroid nodule cytology.

Conclusıon: Although we could not found a relationship between obesity classes and thyroid function tests and nodule features, most of the obese patients had parenchymal heterogeneity. Considering the increasing incidence of obesity and frequency of thyroid nodules, thyroid ultrasonography will be useful in obese patients.

Background: Primary Hyperparathyroidism (PHPT) is a common endocrine disorder that is characterized by hypercalcaemia and elevated or inappropriately normal serum levels of parathyroid hormone. Most often, the presentation of PHPT is asymptomatic. PHPT can manifest with osteoporosis and hypercalciuria as well as with vertebral fractures and nephrolithiasis, both of which can be asymptomatic. Our aim in this study; to determine the frequency of kidney stones in patients operated for primary hyperparathyroidism and to compare the biochemical values of symptomatic and asymptomatic patients with kidney stones.

Methods: It was planned to include patients who had undergone parathyroidectomy, who applied to Ankara Yıldırım Beyazıt University Atatu¨rk Training and Research Hospital between December 2006 and January 2019 and to Ankara City Hospital Endocrinology and Metabolic Diseases Clinic between February 2019 and November 2021.

Results: Of 886 patients who were operated for primary hyperparathyroidism, 15.9% (n:141) were male. 189 (%21.3) patients had symptoms at the time of diagnosis. Diffuse body pain (37%), flank pain (22.2%), fatigue (11.6%), dyspepsia (6.9%), polyuria and polydipsia (4.2%) were the most common symptoms. Of the patients, 45.6% (n:388) had osteoporosis, 24.6% (n:253) had osteopenia, and 30.3% (n:257) kidney stones. Urinary symptoms were present in 133 (16.5%) patients. Genetic analysis was performed on 83 patients. 7.2% of the patients who underwent genetic analysis were men-1. The mean age of the patients was 53.6± 11.9 (18-85) years. The mean preoperative total calcium of the patients was 11.1±1.1 (6.3-18.6) mg/dl. The mean preoperative phosphorus was 2.6±0.7 (0.7-9.0) mg/dl. The mean preoperative 24-hour urinary calcium of the patients was 380.5±198.2 (24-1438) mg/24-hour. The mean preoperative 24-hour urine phosphorus was 797.9±350.4 (30.2-3798) g/24 hour. 257 patients with kidney stones were divided into two groups according to urinary symptoms. 70.2% (n:92) of 131 patients with urinary symptoms and 82.7% (n:91) of 110 patients without urinary symptoms were women. The proportion of women was significantly higher in the group without urinary symptoms (P:0.035). The median age was significantly higher in the group without urinary symptoms compared to urinary symptoms group (54.7 years vs 51.5 years, P:0.039). osteoporosis rate, total calcium value, phosphorus value, parathormone value, 24-hour urinary calcium and 24-hour urine phosphorus value were similar for the two groups.

Conclusion: Patients with symptomatic nephrolithiasis were younger and more male dominated.

Von Hippel-Lindau (VHL) syndrome is a pathological condition that causes various clinical symptoms and is difficult to diagnose. The most common pathological lesions are hemangioblastomas of the central nervous system, retinal angiomas, renal clear cell carcinomas, and pheochromocytomas. Here we report a case of likely to be VHL due to his family history.

Case: A 33-year-old male suffering from hypertension and a history of hemangioblastoma operated in 2019. The patient had an endoscopic examination after developing nausea, vomiting and weight loss. His endoscopic biopsies include grade 2 neuroendocrine tumors (NET). The patient refer to endocrinologist. The father of the patient died at age of 40 due to brain tumor and his brather was operated due to retinal and cerebral hemangioblastoma (in 2013) since that date the familyhad been followed up in the department of neurosurgery with suspicion of VHL. His plasma free metanephrines and urinary metanephrines was high and a computer tomography scan, MIBG and MRI scan of the abdomen showed a solid mass in the lower pole of the lenf kidney at 2.5X2 cm, pancreatic cysts and right adrenal mass at 36X40 laparascopic adrenalectomy and parsiel nefrectomy was performed. The Pathological examination revealed renal cell carcinoma and pheochromocytomas with a low PASS score. The contro plasma free metanephrines and urinary metanephrines were withen normal range.

Conclution: Since pheochromocytomas can have low activity, the classical symptoms may be missing. The absence of symptoms can make it difficult to diagnose pheochromocytoma and Even if we couldn’t perform the genetic examination there is a strong association between pheochromocytoma and VHL syndrome, and pheochromocytoma is an important feature in the clinical classification of VHL syndrome. The family history of retinal or central nervous system hemangioblastoma (Hb) exists, only one Hb or visceral lesion (renal tumours, pancreatic cysts or tumours, pheochromocytoma, papillary cystadenomas of the epididymis) is required to make the diagnosis of VHL and Due to the risk of pheochromocytoma, the radyologıc sxanning and biochemical tests shoud performed.

Introduction: Immune checkpoint inhibitors are relatively new and promising treatments for a variety of solid tumors. Nivolumab is an anti-cancer monoclonal antibody that inhibits anti-programmed death-1 (PD1) and modulates T-cell response. It has been shown to significantly improve survival in many types of cancer, but clinical studies have also reported an increased risk of developing immune-related adverse events. In particular, immune-related adverse events may be related to the endocrine system. It has been reported that approximately 8% of patients treated with PD-1 inhibitors demonstrate hypothyroidism. We present a case of thyroid dysfunction caused by nivolumab.

Case: A 64-year-old male patient was treated with nivolumab for 10 months for tonsillar squamous cell carcinoma. He had no history of thyroid disease. Laboratory studies performed before the administration of nivolumab revealed normal thyroid function with normal levels of anti-thyroid peroxidase and antithyroglobulin antibodies. 9 months after starting treatment, the patient’s thyroid

stimulating hormone (TSH) levels suddenly increased to 57.70 mU/l (normal range 0.55-4.78 mU/l). Free T3 level was 1.65 pg/l (normal range 2.3 - 4.2 pg/l) and free T4 level was 0.24 ng/dl (normal range 0.89-1.76 ng/dl). We suspected nivolumab-induced hypothyroidism in the absence of other possible causes and started thyroid hormone replacement. The patient was followed as euthyroid with L-thyroxine 100 mg/day.

Conclusions: Immunotherapy has demonstrated significant clinical efficacy in many types of cancer. Immune checkpoint inhibitors aim to stimulate the immune system against cancer cells but should not be considered independent of some side effects. Thyroid dysfunction should be considered as a possible immune-related adverse event. Therefore, it is important to evaluate thyroid dysfunction at baseline and before the administration of each dose of nivolumab.

A 87 year old woman admitted with complaints of hoarseness and a palpable mass which she noticed 1 week ago. She had hypothyroidism for 25 years. On examination, there was a hard and fixed palpable 4x4 cm mass on the right side of the neck. In laboratory evaluation, thyroid function tests were normal, thyroid auto-antibodies were positive, calcitonin was normal, C-reactive protein was 224 mg/l and liver and kidney function tests were normal. Thyroid ultrasonography revealed a 27.5x51.1x61.0mm isoechoic nodule containing macrocalcifications and areas of cystic degeneration completely filling the right lobe. Fine needle aspiration biopsy(FNAB) of the nodule was reported as atypia of undetermined significance. In the second FNAB;there were atypical cells with spindle cytoplasm, isolated spindle cells described in fibrin in the cell block with necrosis. The specimen was evaluated as suspicious for  malignancy. Lymphoid malignancies were ruled out with flow cytometric analysis. The patient was hospitalized with a prediagnosis of anaplastic thyroid cancer. Neck MRI detected a 9.0x6.5x6.5 cm centrally necrotized mass surrounding right common carotid artery. In 18-FDG-PET-CT scanning, uptake of the lesion was significantly increased and there were multiple metastatic nodules in the lung. A tru-cut biopsy was performed. ‘In cytopathologic evaluation, neoplastic infiltration consisting of fascicular shapes was observed within a fibrous stroma. Spindle cells arranged in ‘herringbone pattern was observed. A large number of mitotic figures drew attention. In the immunohistochemical study, no staining was detected with TTF-1, CD34, PAX-8, CK-7, p63, SMA, desmin, FL-1, S100, synaptophysin and calcitonin. Staining with vimentin was detected. The Ki-67 proliferation index was 90%. BRAF mutation was negative.’ A primary malignant fibrosarcoma of thyroid gland was considered. Because of the advanced age and poor general performance of the patient; chemotherapy and surgery were not considered. 10 sessions of radiotherapy was started. Malignant mesenchymal tumors of thyroid gland comprise 0.3% of all malignant thyroid tumours(1). Fibrosarcomas consist 9.2% of primary malignant mesenchymal tumors of thyroid(2). Although the initial diagnosis that comes to mind in a hard, fixed and rapidly-growing thyroid cancer is anaplastic cancer, malignant mesenchymal tumors like fibrosarcoma should also be considered in differential diagnosis.

References

1.         Bula G, Waler J, Niemiec A, Trompeta J, Steplewska K, Gawrychowski J. Unusual malignant thyroid tumours�"a clinical study of 20 cases. Acta Chirurgica Belgica 2008; 108: 702-07.

2.         Surov A, Gottschling S, Wienke A, Meyer HJ, Spielmann RP, Dralle H. Primary thyroid sarcoma: a systematic review. Anticancer research. 2015;35(10):5185-91

Aim: To determine whether early repeat fine needle aspiration biopsy(FNAB) has an effect on adequate or atypia of undetermined significance/follicular lesion of undetermined significance(AUS/FLUS) cytology rates in thyroid nodules with inadequate or AUS/FLUS in the first FNAB.

Method: Nodules of patients who underwent repeat biopsy due to insufficient or AUS/FLUS cytology between 2019-2022 were included. Demographic data of the patients and ultrasonographic, cytological and histopathological results of the nodules were recorded. Additionally, the time between the two biopsies was noted. In nodules with two FNAB results, the first was called initial, and the second was called rebiopsy. In nodules with more than two FNAB results, the time between each consecutive results was evaluated separately, and for these nodules, again first result was called initial and the second was called rebiopsy for each biopsy period of the nodule. Seven different paired groups were formed according to the time between two consecutive biopsies;before and after 1 month,45 days,2 months,3 months,6 months,9 months,12 months. The groups were compared in terms of adequate or AUS/FLUS cytological results.

Results: 972 nodules of 546 patients who underwent FNAB at least twice were included. The mean age of the patients was 51±12, and the female sex ratio was 79.1% (n=432). FNAB was performed 2 times for 573,3 times for 310, 4 times for 73, 5 times for 13 and 6 times for 3 of the nodules. A total of 2984 cytology results were evaluated. Accordingly,1026 (68.8%) of the initial biopsies were inadequate and 466 (31.2%) were AUS/FLUS. Rebiopsy results are shown in the table. There were no differences in adequate or AUS/FLUS rebiopsy results according to the different time interval groups(P>0.05 for all). When 1026 samples with inadequate initial FNAB were considered as a separate group, to perform rebiopsy before or after any time interval had no effect on adequate or AUS/FLUS results. Similar results were obtained when a subgroup was created for samples with initial AUS/FLUS cytology(P>0.05 for all). Also, there was no cut-off time for an adequate or AUS/FLUS rebiopsy result.

Conclusions: In patients with inadequate or AUS/FLUS initial biopsy, the rate of adequate or AUS/FLUS cytology results at rebiopsy did not vary with the timing of repeat biopsy. As recommended in the ATA guideline, there is no need to wait 3 months for a repeat biopsy. In patients with suspicious nodules in terms of malignancy, biopsy might be repeated before 1 month.

Table 1 Comparison of the parameters after patients with polycystic ovary syndrome excluded

Aim: To determine whether there is any factor that can predict sufficient results in second thyroid fine-needle aspiration biopsy (FNAB) after first nondiagnostic cytological result.

Materials and method: Nodules with non-diagnostic result after first FNAB were included and separated into two groups as sufficient (Group-1) and insufficient (Group-2) second FNAB.

Results: Second FNAB was performed on 643 nodules of 443 patients with initial nondiagnostic cytology. The result was diagnostic in 437(68.0%) nodules (Group1) while it was again nondiagnostic in 206 (32.0%) (Group-2). Thyroid autoantibody positivity were similar in groups. Cystic/mixed structure and heterogeneous echogenity were more frequent in Group-2 (P=0.020 and P=0.011, respectively). Solid structure and isoechoic appearence were more frequent in Group-1 (P=0.003 and P=0.020, respectively). Border regularity, micro/macrocalcification, taller-than-wide shape, presence of halo were comparable in two groups (P>0.05). There were also no significant differences in terms of nodule dimensions, volume and rate of subcentimeter nodule between two groups(P>0.05). In multivariate analysis, likelihood of sufficient cytology was 1.943 times higher in isoechoic nodules in comparison to heterogeneous nodules (95 CI:1.253-2.977, P=0.003), whereas the effect of nodule structure on sufficient result became insignificant (P=0.432). Sufficient results group were cytologically distributed as 299 (68.4%) benign, 131 (30.0%) AUS/FLUS, 2 (0.5%) FN/SFN, 1 (0.2%) SFM and 4 (0.9%) malignant. 35 patients in Group-1 and 20 patients in Group-2 underwent thyroidectomy. Malignant histopathology was observed in 12/60(20%) nodules in Group-1 and in 3/37(8.1%) nodules in Group-2 (P=0.116)(Table).

Conclusions: Heterogeneous echogenity and cystic/mixt structure were more frequent in insufficient group, but after multivariate analysis, only isoechoic texture was determined to predict sufficient cytological result in rebiopsy. Second biopsy should be done to all nondiagnostic nodules because of comparable malignant histopathology results.

 IQR:interquartile range

Introduction: Insulinoma is a rare neuroendocrine tumor that is difficult to diagnose due to its obscure location. Conventional radiographic methods have low sensitivity and are inadequate to detect insulinoma. Selective arterial calcium stimulation test (SACST) is 95-100% sensitive in the diagnosis of insulinomas. Here, we presented two cases of insulinoma that could not be located by radiographic methods and evaluated them with SACST.

Case 1: A 48-year- old woman who had dizziness was referred to our endocrine clinic with a suspicion of insulinoma. A 72-hour fasting test was performed to establish a diagnosis of endogenous hyperinsulinemia. After 19 h hypoglycemic symptoms emerged and fasting serum glucose (FSG) was 27 mg/dl, insulin 6,5 mU/l, and C-peptide 2 mg/l. MRI of the abdomen, Galium-68 Dotatate scintigraphy, and endoscopic ultrasonography (EUS) failed to detect the tumor. SACST was performed to localize the tumor. Calcium injection of the gastroduodenal artery caused a more than 11-fold increase in hepatic insulin above baseline indicating a lesion in the head region of the pancreas. Intraoperative ultrasonography of the pancreas revealed a 1 cm nodular lesion in the head. Proximal pancreatectomy was performed. Histopathological findings were consistent with well-differentiated neuroendocrine tumor showing positive staining with synaptophysin and chromogranin. After surgery, the patient was free of all previous symptoms.

Case 2: A 67-year- old woman was admitted to the clinic due to dizziness and diaphoresis. She applied to the emergency department once with a loss of consciousness. There was a weight gain of 4-5 kg during this period. After 12 h of the 72-hour fasting test, hypoglycemic symptoms emerged, and FSG was 36 mg/dl, insulin 6,9 mU/l, and C-peptide 1,7 mg/l. MRI of the abdomen, Galium-68 Dotatate scintigraphy, and EUS failed to demonstrate the tumor. SACST was performed and calcium injection of the splenic artery caused a more than 9-fold increase in hepatic insulin above baseline which was suggestive of an insulinoma lesion in the tail of the pancreas. Intraoperative ultrasonography of the pancreas revealed a 1 cm nodular lesion in the tail. Distal pancreatectomy was performed. No hypoglycemia has occurred since the surgery.

Conclusions: The localization of insulinoma is critical for curative surgery and might be problematic. Because of the low sensitivity of non-invasive imaging procedures in tumors smaller than 2 cm, invasive methods can be used for the localization like in our cases.

Background: Hypoparathyroidism (HypoPT) is a rare condition that is characterized by hypocalcemia and hyperphosphatemia due to low or inappropriately normal serum levels of parathyroid hormone (PTH) for at least 6 months. The long-term complications of hypoparathyroidism indicate the necessity of screening them. In the follow-up of these patients according to hypoparathyroidism guidelines is recommended; calcium, phosphorus, albumin, magnesium, creatinine, and eGFR levels should be checked annually or more frequently than clinical status. A 24-hour urine calcium excretion is recommended once a year. Renal imaging is recommended in patients with elevated creatinine or high urinary calcium excretion, or patients suggesting renal stones. For basal ganglia calcification, brain MRI or CT is advised. A yearly eye examination is recommended for cataracts. In our study, in the long-term follow-up of hypoparathyroidism patients, it was examined whether the guidelines were followed.

Methods: Between February 2019 and September 2021, patients aged ≥18 years with hypoparathyroidism who were followed by the routine scheduled monitoring visit at the outpatient clinic of the endocrine and had their data retrospectively documented. Comorbidities, imaging, and hormonal tests and results of these patients were evaluated.

Results: Among the 264 patients, the mean age was 49.34±12.98 (22-91). 211 (79.9%) of the participants were female. All patients’ had blood biochemistry tests. Of the patients, 3% had eye examinations, 9.8% had brain imaging, 18.6% had renal imaging, 11 % had 24 h urinary Ca results. Cataract was observed in 2 (0.8%), basal ganglia calcification was observed in 4 patients (1.5%). Nephrocalcinosis or nephrolithiasis was observed in 2 patients (0.8%). Hypercalciuria was defined as a 24 h urine calcium excretion >300 mg/24 h and was observed in 8 of participants with hypoparathyroidism. (Table 1)

Table 1 Hypoparathyroidism complications screening

Introduction: While Graves’ disease is a common cause of thyrotoxicosis, tyroid hormone resistance (THR) is a rare cause of high thyroid hormones. Coexistence of Graves’ disease and THR which can cause quite a lot of difficulties in diagnosis and treatment was reported very rarely in the literature. Here, we report a patient with THR and Graves’ disease in whom remission was achieved with medical therapy.

Case: A 38-year-old woman applied to our clinic with sweating and palpitation. Familial history revealed THR in her sister. Her body temperature was 37.2°C, heart rate was 120 beats/minute, respiratory rate was 18 breaths/minute and blood pressure was 120/70 mmHg. In laboratory examinations, thyroid stimulating hormone (TSH) was 0.018 mU/l (0.55-4.78 mU/l), free T4 was 2.64 ng/dl (0.89- 1.7 ng/dl), free T3 was 9.05 ng/l (2.3-4.2 ng/l), anti-thyroglobulin and anti-thyroid peroxidase were negative, TSH receptor antibody (TRAB) was positive. Thyroid ultrasonography revealed chronic thyroiditis and technetium 99m scintigraphy showed heterogeneous activity. When laboratory results were examined retrospectively, we saw that in previous 3 years, her TSH, free T4 and free T3 ranged between 0.84-1.75 mU/l, 1.87-2.12 ng/dl and 4.77-5.86 ng/l, respectively. Thus, the patient had the lowest TSH value and highest free thyroid hormones in her life when she applied. With the current laboratory results and imaging findings, Graves’ disease was diagnosed. Methimazole and propranolol treatment was started. Methimazole was switched to propylthiouracil due to the development of skin rash. Owing to family history and her previous thyroid hormone profile, THRB gene mutation analysis was requested from the patient. Heterozygous c.1001T>C mutation was detected. Under treatment, her symptoms resolved, TSH returned to normal, free T3 and T4 were followed as close to the upper limit or slightly elevated. The patient’s propylthiouracil medication therapy was discontinued after 18 months. At the time of discontinuation her TSH was 0.96 mU/l, free T3 was 6.05 ng/l, free T4 was 1.98 ng/dl, TRAB was negative. At the last visit, 2 years had passed since drug discontinuation and her serum TSH was 0.51 mU/l, free T3 was 4.86 ng/l and free T4 was 1,50 ng/dl.

Discussion: Treatment with anti-thyroid drugs remains the primary choice for Graves’ hyperthyroidism complicated by THR. The optimal treatment is to normalize TSH while keeping free thyroid hormones slightly higher than the upper limit. Iodine therapy and surgery are not generally recommended, since they may induce severe hypothyroidism

Aim: It is hypotethically thought that increased frequency of breast cancer in patients with primary hyperparathyroidism (PHPT)may be due to the fact that calcium accumulation in the breast may be higher in patients with PHPT giving rise to more breast-related examinations. Although there are many studies or case reports showing calcification in many organs and tissues, in PHPT, there is not any study investigating breast calcification in these patients in the literature. We aimed to determine the frequency and features of breast calcification and distribution of BIRADS scores in patients with PHPT.

Method: Female patients ≥40 years old with PHPT and and age-matched healthy women were included. Demographical, antropometric and laboratory findings were noted. Mammography was performed in all patients and controls. Calcification types and BIRADS scores were recorded. Clustered microcalcification, ductal calcification, linear thin or segmental calcification were considered suspicious calcification. Skin calcification, scattered, punctate, vascular calcification and macrocalcification were termed as benign calcification. Two groups were compared in terms of demographical, laboratory findings, presence of calcification, calcification types and BI-RADS in mammography. Patients were divided in two groups according to the duration of PHPT as less or more than 48 months.

Results: Sixty-one patients and 75 control were enrolled. While age distribution was similar(57.0±7.9 vs 55±7.5, P=0.153), body mass index was higher in patient group (32.4±6.7 vs 29.2±6.2 kg/m² , P=0.005). Median duration of PHPT was 46 (1-85) months. BI-RADS score was comparable and the most frequent score was BIRADS-0. Presence of breast calcification and calcification types were not different in two groups. Demographical, laboratory and mammographic findings are summarized in table. Presence of calcification was similar in PHPT patients with disease duration of less and more than 48 months. There was not any cut-off for disease duration that can predict presence of calcification. Of the 3 patients (all was with PHPT) who underwent excisional breast biopsy, one resulted in invasive breast ca, one as atypical ductal hyperplasia, and the other as benign.

Conclusion: Female patients with PHPT did not have an increased incidence of breast calcification compared to healthy women, suggesting that calcification is not responsible for the increased incidence of breast cancer in these patients. Distribution of BI-RADS scores was also not affected by the presence of PHPT.

Background: Adrenal incidentalomas (AI) are lesions discovered incidentally on imaging without clinical symptoms or examination findings. AI can produce hormones in 5-30% of cases. Autonomic cortisol secretion (ACS) is the most common of these. Although ACS is asymptomatic, it increases the risk of metabolic disorders.

Methods: Patients aged ≥18 years with adrenal adenoma and upper abdominal MRI who presented and were examined in the endocrinology outpatient clinic, had their data retrospectively documented. Comorbidities, examinations and hormonal tests and results of these patients were evaluated. Those who failed dexamethasone suppression tests (cortisol >1.8 g/dl) and did not have Cushing’s syndrome were classified as ACS.

Results: Among the 465 patients, 311 (66.9%) were women with a mean age of 54.8±10.2 (18-82). Of the patients, 31.4% had diabetes mellitus (DM), 53.8% had hypertension (HT), 30.8% had hyperlipidemia (HL), 11.8% had coronary artery disease (CAD), 1.3% had heart failure (HF) and. Hormone testing revealed that 31 (6.6%) of the patients had primary aldosteronism, 7 (1.5%) had pheochromocytoma, and 75 (16.1%) had ACS. Patients with and without ACS were compared for the presence of other additional diseases and adenoma size (Table-1). DM, HT and HL were higher in the ACS group (P<0.05, for each). Adenoma size was larger in the ACS group (P<0.05). Although the gender distribution was similar in both groups (P>0.05), the OCS patient was older (P=0.006).

Conclusion: Individuals with large adenomas are more likely to have ACS. Large adrenal adenomas should be monitored for ACS and associated cardiometabolic risks, as well as necessary treatments.

Table 1. Comparison of patient characteristics with and without autonomic cortisol secretion

T2DM type 2 diabetes mellitus, HT hypertension, HL hyperlipidemia, CAD coronary artery disease, HF heart failure

Background: Persistent Müllerian duct syndrome(PMDS) is a rare sexual development disorder characterized by a normal male phenotype.Müllerian structures cannot regress due to the absence of anti-müllerian hormone(AMH) or resistance to AMH receptor. In addition to male internal genitalia, female reproductive organs, including the uterus, uterine tubes, and upper 1/3 of the vagina are also detected. We will present a patient with PMDS who presented with bilateral cryptorchidism.

Case: A 31-year-old single man was referred to our clinic because of bilateral undescended testes and a rudimentary uterus detected during the evaluation of the lower abdominal pain.

On physical examination, his body mass index(BMI) was 21.2. His arm span was 170 cm, and his upper-lower segment ratio was 0.96. Beard, axilla, and pubic hair development were normal; however, testes were not in the scrotum bilaterally.His karyotype analysis was 46XY.

His prenatal, natal, and postnatal histories were not remarkable. His parents were not consanguineous; the younger brother had a history of undescended testis operation at age one.

In laboratory examination, blood glucose, renal and liver functions were normal. Androstenedione, DHEAS, total and free testosterone, FSH, LH, total-hCG, AFP were normal. AMH>9µg/L. In the spermiogram, no sperm was observed.

A rudimentary uterus and proximal vagina were observed in the abdominal computed tomography (CT). Symmetric solid masses measuring 55x40 mm compatible with bilateral undescended testis were detected in the ovarian lodges. The mass extended to the inguinal canal on the left and the scrotum on the right. In association with these masses, there were also tubular structures with the biggest diameter of 16 mm on the right and 13 mm on the left. Prostate sizes were normal. Seminal vesicles were not observed.

PMDS was considered owing to 46 XY karyotypes, normal testosterone level, normal sexual development, external genitalia findings, accompanying Mullerian structures, and a high level of AMH. AMH gene mutation was not detected. However, AMH receptor type 2(AMHR2) gene mutation could not be studied. Bilateral undescended testicles, uterus, uterine tubes, and the tubular structures in the abdomen were excised. Classical type seminoma with lymphovascular invasion was detected in the right-side tubular structure. Tumor-negative testicular tissue was frozen for possible fertility in the future.

The patient received one cycle of Carboplatin. No metastasis was detected in the post-operative PET-CT scan. In post-operative evaluation, FSH, LH levels were high, total and free testosterone levels were low. AMH < 0.01 µg/L.The patient was started on testosterone replacement therapy.

Conclusion: PMDS is a rare cause of male pseudohermaphroditism. Malignant degeneration and infertility are two critical points in terms of treatment. Early diagnosis with increased awareness is essential in preserving fertility and preventing malignant degeneration.

Introduction:

The prevalence of diabetes mellitus (DM) continues to increase worldwide. Diabetic retinopathy (DRP) is one of the most common complications of Type 2 DM. Recently, the effect of thyroid hormones on diabetic microvascular complications has gained much attention. This relationship is explained by the important effects of thyroid hormones on endothelial function. There are studies

investigating the relationship between TSH and diabetic nephropathy and DRP. There are very few studies evaluating free thyroid hormone levels. In this study, it was aimed to investigate the relationship between free thyroid hormone levels and DRP in euthyroid patients with type 2 DM.

Method:

In this study, the biochemical records of patients with Type 2 DM who had euthyroid status and evaluated for retinopathy, applied to the endocrinology and ophtalmology clinics of our hospital between January 2018 and August 2018. Demographic data of the patients and characteristics that may be associated with diabetic retinopathy were evaluated. Whether the patients had DRP and, if any, retinopathy levels were recorded. It was evaluated whether there was a difference in free thyroid hormone levels between the groups with and without DRP.

Results:

A total of 171 patients, 106 men and 65 women, were included in the study.Mean age was 57.19 ±10.81 years. DRP was not present in 127 patients (74.2%), nevertheless 36 patients (21%) had nonproliferative DRP and 8 patients (4.6%) had proliferative DRP. There was no difference between the groups in terms of age, gender, hypertension, cardiovascular disease, fasting plasma glucose, serum creatinine, lipid levels and microalbuminuria. The duration of diabetes was longer

in the nonproliferative DRP group (P=0.026). HbA1c levels were higher in the proliferative DRP group (P=0.05). No significant difference was found in terms of TSH levels and free thyroid hormone levels in all three groups.

Conclusion:

In our study, the relationship between free thyroid hormone levels and DRP in euthyroid type 2 DM patients was investigated. Diabetes duration and Hba1c levels were found to be risk factors in DRP similar to the literature. When the groups with and without DRP were compared, no difference was found in TSH and free T4 and free T3 levels.

A 36 years of old patient was admitted to the intensive care unit of cardiology when he experienced palpitations and orthopnea. The patient’s complaints started about 2 years ago as syncope and sudden shortness of breath. Thorax CT showed pleural effusion and increased cardiothoracic index. Findings on ECHO were : Ejection fraction 35%, severe mitral regurgitation and global hypokinesia. Coronary angiogram showed a fibrocalcific plaque noted in in the distal LAD. The patient was started on Furossemide, spironolactone, isosorbide mononitrate. Despite the treatment, the patient’s complaints gradually increased and over the course of the next 24 months, the patient was repeatedly hospitalised due to heart failure, and his medication was adjusted several times. Two years later, the patient was admitted to our center with the diagnosis of acute heart failure. A decrease in ejection fraction was detected in the new echocardiography (%10), and no further clinical improvement was seen, the decision was then taken to initiate treatment with levosimendan and noroadrenaline. Dilated cardiomyopathy was observed with cardiac MRI. He was consulted to the endocrine department because of suspected acromegaly. When he was evaluated, he complained of shortness of breath, arthralgia and increasing shoe size. Physical examination was positive for acral growth, nose widening, and prognathism. GH and IGF-1 levels were increased at diagnosis (table 1), the baseline and peak GH concentrations were 8.74 and 34.4 ng/ml during 75-g OGTT, showing paradoxical increases in GH (table 2). Pituitary MRI showed a non-invasive, intrasellar, macroadenoma (fig1). The diagnosis made was: Acromegaly due to growth hormone secreting pituitary macroadenoma leading to dilated cardiomyopathy. His family history was negative, but due to his young age and aggressive clinical course, the patient was screened for AIP gene mutation; a germline AIP mutation was not identified. TSS was scheduled, and primary medical treatment with sandostatin lar 20 to improve the patient’s condition. However, the patient developed cardiogenic shock and unfortunately before surgery and before assessment of response to therapy.

Table 1

Table 2

Introduction:

The risk of malignancy in thyroid nodules is reported by the Bethesda system by performing fine needle aspiration biopsy (FNAB). Atypia of undetermined significance (AUS) or follicular lesion of undetermined significance (FLUS) (Bethesda 3) and suspicious for a follicular neoplasm (Bethesda 4) create uncertainty about treatment and follow-up. Molecular tests, ultrasonographic features of the nodules, and calcitonin level help us for this uncertainty. Here, we will present a patient whose FNAB cytology was Bethesda 3 and Bethesda 4.

Case:

A 53-year-old female patient was admitted to our outpatient clinic after detecting a thyroid in neck ultrasound. She had familial Mediterranean fever, osteoporosis, and renal transplantation (5 years ago). In addition, the patient stated that she had been operated on the parathyroid gland while she was receiving dialysis treatment. There was no document related to parathyroid surgery. In laboratory tests, thyroid function tests, calcitonin, calcium levels were normal. 25-OH vitamin D, parathormone level, creatinine, eGFR were 14 ng/ml, 152 pg/ml, 1.51 mg/dl, 39 ml/minute respectively. Secondary hyperparathyroidism due to vitamin D deficiency was considered. On thyroid ultrasound, a hypoechoic nodule that containing cystic degeneration areas was observed adjacent to inferior carotid artery in the right lobe. The dimensions of nodule were 9.7x11.4x13.7 mm. FNAB was reported as Bethesda 3. The second FNAB cytology was also reported as Bethesda 4.Molecular testing could not be performed in our hospital. The microscopy of FNAB revealed “some of the cells were small, round, monotonous nuclei with pale cyanophilic cytoplasm with unclear borders”.No uptake suggestive of parathyroid lesion was observed in parathyroid scintigraphy. Third FNAB cytology was nondiagnostic; Parathormone washout was 525 pg/ml. Due to the high suspicion of parathyroid lesion, fourth FNAB and diluted PTH washout were performed. Fourth FNAB cytology was Bethesda 3, diluted parathormone level was 103871 pg/ml. The lesion was evaluated as intrathyroidal lesion (adenoma or parathyroid seeding due to surgery). Follow-up was planned for the patient.

Conclusion:

In parathyroid lesions evaluated as thyroid nodules, FNAB cytology and microscopy give us an idea in terms of intrathyroidal parathyroid lesion. Parathyroid scintigraphy also does not always show uptake. In this situation, PTH washout can be done. If the ultrason features, FNAB microscopy and PTH washout are inconsistent, diluted PTH washout may provide accurate results due to possible hook effect. In addition, intrathyroidal parathyroid seeding should also be kept in mind in patients who have undergone parathyroid surgery for tertiary hyperparathyroidism.

Introduction:

Goiter means that the thyroid gland is larger than the normal size for the patient’s age and gender. Some of the causes of goiter are iodine deficiency, thyroid nodules, Graves’ disease (GD). Goiter, hyperthyroidism, ophthalmopathy and dermopathy can be seen in GD. Compression symptoms due to goiter (dyspnea, dysphagia, superior vena cava syndrome) are also seen. Here, we will present a case of GD with superior vena cava syndrome.

Case:

A 50-year-old male patient, who had been using methimazole for 6 years due to hyperthyroidism, applied to our outpatient clinic with swelling in the neck. The patient was taking methimazole 10 mg/day. On physical examination, he had goiter, bilateral venous collaterals in the neck, and inactive Graves’ ophthalmopathy. Pemberton’s sign was positive. In laboratory tests, TSH, fT4, fT3, antiTPO, antiTG, TSH receptor antibody were: <0.008 mU/l, 1.01 ng/dl, 10.6 ng/l,>13000 U/l (<60 negative), 724 IU/ml (<1.3 negative), 34.3 U/l (≤1 negative), respectively. In the thyroid ultrasound, the dimensions of the right lobe were 33.9x33.4x73.4 mm, the dimensions of the left lobe were 35.3x50x78.5 mm, the dimension of the isthmus was 20 mm, no thyroid nodule was observed. The thyroid gland showed retrosternal extension. Thyroid scintigraphy was consistent with GD. Computed tomography of the neck and thorax was performed to evaluate the differential diagnosis and cervical region: The dimensions of both thyroid lobes have increased considerably, extending to the paraesophageal, paratracheal, and intrathoracic retrosternal areas, and significant extrinsic compression of the larynx and esophagus was observed. In addition, bilateral subclavian veins were pressed by the thyroid gland, and diffuse dilated venous structures were observed in the skin-subcutaneous part of the anterior of the thyroid. Varicose dilated veins were observed in the anterior mediastinum. (Secondary to subclavian vein compression?). No pathological finding was detected in the lung parenchyma. Bilateral total thyroidectomy was performed. Its pathology was reported as diffuse toxic hyperplasic thyroid gland. Venous collaterals in the neck of the patient disappeared in the postoperative period. Clinical improvement was observed.

Conclusion:

The most common cause of hyperthyroidism is GD. Compression symptoms due to diffuse hyperplasia of the thyroid gland may be seen. In particular, the retrosternal extending goiter may cause superior vena cava syndrome by compressing the vascular structures. The most common cause of superior vena cava syndrome is malignancy. GD should also be considered in the differential diagnosis of superior vena cava syndrome. Improvement in this situation is expected with thyroidectomy.

Backgorund:

Adrenal incidentalomas (AI) are lesions discovered incidentally on imaging without clinical symptoms or examination findings. AI can produce hormones in 5-30% of cases. Autonomic cortisol secretion (ACS) is the most common of these. Although ACS is asymptomatic, it increases the risk of metabolic disorders.

Methods:

Patients aged <18 years with adrenal adenoma and upper abdominal MRI who presented and were examined in the endocrinology outpatient clinic, had their data retrospectively documented. Comorbidities, examinations and hormonal tests and results of these patients were evaluated. Those who failed dexamethasone suppression tests (cortisol>1.8 g/dl) and did not have Cushing’s syndrome were classified as ACS.

Results:

Among the 223 patients, 138 (61.9%) were women with a median age of 56 (18-80). Of the patients, 26.9% had diabetes mellitus (DM), 54.3% had hypertension (HT), 17.9% had hyperlipidemia (HL), 12.1% had coronary artery disease (CAD), 1.3% had heart failure (HF). Hormone testing revealed that 6 (2.6%) of the patients had primary aldosteronism, 5 (2.2%) had pheochromocytoma, and 35 (15.6%) had ACS. Patients with and without ACS were compared for the presence of other additional diseases and adenoma size (Table-1). DM, HT and HL were higher in the ACS group (P<0.05, for each). Adenoma size was larger in the ACS group (P<0.05). Both groups had comparable age and sex distribution (P>0.05).

Conclusion:

Individuals with large adenomas are more likely to have ACS. Large adrenal adenomas should be monitored for ACS and associated cardiometabolic risks, as well as necessary treatments.

Table 1. Comparison of patient characteristics with and without autonomic cortisol secretion

T2DM type 2 diabetes mellitus, HT hypertension, HL hyperlipidemia, CAD coronary artery disease, HF heart failure

Background:

Medullary thyroid cancers (MTC) originate from parafollicular C cells and constitute 3-5% of all thyroid cancers. Calcitonin (CT) measurement is useful in the diagnosis of MTC. The sensitivity and specificity of CT are low in the measurement alone, and the sensitivity and specificity increase when used with pentagastrin and calcium stimulation tests. However, the difficulty of accessing pentagastrin, the uncertainty of the cut-off value in calcium stimulation tests, the differences in calcitonin assay and the costs complicate the use of serum CT and stimulation tests in the diagnosis. For this reason, guidelines do not offer opposing or supportive recommendations about the routine measurement of CT in patients with thyroid nodules. In this study, we aimed to investigate the contribution of CT washout of the nodule (WO) to routine CT measurement for MTC diagnosis.

Methods:

In our clinic for the last three years, calcitonin values have been routinely measured in patients with nodular thyroid disease. CT-WO is performed for the nodules of patients whose calcitonin values are still above the laboratory cutoff levels in repeated measurements after excluding confounding factors. CT-WO was implemented after the thyroid fine-needle aspiration biopsy specimen was spread on a slide. The remaining material was washed with 1 mL of saline, and then the CT level was measured. In this study, the results of 33 patients who were operated on will be presented.

Results:

Papillary thyroid cancer (PTC) was found in 12 (36.4%), MTC in 14 (42.4%) and benign pathology in 7 (21.2%) of the patients. CT washout was performed on 69 nodules of these patients before surgery. According to the pathology reports, eleven of these nodules were PTC, 13 were MTC, and 45 were benign. PTC and MTC were detected incidentally in two separate patients. In patients with MTC, serum CT and CT-WO values were significantly higher than the other two pathology groups (P=0.001). ROC analysis was performed for serum CT value, and the level 29.9 determined MTC with 100% sensitivity and 90% specificity (AUC=0.975 (0.932-1), P<0.001). Also, ROC analysis was performed for the CT-WO values of the nodules, and level 413.5 determined MTC with 100%

sensitivity and 86% specificity (AUC=0.987 (0.965-1), P<0.001). The median MTC diameter in the thyroidectomy specimens was 1 cm (0.6-5.5). Micro MTC was detected in 8 (61.5%) of the patients.

Conclusion:

CT-WO appears to be useful in diagnosing MTC early and accurately.

Aim:

Postoperative hypocalcemia is seen in 26-42% patients after parathyroidectomy. There are quite a lot of studies investigating preoperative factors that might be used to predict postoperative hypocalcemia in thyroidectomized patients, however there are less studies in parathyroidectomized patients.In this study, our aim was to determine whether any preoperative clinical, laboratory or ultrasonographical feature anticipate hypocalcemia in parathyroidectomized patients due to primary hyperparathyroidism (PHPT).

Material and Methods:

All patients operated for PHPT between 2019-2022 were retrospectively evaluated.Patients undergoing minimally invasive parathyroidectomy were enrolled.Demographic, clinical, ultrasonography and histopathology results were noted and compared in patients with and without hypocalcemia (Group-1 and Group-2,respectively) within two days after surgery.

Results:

Of 179 parathyroidectomized patients, 93 were operated with minimally invasive procedure. Postoperative hypocalcemia was observed in 21 (22.6%) patients. Group-1 was younger compared to Group-2 (P=0.036).Gender distribution and presence of osteoporosis were comparable.Nephrolithiasis was less prevalant in Group 1 (P=0.046).Preoperative levels of corrected calcium, phosphorus, magnesium, parathyroid hormone, alkaline phosphatase, 25 OH vitamin D were similar in two groups. Fractional excretion of calcium (FECa) was lower in group-1 (P=0.048).The optimal cut-off level of FECa that was predictive for postoperative hypoprathyroidism was 0.0216 with a sensitivity of 61.9% and specificity of 54.9% (AUC 0.643±0.062, P=0.048).Ultrasonographic and histopathologic diameters and volumes of parathyroid lesions were not different in both groups (p>0.05 for all).Histopathological diagnosis was parathyroid adenoma in 76 (64.5%) patients, parathyroid hyperplasia in 9 (9.7%) patients, and cell-rich parathyroid gland in 8 (8.6%) patients.The distribution of the histopathological results were similar in two groups(P=0.750).

Conclusions:

Younger patients, patients with lower FECa and without nephrolithiasis undergoing minimally invasive parathyroidectomy for PHPT might require closer follow-up for the development of postoperative hypocalcemia. FECa lower than 0.0216 might help to predict occurrence of postoperative hypocalcemia.

Aim:

To determine whether multiple fine needle passes to the same thyroid nodule in the fine needle aspiration biopsy (FNA) session affect sufficient and/or atypia of undetermined significance/follicular lesion of undetermined significance (AUS/-FLUS) cytological result.

Materials and Methods:

Ultrasonography (US) and cyto-histopathology results of the nodules of patients who were diagnosed with thyroid nodules and underwent FNA between May-August 2021 were retrospectively analyzed. The nodules were divided into two groups according to the number of needle passes performed in the same FNA session as those with one pass (one-pass group) and those with two or three passes (multiple-passes group). The two groups were compared in terms of cytological adequacy and the rate of AUS/FLUS diagnosis as well as US features and TIRADS scores.

Results:

A total of 1500 thyroid nodules of 708 patients (575 female and 133 male) were included in the study. The mean age of the patients was 51.57±12.51 years. 1409 (93.9%) nodules were performed one pass, and 91 (6.1%) were performed two (n=85) or three passes (n=6). While the cystic/mixed nodule ratio and macrocalcification rate were higher in the multiple-passes group, the rates of coalescent nodules and presence of halo were higher in the one-pass group (P=0.001, P=0.039, P=0.006, and P=0.040, respectively). TIRADS 3 score was higher in multiple-passes group (P=0.001). The adequacy and AUS/FLUS ratios were similar in the two groups.When nodules with macrocalcifications and cystic/mixed structures were evaluated as two separate subgroups, the adequacy and AUS/FLUS ratios were similar in one-pass and multiple-passes groups.

Conclusion:

Two or three passes to thyroid nodules have similar cytological adequacy and AUS/FLUS ratios compared to one pass.Although more passes are performed in cystic/mixed and macrocalcified nodules estimating that the material would be insufficient with macroscopic on-site evaluation, needle insertion of two or three times does not contribute to the adequacy and also the AUS/FLUS ratio compared to one pass.

Objectives:

The novel coronavirus disease-2019 (COVID-19) is the fastest-spreading disease worldwide, with over 380 million cases and 5 million deaths. The presence of diabetes mellitus (DM) in patients with COVID-19 was associated with mortality, acute respiratory distress syndrome, disease progression. COVID-19 was progressed with some hematological disorders, especially lymphopenia. Studies implicated that neutrophil-to-lymphocyte ratio (NLR) level can be a reliable marker in showing the severity of COVID-19 disease. A routine hematology analyzer measures the percentage of large unstained cells (%LUCs), reflecting activated lymphocytes and peroxidase-negative cells. In previous studies, the%LUCs was found to be associated with disease progression in patients with HIV. This study aims to investigate whether the%LUCs and NLR parameters are associated with disease progression in diabetic patients with COVID-19.

Materials and Methods:

The data of the patients hospitalized in the Infectious Diseases Service and Intensive Care Unit with a COVID-19 in Ankara City Hospital between 15.03.2020 and 15.07.2020were collected in our retrospective study. This study included 656 patients with COVID-19, 131 withDM, and 525 with theDM-free control group.White blood cell (WBC) count, neutrophils, neutrophil percentage, lymphocytes, lymphocyte percentage, LUCs,%LUCs, NLR, platelets, hemoglobin which was taken within the first 24 hours after admission, and history of DM were noted from the records.

Results:

The mean age was 61.29±13.81 years in the diabetic patient group and 44.37± 17.14 years in the non-diabetic control group with COVID-19, which was significantly higher in the diabetic group (P<0.001). NLR,WBC count, neutrophils, and neutrophil percentage were statistically significantly higher in patients with DM (respectively, P<0.001, P=0.008, P=0.008, P=0.003, and P=0.049). There were no significant differences between the groups regarding lymphocyte, platelet, LUCs, and%LUCs values (P>0.05).

Conclusion

There are studies in the literature that a decrease in%LUCs value and an increase in NLR are indicators of severe disease in COVID-19. Our study did not detect a difference in%LUCs value in diabetic patients, but our study is a preliminary study. Analysis of the data with clinics continues with more patients.

OBJECTIVE: Catecholamine-secreting tumors originating from chromaffin cells of the adrenal medulla are called pheochromocytomas. Although pheochromocytomas may occur at any age, they are most common in the fourth to fifth decade.The symptoms of pheochromocytomas are caused by tumoral hypersecretion of catecholamines, 85 percent of catecholamine-secreting tumors are m the adrenal. Adrenal medullary hyperplasia (AMH) is defined as nodular or diffuse lesion of <1 cm in the adrenal medulla, where larger lesions are regarded as pheochromocytoma. ln this report, we present a case diagnosed as nine- millimeter symptomatic AMH.

CASE: A 30-year-old man presented with newly diagnosed hypertension; because he was a doctor, he had examined his blood pressure and found it had risen to 160 mmHg. The endocrinological reasons that may cause secondary hypertension were investigated; 24-hour urine catecholamines were high. High values of catecholamines as well as metanephrine 608 ug/24h (52-341 ug/24h) and normetanephrine 1227 ug/24h (88-444 ug/24h).Plasma renin activity, aldosterone, thyroid-stimulating hormone, intact parathyroid hormone, calcium, calcitonin, carcinoembryonic antigen, metanephrine. normetanephrine. epinephrine, norepinephrine levels were in the normal range. One milligram dexamethasone suppression test was suppressed. The findings of a physical examination were all normal. He had no medical or family history of pheochromocytoma and related syndromes. However his cousin had hypertension diagnose when he was 30 years old. No pathology was detected in the retinal examination. Ultrasonography revealed no morphological abnormalities of the thyroids, parathyroids. No pathology was detected in the adrenal MRI. 1231-metaiodobenzylguanidme (MIBG) single-photon emission computed tomography (SPECT) revealed specific uptake in a seven-millimetric nodule in the left adrenal gland Gallium-68 DOTA-O-Phel-Tyr-3 octreotate positron emission tomography (Ga-68 DOTATATE PET) was performed; reported as specific asymmetric uptake in a nine-millimetric nodule in the left adrenal gland. Adrenal MRI was re-evaluated; was reported as seven millimetric asymmetric nodular thickenings m the left adrenal gland. The patient was consulted with the genetic department, and there was no mutation at the succinate dehydrogenase beta (SDHB) gene. Other genetic tests have not yet been concluded. He was prescribed doxazosin which controls his blood pressure. Two months later, he had a surgery of laparoscopic left partial adrenalectomy. Histopathological findings confirmed a diagnosis of AMH. The patient s urine catecholamine levels decreased after surgery, his blood pressure was kept under control without medication.

CONCLUSION: A diagnosis of unilateral AMH is important because AMH resection can effectively treat hypertension. Because the lesions in AMH are small, they may not be visualized on CT or MRI so; 1231- MIBG-SPECT and Ga-68 DOTATATE PET are necessary diagnostic scanning modalities for AMH.

Introduction: Gastric neuroendocrine tumors (NETs) derive from enterochromaffin-like cells in the gastric mucosa (1). Neuroendocrine hyperplasia of the stomach is a rare but important cellular event which can lead to development of gastric neuroendocrine tumor (2).

Case report: A 63-year-old female patient was admitted to our clinic with hypercalcemia. She had asthma, sleep apnea syndrome and oral lichen planus which was erosive and resistant to treatment for five years. Laboratory tests were as follows; calcium 11.5 mg/dL(8.4-10.2), albumine 3.9 g/dL(3.5-5.2), phosphorus 2.5 mg/dL(2.5-4.5), creatinine 0.74 mg/dL(0.5-1.1), parathyroid hormone 194pg/mL(15-65), 25OHvitaminD3 21.2 ng/mL(25-80), 24-hours urine calcium 236.5 mg/24hour (100-300). DEXA revealed a L1-L4 t-score of -2, femoral neck t score of -2.2, radius t score of -4.1. A lesion consistent with parathyroid adenoma was detected in ultrasonography and the patient underwent parathyroidectomy. A parathyroid adenoma and branchial cleft cyst were detected histopathologically. Upper GIS endoscopical biopsy performed for iron deficiency anemia was consistent with gastritis, atrophic intestinal metaplasia and neuroendocrine cell hyperplasia. Endosonography showed a 4 mm yellowish-colored appearance suggesting a carcinoid tumor, and 6 and 3 mm xanthoma in the posterior corpus wall and proximal antrum. Linearly increased pathological Ga-68 DOTATATE activity was observed in the posterior wall of the gastric corpus. Chromogranin A was 255.9ng/mL(0-100), gastrin was 607 pg/mL(13-115), neuron specific enolase was 13.4 ng/mIL(0-17). Multiple gastric biopsy results revealed a grade 1/3 (well differentiated) neuroendocrine tumor with Ki 67 proliferation index <2% and micronodular neuroendocrine hyperplasia in nontumoral areas, polypectomy was performed to two polip. Ga-68 DOTATATE imaging performed one year later showed decreased involvement of the gastric corpus and fundus. Calcium, parathyroid hormone, 24-hour urine catecholamines, pituitary hormones and pituitary MRI were normal. No mutation was detected in CDKN1B, MEN1 and RET genes.

Discussions: The diagnosis of gastric neuroendocrine tumor may be possible by multiple gastric biopsy in cases with gastric neuroendocrine cell hyperplasia (3). Patient with gastric neuroendocrine tumor and parathyroid adenoma may not have mutation in MEN genes.

BACKGROUND: Eosinophilic granulomatosis with polyangiitis (EGPA, Churg-Strauss syndrome) is a rare multisystem necrotizing vasculitis that involves the small-to-medium-sized blood vessels and characterized by chronic rhinosinusitis, asthma, and eosinophilia. We report a rare case of the syndrome of inappropriate antidiuretic hormone (ADH) secretion (SIADH) secondary to EGPA.

CLINICAL CASE: A 53-year-old man applied with complaints of pain in the large joints and morning stiffness in knee for two months. The patient had the history of impaired fasting glucose, asthma, nasal polyp, urticaria, angioedema, hypertension, hyperlipidemia and obsessive-compulsive disorder. Physical examination revealed intrinsic muscle atrophy and weakness in right hand. Peripheral eosinophil count was 9.78x109/L (0.02-0.5), erythrocyte sedimentation rate 39 mm/h (0-20), and Creactive protein 0,0577 g/L (0-0.005). Rheumatoid factor, antinuclear, anti neutrophyl cytoplasmic and anti-cyclic citrulinated peptide antibodies were negative, complement 3 and 4 levels were within normal ranges. Migratory ground-glass pulmonary opacities had been reported in multiple previous chest computed tomography scans. Echocardiography revealed findings compatible with eosinophilic involvement. Electroneuromyographic evaluation showed acute distal axonal neuropathy of right ulnar nerve. EGPA was considered in the patient and oral methylprednisolone treatment was initiated. After myeloproliferative disorders were excluded by bone marrow biopsy, intravenous immunoglobulin (IVIG) and cyclophosphamide treatment and gradual tapering of oral steroids were planned. In pretreatment examination hyponatremia was detected (serum sodium was 123 mEq/L (132-146)) which persisted during follow-up. In twenty-four hour urine analysis, sodium was 387 mEq, creatinine was 1156 mg and volume was 3000 mL. When his medical records were investigated it was observed that hyponatremia was present for nearly two years. He had neither hyponatremia symptoms nor hypervolemia. No history of diuretic use, hyperlipidemia, and hyperproteinemia was present. Thyroid, adrenal, renal, and hepatic function tests were normal. While serum osmolality was 270, urine osmolality was 911 mOsm/kgH2O. So, SIADH diagnosis was made. Cranial MRI revealed no hypothalamo-hypophyseal ischemia, infiltration or mass lesion. Fluid intake was restricted. Although the patient's sodium level did not return to normal, it rose up to 130 mEq/L. After second cycle of EGPA treatment (cyclophosphamide and IVIG), serum sodium level was became normal.

CONCLUSION: Underlying pathologies of SIADH are numerous and treat-to-target approach improves it and so hyponatremia. There is only four other documented cases of SIADH with EGPA. We hypothesized that blood supply to the hypothalamus and/or posterior hypophysis might be affected from EGPA vasculitis. This report is important because showing that SIADH may be potentially resulted from or concomitant with EGPA

Introduction: It is recommended to determine levothyroxine (LT4) dose individually in patients with hypothyroidism. However, higher doses of LT4 therapy are required to achieve target TSH levels in significant number of patients. Oral LT4 absorption occurs in the small intestine, especially in the jejunum and proximal ileum, while a small amount is absorbed in duodenum. Causes of LT4 malabsorption include helicobacter pylori infection, chronic atrophic gastritis, celiac disease, lactose intolerance, pancreatic insufficiency, cirrhosis, nephrotic syndrome, gastrointestinal malabsorptive surgical procedures, short bowel syndrome, drug and diet-related interactions. Here, we present a case of ileostomy with multiple small intestine resection, which is a rare cause of LT4 malabsorption.

Case: A 59-year-old male patient was consulted to our endocrinology clinic due to high TSH levels before ileostomy closure from the gastrosurgery clinic. The patient underwent total thyroidectomy in 2009 due to medical recurrence Graves disease and had postoperative hypothyroidism, he was euthyroid with levothyroxine treatment of 175 μg/day. With the diagnosis of rectal cancer in January 2020, the patient underwent a low anterior resection and colostomy. Pathology reported as moderately differentiated adenocarcinoma, followed by chemotherapy and radiotherapy. In October and November 2020, segmental small bowel resection due to radiation ileitis, ileus was performed. Ileostomy was performed in November 2020 for the patient whose colostomy did not work for a long time. Despite medical treatment, ileostomy was planned to be closed after 8 weeks due to the daily discharge of 14 times from ileostomy. It was consulted preoperatively in January 2021 due to TSH:66 mU/l. The oral levothyroxine dose was gradually increased from 150 μg/day to 350 μg/day due to increase in TSH to 80 mU/l, despite appropriate replacement of levothyroxine. When his TSH level was 37 mU/l, free T4 and T3 were normal with 350 μg/day oral levothyroxine, ileostomy was closed in February 2021. The patient’s free T4 and T3 values started to increase in 3 days after

ileostomy closure, and levothyroxine dose was gradually decreased. The patient has been followed euthyroid with levothyroxine doşe of 150 μg/day.

Conclusion: Intestinal absorption problems may cause high-dose LT4 therapy. The decrease of the intestinal absorption surface and the shortening of the intestinal transit time can be considered among malabsorption mechanisms. Further research should be conducted in the presence of increased serum TSH levels despite high dose LT4 therapy.

Introduction: While cervical lymph nodes are the region where head and neck malignancies frequently metastasize, prostate carcinoma rarely metastasizes to this area. Here, we will present a case with papillary thyroid microcarcinoma whose pathological lymph node cytology in the cervical region was found to be prostate carcinoma metastasis.

Case: Since thyroid fine needle aspiration cytology (FNAC) results were nondiagnostic 3 times, an 64-year old male patient underwent bilateral total thyroidectomy. His pathological examination was compatible with papillary microcarcinoma, and was given 100 mci radioactive iodine (RAI) treatment. While post-ablation whole body scan (WBS) revealed the activity involvement compatible with residual tissue in the right lobe region, the diagnostic WBS was found to be normal (TSH, Tg and Anti Tg values are shown in Table 1). In PET-CT, pathological increased activity uptake was detected in the bilateral level IV lymph node area. Neck ultrasonography showed a lymph node with pathological appearance and 8.5×8.7×11 mm in size at left level IV. Cytological examination of this lymph node was compatible with carcinoma metastasis. Also, another pathological looking lymph node on the left level IV with 7.7×9.4×10.8 mm in size was found to be compatible with malignant cytology, carcinoma metastasis (Table 1). An immunohistochemical study of the prostate and thyroid origin (PSA, TTF1) has been conducted in cytology, but a definitive clue for the origin of the tumor has not been obtained. Thereupon, the FNAC was repeated from the level IV lymph node (8.5×8.7× 11 mm) of the patient and nondiagnostic cytology was found, afterall the cell block was applied. Finally, left level IV lymph node cytology was reported to be compatible with prostate adenocarcinoma metastasis.

Table-1

TSH; thyroid stimulating hormone, Tg; thyroglobulin, Anti-Tg; anti- thyroglobulin,

WBS; whole body scan, RAI; radioactive iodine

Conclusion: Metastatic prostate adenocarcinoma (PAC) to cervical lymph nodes is rare. If the history is unknown, cases may be misdiagnosed as metastases from cervical neoplasms. Findings showing metastatic PAC to the cervical lymph nodes in FNAC are; the involvement of left-sided cervical lymph nodes and cellular smears consisting of flat layers with granular cytoplasm and uniform polygonal cells arranged in the acini, fuzzy cell borders, and round-oval nuclei with prominent nucleoli.

Introduction: Type 2 diabetes and hyperlipidemia are primarily managed with lifestyle modifications, self-monitoring of blood glucose, and medication. Patients who are obese and cannot achieve normal blood glucose levels despite diet, exercise, and multiple medications may be considered for bariatric surgery. Many diabetic patients with very high triglyceride levels are at high risk for ASCVD and therefore after triglyceride levels are controlled the patient should be evaluated for cardiovascular disease risk. Bariatric surgery is more effective at inducing weight loss than either diet or medications. Baratric surgrey is alsow associated more robust decrease in serum triglyceride levels and increase in HDL-C levels. Here we describe a bariatric surgery results of obese multidrug hypersensitive patient with a high level of serum triglyceride.

Case: 44 years old woman, had Type-2 Diabetes Mellitus and hyperlipidemia for at least 3 years. She had no medication due to multidrug hypersensitive. Her BMI was 39.9, fasting glucose, serum triglyceride, VLDL, HDL, HbA1C are: 166 mg/dl, 2166 mg/dl, 433 mg/dl, 32 mg/dl, 60 mmol/mol respectively. İn addition to Initial treatment of very low-fat diet, we immediately started medication to reduce triglyceride levels into a safe range to prevent triglyceride-induced pancreatitis. After 10 day of receiving fenofibrate and dapagloflozin she had an generalized acute urticaria need hospitalization and first treated with antihistamine drugs. Here serum triglyceride level was 1906 that force us to continue medication tratment with antihistamine drug. After 4 mounth of treatment and weight loss (10 kg) we didn’t reach therapy goals of hyperlipidemıa. The patient had a bariatric surgrey after mutidisplanary consensur. After surgrey she stoped medication and her serum triglyceride measure was 240 mg/dl.

Conclusion: We report a case of generalized urticaria probable or very probable induced by fenofibrate underwent bariatric surgery. Approximately 60-70%of patients with obesity are dyslipidemic. The Roux-en-Y gastric bypass and laparoscopic sleeve gastrectomy have been shown to improve A1C, reduce weight, and reduce the number of medications patients need for diabetes management. Comorbidities such as hyperlipidemia and hypertension also may improve. A reduction in medication of hypersensitive patients can be considered an additional benefit of bariatric surgery.

Background: The risk of cancer is relatively higher in Graves’ patients presenting simultaneously with thyroid nodules. Radioiodine (RAI) therapy recommended in intermediate-high risk differentiated thyroid carcinoma may be associated with worsening of a pre-existing Graves’ orbitopathy (GO) or developing a new onset. The impact of RAI therapy in patients with differentiated thyroid cancer on the course of a pre-exisiting GO has not been specifically investigated. we report a sever GO patient treated by recombinant Tsh (RhTSH) for intermediate-risk of papillary thyroid cancers (PTC).

Case: A 47-year-old man, presented to our center with exophthalmos and ptosis of eyes. His thyroid function tests and thyroid autoantibodies were as follows: TSH; 0.01 (0.4–4 uIU/ml), FT3; 5.41 (1.6–4.9 pg/ml), FT4; 1.74 (0.78–1.76 ng/dl); anti TPO was positive TSH-R Ab; 1.249. On the ultrasonographic examination of the thyroid gland the paranchyme was heterogeneous and in the right lobe 11.2 × 8.9 mm heterogeneous, iso-hyporechogenic nodule and pathologic lymphadenopathy were detected in levels 4 of neck. US-guided fine-needle aspiration biopsy was performed and the cytological examination were suspicious for papillary thyroid cance of the nodule and malign sitology of the lymph node. Computed tomography scan of orbita demostrated bilateral anterior bulging of bulbus oculi clearly and bilateral enlargement of medial, inferior and superior rectus muscles and also swelling of the optic nerve. In addition to antithyroid and beta blocker, for severe ophthalmopathy intravenous pulse therapy with high doses of methylprednisolone as 500 mg tapered in 24 weeks duration, followed by 250 mg for 24 weeks. He 

underwent thyroidectomy and a dissection of the santral and right lateral lymph nodules was conducted. The diagnosis were PTC with < 5% of hobnail variant and mestatic lymph nodules was confirmed. Once stabilized of GO under oral methylprednisolone and became euthyroid he reseved 150 mCi RAI with rhTSH with no changes in GO after One month observation.

Discussion: The risk of cancer is relatively higher in Graves’ patients in the presence of an accompanying nodular disease. Moreover, some authors reported that thyroid cancer associated with GD seemed to be more aggressive. RAI therapy is recommended in high-risk differentiated thyroid carcinoma, but it might worsen or induce a new onset of GO. Glucocorticoid treatment should be given especially in patients who will receive high doses of RAI. RAI with rhTSH had no difference in GO outcome at first month.

Background: Primary thyroid lymphoma (PTL) is defined as a lymphoma involving only the thyroid gland or the thyroid gland and adjacent (regional) neck lymph nodes. Primary lymphomas of the thyroid are uncommon tumours, representing approximately 5% of the thyroid neoplasms and 2% of extranodal lymphomas. The most characteristic presentation is that of a rapidly enlarging neck mass often associated with dysphagia. The majority of patients are euthyroid and one third of patients have compressive symptoms. The mass is usually fixed to surrounding tissues and half the patients have unilateral or bilateral cervical lymph node enlargement. Abscess formation in the background of thyroid lymphoma with thyrocutaneous fistula is further rare. Reaching the final diagnosis can be delayed if insufficient biopsy material is obtained and it may be difficult to distinguish thyroid lymphoma from anaplastic carcinoma and thyroiditis. The present study describes the case of a patient who was presentad with abscess formation suggesting the possibility of anaplastic carcinoma and finaly  diagnosd by diffuse large B-cell lymphoma.

Case: A 73-year-old female presented with anterior neck pain, hoarseness and rapidly expanding mass with abscess formation on here neck. The patient was admitted to our clinic for preoperative thyroid surgery suggesting the possibility of anaplastic carcinoma due to fine needle aspiration cytology of suspicious for malignancy. Her serum TSH was elevated to 47 mU/l and anti TPO was very high. Here neck ultrasound showed a significantly enlarged, diffuse parenchymal inhomogeneity and ill defined border of the thyroid gland. We performed Tru-cut biopsy and histological diagnosis was Diffuse large B-cell lymphoma of the thyroid gland. After 18FDG-positron emission tomography/computed tomography (PET/CT) scanning the patient reseaved 6 regimen of chemotherapy R-CHOP (rituximab, cyclophosphamide, doxorubicin [hydroxydoxorubicin], vincristine [Oncovin], prednisone with antibioticsand she has a good physical condition.

Discussion: Thyroid abscess is a rare clinical situation. It is most commonly associated with pyriform sinus fistula. Abscess formation in the background of thyroid cancer with thyro-cutaneous fistula is further rare. PTL is an uncommon malignancy of the thyroid. PTL occur most commonly in elderly women and are commonly of B-cell origin. Fine needle aspiration has become the procedure of choice for the initial pathological diagnosis of thyroid nodule. However, studies have also shown inconsistent results in the diagnosis of lymphoma of the thyroid. But clinical and radiological suspicion and cytomorphological features can help reaching the correct diagnosis in such cases.

Objective: Radioactive iodine (RAI) therapy is widely used in both diagnosis and treatment of benign and malignant thyroid diseases. It is generally a well tolerated therapy. Bone marrow suppression is often a temporary side effect with a decrease in white blood cells and platelets up to 6–10 weeks. In this study, we aimed to examine hematological changes in patients who received RAI treatment for benign or malignant diseases of the thyroid.

Methods: The records of patients who applied to our endocrinology clinic between January 2016 and January 2019 and received RAI treatment for benign or malignant etiologies were evaluated retrospectively. The demographic data of the patients and data on thyroid disease, additional diseases, and the drugs used were recorded, the patients were grouped according to the etiology and

the RAI dose they received. Blood count parameters measured before RAI treatment within 7 days, after RAI treatment and at the last control of the patient were recorded and compared in these patients.

Results: In the study, data of total 202 patients, including 158 women (77.5%) and 44 men (21.6%), were evaluated. 168 of these patients (82.4%) had received RAI treatment due to malign, and 34 benign (16.7%) etiologies. The median age they received RAI was 45 (20–84), while the median dose of RAI was 75 mCi (10–200). Pre-treatment and first control interval was median 44 (18–93) days, and the median time between pre-treatment and last control was 35 (4–56) months. In comparison of hematological parameters before and after treatment, the median leukocyte count was 7.72 (3.89–19.93) × 109/l before treatment, while it was significantly reduced 6.27 (0.86–14.5)

× 109/l at the first control after treatment and 6.78 (3.58–10.8) × 109/l at the last control. Similarly, a decrease in neutrophil and lymphocyte counts was detected after treatment. While the median hemoglobin value was 13.95 (8.8–17.2) g/dl before RAI treatment, it was 13.5 (7.8–17.3) g/dl and 13.5 (6.7–17.6) g/dl at the first and last control after treatment, respectively. The median platelet count was 283 (149–563) × 109/l, and it was 250.5 (134–507) × 109/l at the first post-treatment control and 266.5 (116–539) × 109/l at the last control. While the median value of mean platelet volume(MPV) was 10.8 (8.5–13.8) fL before treatment, it was 10.15 (7.6–13.1) fL and 8.2 (6.6–11.1)fL, respectively, in controls.

Conclusion: In our study, a significant decrease was found in the leukocyte, neutrophil, lymphocyte, platelet counts, hemoglobin levels and mean platelet volumes in the post RAI treatment period. According to these findings, it can be thought that the decrease in hematological parameters continues not only in the acute period but also in the chronic period after RAI.

Introduction: Thyroid cancer is the most common endocrine malignancy and its overall incidence has increased significantly in the last 30 years. Cancer in adolescents and young adults (AYA) is defined by the National Cancer Institute as diagnoses occurring among those aged 15 to 39 years. Thyroid cancer is the second most common cancer in the AYA population. In this study, we aimed to compare clinical, ultrasonographical, cytological and histopathological features of thyroid carcinoma in patients AYA with older counterparts. 

Materials and methods: The medical records of patients who underwent thyroidectomy between December 2006 and September 2016 and were diagnosed with thyroid cancer histopathologically were retrospectively reviewed. Patients were subdivided into two age groups: 1539 (Group1 ) and ? 40 years old (Group 2). Thyroid functions, ultrasonographic features of malignant nodules, cytological and histopathological findings were compared in patients with AYA patients and ? 40 years. 

Results: The study included 229 (22.6%) AYA patients and 784 (77.4%) patients aged ? 40 years. Thyroid functions, thyroid autoantibody positivity and thyroidectomy indications were similar. There were 305 (21.4%) and 1121 (78.6%) malignant foci in Group 1 and 2, respectively. Preoperative US features were similar in the two groups. Cytological results were distributed similarly in two groups (P = 0.512). Of all cancer types, 93.1% in Group 1 and 93.5% in Group 2 were papillary thyroid cancer (P = 0.772). Follicular cancer was found in 2.6% of Group 1 and 2.1% of Group 2 (P = 0.544). Medullary cancer constituted 1% of Group 1 and 1.1% of Group 2 (P = 0.895). Anaplastic cancer was found in 0.4% of Group 1 and 0.4% of Group 2 (P = 0.940). Lymph node metastasis was detected in 9.2% of group 1 and 7.4% of group 2 (P = 0.246). Distant metastasis was not detected in group 1, and it was found in 3 (0.4%) patients in group 2 (P = 0.366). There was not any significant difference in capsular and vascular invasion and extracapsular extension between groups. 

Conclusion: Previous studies have found that although AYA patients are more likely to be diagnosed with locoregional lymph node involvement compared to older patients, they are less likely to be diagnosed with distant metastases. In our study, the rate of diagnosis of lymph node metastasis was higher and the rate of distant metastasis was lower, but the difference was not statistically significant. 

Introduction: Extramedullary plasmacytoma (EMP) is a plasma cell neoplasm of extraosseous tissues. Less than 5% of all plasma cell neoplasms develop extramedullary. EMP is most common in the upper respiratory tract and oral cavity. The thyroid gland is one of the extremely rare regions. It is more common in men and the average age at diagnosis is 55. Primary thyroid plasmacytoma is one of the rare thyroid neoplasms. It often manifests as a rapidly growing mass in the neck and cause symptoms due to mass pressure. Pathological evaluation is particularly important. At the diagnosis of thyroid plasmacytoma, multiple myeloma must be ruled out. Here we present our case of thyroid plasmacytoma diagnosed by tru-cut biopsy.

Case: A 71-year-old female patient, with hypothyroidism and multinodular goiter since 2014, presented with a 6-month history of dyspnea and neck swelling. She had type 2 diabetes mellitus, hypertension, and coronary artery disease. Thyroid gland was grade 3, fixed nodules were bilateral palpable. Thyroid function tests were euthyroid on levothyroxine treatment and thyroid autoantibodies were positive. An ultrasound scan of the thyroid revealed an enlarged thyroid with thyroid nodules on the right and left lobes, extending to the isthmus with a significant increase in size compared to previous controls. Fine needle aspiration cytology was benign. Due to suspicion of

thyroid lymphoma, tru-cut biopsy was performed which suggested plasma cell neoplasia and plasmacytoma. Hematology consultation was made, as a result of the tests, multiple myeloma and other plasma cell disorders were excluded. The patient was evaluated as extramedullary plasmacytoma. In the council of endocrinology and metabolism, hematology, general surgery, nuclear medicine and radiation oncology departments operation was preferred. Bilateral total thyroidectomy was performed, histopathology reported as plasma cell neoplasm. Radiotherapy was not considered to be given to the patient as she had no residue in the examinations performed in the postoperative period. The patient has been followed in remission for one year.

Conclusion: Primary thyroid plasmacytoma is a rare thyroid neoplasm. Clinical examination and imaging methods are usually not determinative in diagnosis, pathological evaluation is at the forefront of diagnosis. Even if fine needle aspiration biopsy is benign, patients should be evaluated for tru-cut biopsy in case of clinical suspicion. In the begining, multiple myeloma must be ruled out. Regular follow-up of the patient is necessary, as conversion to multiple myeloma may occur rarely.

Background: Ultrasonography and fine needle aspiration biopsy are frequently used in the diagnosis of thyroid cancer. However, supportive data might be required in case of diagnostic difficulty. In this study, we investigated whether there is a relationship between thiol/disulfide homeostasis and cytological and histopathological diagnosis of thyroid nodules.

Materials and methods: A total of 119 participants were included in the study (81 euthyroid nodular goiter patients and 28 age and body mass index matched healthy volunteers). The patient group consisted of individuals scheduled for thyroidectomy. Thyroidectomy indications were giant nodule, cytological diagnosis and patient preference. Patients with diseases that would affect thiol/disulfide homeostasis were excluded. Cytological findings, histopathology results were evaluated. Native thiol, total thiol, and disulfide concentrations were measured, and disulfide/native thiol, disulfide/total thiol and native thiol/total thiol ratios were calculated. Thiol/disulfide levels were analyzed with automated spectrophotometric method.

Results: There was no significant difference in oxidative stress parameters between different Bethesda categories. However, the increasing Bethesda categories were weakly positively correlated with the disulfide/native thiol (r: 0.241, p:0.030) and disulfide/total thiol (r: 0.250 p: 0.024). The disulfide concentration was 16.07±9.28 μmol/l in histopathologically benign, 19.85±11.28 μmol/l in malignant, and 14.87±7.62 μmol/l in the control group (P<0.001, f=11.724).

Disulfide/native thiol was calculated as 3.58±2.0 in the benign group, 5.50±2.85 in the malignant group, and 3.41±1.70 in the control group (P < 0.001, f=8.415). Disulfide/total thiol was significantly higher in the malignant compared to benign and control groups (4.96±2.24, 3.27±1.80

and 4.96±2.24, respectively, P <0.001, f=9.49).

Conclusion: Oxidative stress parameters were significantly higher in thyroid cancer. A weak positive correlation was detected between Bethesda categories and the disulfide/native thiol ratio and the disulfide/total thiol ratio. In case of diagnostic difficulties, additional benefit can be obtained from thiol/disulfide measurement.

Background: We aimed to determine clinicopathological features that can predict lymph node metastasis (LNM) in papillary thyroid microcarcinomas (PTMC). 

Methods: Medical records of 872 patients with papillary thyroid cancer >1 cm (PTC >1 cm) and 1184 patients with papillary thyroid microcancer (PTMC) (£1 cm) were reviewed retrospectively. Demographical, clinical and histopathological features of (PTC >1 cm) and PTMC were compared.

Association between clinicopathological features and LNM in PTMC was investigated.

Results: The median age of patients with PTMC was significantly higher than patients with PTC>1 cm (49 vs 46 years old, P < 0.001). Multifocality, capsular invasion, vascular invasion, extrathyroidal extension (ETE) and LNM were more frequent in patients with PTC>1cm compared to patients with PMTC (P <0.001 for each). In PTMC group, those with LNM had significantly higher proportion of multifocality, capsular invasion, vascular invasion and ETE compared to those without LNM (P = 0.007, <0.001, P = 0.011 and P <0.001, respectively). Multifocality and ETE were significant factors for LNM with logistic regression analysis. Multifocality increased the risk of LNM by 1.737 times (95% CI: 1.079–2.979) and ETE increased the risk by 3.528 times (95%: 1.914–6.503). Primary tumor diameter ≥5.75 mm was predictive for LNM with a sensitivity of 0.782 and a specificity of 0.517 in PTMC.

Conclusion: LNM should be investigated more carefully in patients with PTMC in the presence of tumor diameter≥5.75 mm, multifocality or ETE.

Purpose: Poorly differentiated thyroid carcinoma (PDTC); is a rare type of thyroid cancer with a high risk of recurrence, metastasis, and death. Pleural effusion due to thyroid cancer has seldom been reported. In this report, we present a case with PDTC related malignant pleural effusion.

Case: A 66-year-old male patient presented with neck swelling and shortness of breath. At another center, thyroid ultrasonography revealed a multinodular goiter and an irregularly circumscribed lymphadenopathy on the left level IV. He had multiple lung metastases in thorax computed tomography (CT). Positron emission tomography/computed tomography (PET-CT) detected “hypermetabolism in malignant nodules in the thyroid, multiple metastatic lymph nodes in the neck and bilateral metastatic lung nodules.” Cytology of lymph nodes at the right level 3,4,6–2a junction was malignant. The patient underwent bilateral total thyroidectomy, bilateral central lymph node dissection, and right modified radical neck dissection with a final pathologic diagnosis of “poorly differentiated thyroid carcinoma, right lateral and central tumor positive lymph node.” Upon persistence of dyspnea, thoracentesis was performed for a left-sided pleural effusion, which in the end had exudative characteristics. [blood thyroglobulin (Tg): 23960 ng/ml, Tg with pleural fluid dilution > 30000 ng/ml]. Cytology confirmed carcinoma infiltration. In the follow-up, mediastinal, lung, and pleural metastases in addition to effusion in the left hemithorax persisted. We performed pleurodesis after the initial tube thoracostomy. During follow-up pleural fluid cell-block was performed due to continued pleural effusion and reported as carcinoma metastasis. 200 mCi RAI treatment was given after preparation with recombinant thyroid stimulating hormone (TSH). After the comparative PET-CT revealed progression, transthoracic lung biopsy performed and reported as carcinoma metastasis. After these results tyrosine kinase inhibitor (sorafenib) was initiated to the patient.

Conclusion: The most common sites of distant metastasis of PDTC are the lungs and bones. It constitutes about 85% of deaths related to the disease. Less than 1% of malignant pleural effusions are associated with thyroid cancers. Pleural fluid thyroglobulin level and immunohistochemical staining may enhance the diagnostic process.

Background: Our aim was to compare the effectiveness of five different risk-stratification systems using the ultrasonographical features of thyroid nodules in determining malignant histopathology.

Methods: The preoperative ultrasonography (US) features of 6925 nodules of 3030 patients who underwent thyroidectomy between 2007 and 2014 were analyzed retrospectively. The nodules were classified according to Kwak-TIRADS (Thyroid imaging reporting and data system), European Thyroid Association-TIRADS (EU-TIRADS), Korea-TIRADS, American Society of Clinical Endocrinologists (AACE), American Thyroid Association (ATA).1362 nodules (1042 patients) that could be scored in all of these systems were included. Malignancy rate, specificity, sensitivity, positive predictive value (PPV) and negative predictive value were calculated.

Results: In the nodules with high risk scored,malignant histopathology rate were 50%, 27.7%, 32.2%, 29.9%, 31.9% in Kwak-TIRADS, EU_TIRADS, Kore-TIRADS, AACE, ATA, respectively (Table 1). Area under curve (AUC) was higher than 0.5 for all systems (P <0.001,Table 2). When determining optimal cut-off for each system, sensitivity, specificity, PPV, and NPV were about 60%, 75%, 27–30% and 92%, respectively (Table 2). EUTIRADS had significantly lower AUC (corrected P<0.05). AUC of Korea-TIRADS was lower than that of ATA (corrected-P<0.001). AUCs of Kwak-TIRADS, AACE, and ATA were similar and significantly higher than the others (Table 2).

Conclusion: Risk-stratification systems have variable efficiency in predicting malignancy risk since they are operator dependent and require experience in that field. The sensitivity was found to be lower than the previous studies which might be due to retrospective evaluation of US reports rather than real time risk scoring.

Table-1.Distribution of benign and malignant nodules according to riskstratification systems

Aim: Euthyroid Sick Syndrome (ESS) is a thyroid disease appeared in critical and noncritical illnesses. ESS can be seen in patients with end stage renal disease (ESRD). In this study, we aimed to evaluate the frequency of ESS before and after renal transplantation in patients with ESRD, and its association with oxidative stress by evaluating thiol-disulphide levels.

Material and Method: In this study, free triiodothyronine (fT3), free thyroxine (fT4) and thyroid stimulating hormone (TSH) levels were recorded before and after renal transplantation in patients with ESRD. ESS was diagnosed in patients with unresponsive TSH to low fT3 and/ or fT4 levels, Thiol and disulphide parameters of patients before and after transplantation were also recorded.

Results: One- hundred twenty one patients were included in the study. Of these, 69 (57%) were males and 52 (43%) were females. The mean age was 45±12.61 years. ESS was detected in 39 (32%) of 121 patients. Of 39 patients, 24 (61%) had ESS before transplantation and 15 (39%) after transplantation. Frequency of ESS was 19.8% in patients followed with ESRD. Sixteen of 24 (66.7%) patients with ESS before transplantation reached to normal thyroid functions after transplantation. After transplantation, patients with ESS had significantly higher urea and creatinine (respectively, P = 0.025 and P = 0.009), and lower fT4, fT3, total protein, and albumin (P = <0.001; for all parameters) compared to patients without ESS. Patients with ESS before transplantation had also significantly higher creatinine levels compared to patients without ESS (P = 0.034). Free T4 and fT3 levels were significantly low (P <0.001 for both). Thiol- disulphide levels of 20 patients with ESS at any time compared with 68 patients without ESS. We found that native thiol and total thiol were low significantly in patients with ESS (respectively, P = 0.025 and P = 0.044).

Conclusion: Our study is the initial study evaluating the oxidative stress and antioxidation status in etiology of ESS in patients with renal transplantation. Presence of markedly low level of antioxidation in these patients supports the possible role of oxidative stress in etiology of ESS.

Introduction: Steroid cell tumors (SCTs) are a rare subgroup of sex-cord tumors of the ovary that account for less than 0.1% of all ovarian tumors. They are classified into three categories based on the cell origin: stromal luteoma, Leydig-cell tumor, and not otherwise specified (NOS). NOS tumors are the most common subtype and comprise the largest proportion of cases (60%).The clinical presentations are not specific, including abdominal pain, distention and bloating. However, the more significant presentations are those associated with the hormonal activity and virilizing properties of the tumor. The cornerstone of SCT-NOS treatment is surgery.

Case: A 55-year-old female came to our hospital in November 2020 with months’ history of increasing facial and truncal hair. She also had hypertension and diabetes mellitus. In the medical history of the patient, she had been operated for papillary thyroid cancer, sleeve gastrectomy, total abdominal hysterectomy and left salpingo-oophorectomy 30 years ago. Physical examination revealed obesity (body mass index, 37.3 kg/m2).She had a Ferriman–Gallwey score of 24. Abdominal ultrasound identified a 40 × 20 mm solid, right ovarian mass.Biochemical data shows the levels of folicle stimulating hormone and luteinising hormone were as high as 52.1 U/l and 33.3 U/l, respectively. Serum adrenocorticotropic hormone, cortisol, estradiol, serum prolactin, dihydroepiandosterone sulfate were found within reference intervals.Total and free serum testosterone levels were found to be as high as 450 ng/dl (normal 7–49 ng/dl) and 19.99 (normal<4.2 pg/ml), respectively. Magnetic resonance imaging with contrast confirmed the ultrasound findings and detected no adrenal gland enlargement or tumor.The right salpingooophorectomy was done, and the specimen was sent to our department for histopathological examination. On surgical staging laparotomy, it was found that there was an enlarged (3×3×2 cm) right ovary with both solid and cystic component and normal ovarian contour.Microscopically, mitotic activity 2–3/10, mild atypia, and no significant necrosis. Immunohistochemistry revealed a result of MelanA(+), ER (+), CD56(+), Calretinin (+), Inhibin-α

(+), ki-67 (5–6%+). Histological features were consistent with SCTs-NOS type.At post-operative follow-up, her total serum testosterone and serum free testosterone level had gone down to 13 ng/dl and 0.73 pg/ml, respectively. 

Conclusion: SCTs, NOS, are rare ovarian tumors which can be difficult to diagnose. Careful history and physical examination, in addition to laboratory values and imaging studies, are helpful in making the diagnosis.They are usually benign, unilateral and are characterized by hyperandrogenism and virilization. SCTs should be considered in differential diagnosis among women presenting with symptoms of virilization.

Introduction: Glucagonoma is an extremely rare type of functional pancreatic neuroendocrine tumor that is characterized by distinctive clinical manifestations such as diabetes mellitus, weight loss, deep vein thrombosis, and necrolytic migratory erythema which represents the hallmark clinical sign of glucagonoma syndrome. Here, we report the case of a 53-year-old male patient who presented with high amilase and lipase levels. In further investigation a pancreatic tumor was determined and after pancreatic surgery it was diagnosed as glucagonoma.

Case: A 53-year-old male patient was examined routinely in cardiology. In the laboratory analysis, amilase and lipase were detected as above the upper limit of normal [amilase: 212 (Normal range: 30–118 U/l), lipase: 224 (Normal range: 12–53 U/l)]. He did not have any symptoms or signs associated with pancreatitis. Glycosylated A1c was 6.5%. In his past history he did not have diabetes mellitus. In the family history, he reported that his mother had diabetes. He referred to our outpatient clinic for prediabetes. Furtherly, 75 gr oral glucose tolerance test was performed. It was evaluated as impaired fasting glucose (0.min glucose: 115 mg/dl, 120.min glucose: 93 mg/dl). In the

investigation of pancreatic enzyme abnormalities, abdominal ultrasound was performed. In the ultrasound, Grade 2 hepatosteatosis and a heterogenous weakly hypoechoic solid mass located in proximal pancreatic body which was 20x14.5 mm in diameter were detected. In abdominal MRI, a 21x16 mm mass located in posterior part of the pancreatic body which was mildly hyperintense in T2A and hypointense in T1A images was reported, and in contrasted images the tumor was found as prominent minimally according to parachyme, and had also diffusion restriction. For the investigation of neuroendocrine tumor, Ga-68 DOTA-PEPTIDE PET/CT was performed and it demonstrated a high pathologic Ga-68 enhancement in the pancreatic mass (SUVmax: 21.92). Then, the patient was operated. Distal pancreatectomy and splenectomy was performed. The histopathology was reported as grade 1 glucagonoma. Postoperatively, he had diabetes mellitus, he was under insulin treatment. His postoperative amilase, lipase values were normal. The postoperative glucagon value was 248 (normal range: 25–250 pg/ml). 

Conclusion: Glucagonoma is a rare pancreatic neuroendocrine tumor. Most common presentation is the skin lesions. Our patient was diagnosed after investigation of biochemical abnormality. He presented atypically as he did not have most typical presentations like most patients in the literature.

Background: Pituitary xanthogranulomas are extremely rare tumors of the sellar region. A cystic mass lesion was found in the pituitary MRI of our patient diagnosed with central diabetes insipidus (DI). We aimed to present a case who was operated for a pituitary mass and diagnosed with sellar xanthogranuloma.

Case presentation: 37-year-old female patient was applied to our outpatient clinic with complaints of polydipsia, polyuria and headache for 8 months. The anterior pituitary hormone levels were in normal. Plasma osmolarity: 291 mOsm/kg, urine osmolarity: 130 mOsm/kg, urine density: 1006 and serum electrolytes were in normal range. Pituitary MRI revealed a cystic mass lesion with prominent hyperintense mucoid content in T1-weighted sequences with a diameter of approximately 10 × 11 mm and completely obliterating the neurohypophysis in the posterior of the adenohypophysis. Also the cystic mass lesion showed expansion towards the posterior suprasellar system. Her visual field examination was found normal. The patient was admitted to our clinic for the water deprivation test. Complete central DI was diagnosed. Desmopressin treatment was started on. The clinic and laboratory findings of DI were improved after desmopressin treatment. The patient was evaluated by neurosurgery department. Transsphenoidal surgery was performed for the mass lesion in the pituitary. The pathology result was reported as sellar xanthogranuloma. Desmopressin therapy was continued in the postoperative period. Clinical and laboratory findings were found normal under desmopressin treatment. Pituitary MRI performed 3 months after the operation, no finding of residual-recurrent adenoma was detected in the sellar region.

Conclusion: Sellar xanthogranulomas are very rare seen intracranial tumors. They have not any typical radiological feature. Patients can present with clinical signs such as headache, visual disturbance, vomiting, DI and hypopituitarism.

Introduction: Pituitary gland tumors constitute approximately 10–15% of primary brain tumors, and posterior pituitary tumors are extremely rare. Granular cell tumor (GCT) is a low grade non-neuroendocrine neoplasm. Here, we will present our case who was found to have GCT during follow-up of diabetes insipidus (DI).

Case: A 23-year-old male patient applied to our outpatient clinic for routine control. 12 years ago, he was diagnosed with growth hormone deficiency and central hypothyroidism during tests performed for short stature, and used growth hormone and levothyroxine treatments, and it was learned that these treatments were discontinued after puberty, and he had been using desmopressin for partial DI for 10 years. He was using desmopressin 240 mg/day at presentation. His height and weight were 165 cm and 60 kg, his blood pressure was 120/80 mm Hg, and his pulse was 72 beats/min. Systemic examination was normal. Serum Na level was 142 mEq/l, serum osmolality was 291 mOsm/kg, spot urine osmolality was 693 mOsm/kg, and urine density was 1020 (Table 1). On the neurohypophysis lodge, a high-signal lesion area (granular cell tumor?) was observed with magnetic resonance imaging in T1A and T2A series with 1.4 × 1 × 0.6 cm dimensions, which created convexity at the base of the sella contour. When the pituitary images of previous years were examined, it was reported that neurohypophysis was normal in 2010 and 2016, tubular structure showing loss of signal in all sequences in the neurohypophysis (vascular structure?) was observed in 2013, and in 2019, it was determined that a lesion (lipoma?, terotoma?, dermoid cyst?) was detected in the neurohypophysis lodge, which showed suppression (?) in a fat-suppressed sequence of 13 × 7 mm in size, and did not form a distinct opacification pattern in dynamic study. He was evaluated in a multidisciplinary council and follow-up was planned.

Discussion: DI was seen in 3–5% of GCT cases. In our case, no tumor was observed on neurohypophysis at the time of diagnosis, but GHT was detected during follow-up. We are of the opinion that periodic pituitary imaging in DI cases may increase the possibility of detecting rare tumors such as GHT.

Na; Sodium, K: Potassium, TSH: Thyroid stimulating hormone, st4: Thyroxine, GH: Growth hormone, 

IGF1:Insulin-like growth factor, FSH: Follicle stimulating hormone, LH: Luteinizing hormone, ACTH:Adrenocorticotropic hormone

Introduction: Pituitary adenomas secreting TSH (TSHoma) are a rare cause of hyperthyroidism. They account for approximately 0.5–3 % of functioning pituitary tumours and much less than 1% of all cases of hyperthyroidism. TSHoma should be considered in all hyperthyroid patients, especially those with diffuse goitre and no extrathyroidal signs of Graves’ disease.

Case 1: A 30-year-old female applied to the internal medicine department with complaints of palpitations, diarrhea, sweating and weight loss. In repeated examinations, high levels of TSH, fT3 and fT4 were detected, TSH, fT3 and fT4 values examined in 3 different centres and again found to be high.The serum sex hormone-binding globulin concentration was slightly elevated. In family screening, no thyroid dysfunction was detected. In pituitary MRI, 5 mm adenoma was detected.The serum α-subunit level was 2.4 ng/ml (normal < 1.2), and the α-subunit/TSH molar ratio (α-subunit ×10/TSH) was 4.3 (normal < 1).We performed an analysis for mutations in the THRB gene; no mutations found. The serum TSH concentration didn’t increase in response to the thyrotropin-releasing hormone, while a fall in serum TSH concentrations was detected in response to administered T3. Since the tests showed discordance, a short course of long-acting (LAR) somatostatin analogue (SSA) was administered. Thyroid function tests returned to normal with LAR-SSA therapy and strengthened the diagnosis of TSHoma. Surgery was planned.

Case 2: A 35-year-old male patient was referred to the endocrinology department when elevated TSH, fT3 and fT4 values were detected in the smoking cessation outpatient clinic. Repeated examinations in the same centre and two different centres showed high TSH, fT3 and fT4 levels. No thyroid dysfunction was found in first-degree relatives.The serum sex hormonebinding globulin concentration was normal,and the serum α-subunit level was 0.7 ng/ml (normal<0.5). In pituitary MRI, 7 mm adenoma was detected. The serum TSH concentration didn’t increase in response to the thyrotropinreleasing hormone,while a fall in serum TSH concentrations was detected in response to administered T3. Since the tests showed discordance,a short course of LAR-SSA was administered. Thyroid function tests returned to normal with LAR-SSA therapy and strengthened the diagnosis of TSHoma. Surgery was planned.

Conclusion: Most TSHomas are detected as pituitary macroadenomas. The presence of a microadenoma on MRI is not specific for a TSH-secreting tumour and can be seen as an incidental finding in 10 per cent of normal individuals. The rutin tests used for the differential diagnosis of TSHoma and Thyroid hormone resistance sometimes may be discordant. In such cases, performing

the LAR-SSA test strengthen the diagnosis.

Introduction: Pituitary apoplexy is seen in 1.5–27.7% of pituitary adenomas. Common etiologies include hypertension, diabetes mellitus, radiotherapy, contrastenhanced MR, surgery, drugs, anticoagulant, antithrombotic, estrogen, head trauma and pregnancy. SARS-CoV-2 had spread rapidly, and caused COVID-19 pandemic. Although it mainly causes respiratory problems, there may also be extrapulmonary involvement. COVID-19 infection is associated with hemorrhagic complications, cardiac and renal infarction and cerebrovascular hemorrhage. In this report, we present a patient who was followed up with microprolactinoma and developed hemorrhagic degeneration in adenoma after Covid-19 infection.

Case: A 26-year-old female patient was found to have serum prolactin of 94.19 mg/l (4.79–25.3) in the tests performed due to menstrual irregularity and complaints of galactorrhea by provocation. Control prolactin was 104 mg/l, and macroprolactin was negative. Other anterior pituitary hormones, kidney and liver function tests were normal. A 4 × 6 mm microadenoma was detected on pituitary gland in pituitary MRI. Cabergoline 0.5 mg/week was initiated in March 2019 with the diagnosis of microprolactinoma. The pituitary MRI taken in February 2021 revealed a 7 × 5.5 mm lesion in the adenohypophysis with the presece of hemorrhagic degeneration. There were no complaints of severe headache, nausea, vomiting, or visual impairment during system inquiry. Anterior pituitary hormone levels were normal. Medical history showed that she was diagnosed with Covid-19 in September 2020. She used hydroxychloroquine sulfate 2 × 200 mg (5 days) and enoxaparin sodium 2 ×0.6 mg (10 days) and then acetylsalicylic acid for 10 days. It was thought that hemorrhagic degeneration might be due to the antiaggregant/antithrombotic treatment she had received or the Covid-19 infection itself.

Discussion: Case reports of pituitary apoplexy following Covid-19 infection have been presented in the literature. It is unclear whether this infection occurs as a contributing factor to pituitary apoplexy or coincidentally. It is possible that coronavirus infection could cause an acute hemorrhagic infarction of the gland. This risk increases with anticoagulant and antiaggregant treatments used during Covid-19 infection. Although bleeding into adenomas is spesific to macroadenomas, it should be kept in mind that it may also occur with microadenomas.

Background: Mucormycosis is an opportunistic fungal infection that can be aggressive and mortal. Diabetic ketoacidosis(DKA) is a risk factor for mucormycosis. We present a case with mucormycosis presenting with newly diagnosed diabetes mellitus and DKA.

Case presentation: A 34-year-old male patient presented with confusion and vomiting. He had no comorbiditiy. On admission the patient was afebrile, hypotensive (85/55 mm/hg) and had tachycardia (120/bpm). Laboratory investigations revealed hyperglycemia (673 mg/dl), severe metabolic acidosis (pH:6.86, bicarbonate:2.6 mmol/l) and urinary ketones. The patient was intubated due to cardiac arrest and followed up in the intensive care unit for 15 days. After that, the patient with newly diagnosed diabetes was admitted to our clinic for blood glucose regulation. During follow up, he described a feeling of swelling in the left half of the face and blurred vision. There was an erythematous appearance on the left eyelid. Diagnostic nasal endoscopy showed widespread crusting filling left nasal cavity and necrosis in the adjacent septum and middle meatus

which was suggestive of mucormycosis. Paranasal sinus CT revealed mucosal thickening in the left frontal sinus, left anterior-posterior ethmoidal cells, sphenoid sinus in the left compartment and in the left maxillary sinus, causing almost complete loss of ventilation. Mucosal thickening was observed in the left compartment of the sphenoid sinus and the ethmoidal cells on the left. Left frontal and left sphenoethmoidal recesses were obliterated. Left precentral fatty tissue and left pterygopalatine fossa, around the sphenopalatine foramen were dirty. Orbital CT was normal. Cranial MRI showed 22 × 10 mm flair hyperintensity accompanied by effacement in the sulcus in left frontal lobe, frontobasal-orbitofrontal level, cortical-subcortical located in the medial part. In this location, frontal bone integrity was not clearly differentiated, and signs of inflammation were observed in the adjacent frontal sinus. The patient was operated urgently. Histopathology confirmed the diagnosis of mucormycosis. Liposomal amphotericin-B treatment was started. The patient was discharged with intensive insulin treatment after five weeks.

Conclusion: Mucormycosis is an invasive and progressive disease which requires immediate diagnosis and treatment including surgical debridement. Although uncontrolled and long standing diabetes is a well-known important risk factor for this opportunistic infection, it is rare to see it in patients with newly diagnosed diabetes. Our case is important in terms of showing that this infection can also occur in newly diagnosed diabetes.

Background: We aimed to determine the awareness of obese, overweight and normal weight patients about the complications, causes and prevention of obesity. Methods: Patients who admitted to our clinic during a four months period were included. Demographical features, familial histories of obesity, smoking, alcohol use, chronic diseases, medications, medical nutrition therapy and exercise habits were determined. Answers of agree, not agree or no idea were obtained for 40 questions regarding the definition, consequences, risk factors and prevention of obesity. Patients were grouped as normal, overweight and obese according to the WHO criteria.

Results: Data of 352 patients (282 female and 70 male) were analyzed. There were 51(14.5%) normal weight, 72 (20.5%) overweight and 229 (65.0%) obese patients. Median ages were 49, 44 and 33 in obese, overweight and normal patients, respectively (P < 0.001). Education level was lower and familial history of obesity was higher in obese patients (P < 0.001). The rates of agreeing that obesity may cause insulin resistance, type 2 diabetes, cardiovascular disease, hypertension, dyslipidemia, fatty liver, sleep apnea, asthma, gastrointestinal problems, depression, mental problems, limitation of movement and mortality varied between 69.60% and 92.61%. Only 130 (36.93%), 138 (39.20%) and 191 (54.26%) patients agreed that obesity is associated with cholelithiasis, pancreatitis and cancer, respectively. The rate of patients who thought that obesity may cause death, sleep apnea and asthma were significantly higher in obese compared to normal weight patients. Approximately half of the patients agreed that obesity in family, eating too much, skipping meals, and engaging in other activities during eating are risk factors for obesity. Rates of agreement about risk factors for obesity were similar in three groups. More than 2/3 of patients agreed with how a healthy diet should be, and believed in the benefit of exercise. The rate of those who agreed that 4–6 meals/day and not to miss snacks are important for a healthy diet was highest in the obese group (72.92%, P = 0.043). There was no significant difference between groups in terms of other questions regarding a healthy diet.

Conclusion: While awareness about some of the obesity associated complications are high, awareness about others such as gall bladder disease, pancreatitis and cancer are low. Obese patients have higher awareness that obesity can cause death, sleep apnea and asthma. The knowledge about risk factors of obesity related with eating habits was relatively low. It is important to raise awareness of both obese and non-obese patients for the prevention and appropriate treatment of obesity.

Introduction: Lung transplantation was associated with a 32% prevalence of hypercholesterolemia and a 41% prevalence of hypertriglyceridemia. The prevalence of dyslipidemia in liver transplant recipients is 43% and 31% –51%. In this report, we present 2 cases who developed dyslipidemia after transplantation.

Case 1: The blood test of a 73-year-old male patient who had lung transplantation about 3 years ago revealed Triglyceride (TG) 475 mg/dl (<150), LDLCholesterol: 382 mg/dl (<100), HDL 53 mg/dl (>40), Total cholesterol 431 mg/dl (<200) and HbA1C: 8.3. Six months ago, he was diagnosed with diabetes mellitus by his primary physician. He was on everolimus, prednisolone, and mycophenalate sodium therapy, and was referred to us. There were no cutaneous findings related to hyperlipidemia. After the diet and blood sugar regulation, the tests were repeated; TG was 422 mg/dl and LDL was 366 mg/dl. He had elevated liver function test (LFT) levels, and hepatitis panel and liver auto antibodies were negative. Atorvastatin 1×10 mg was initiated on 14/02/2020. TG was 210 mg/dl (<150), and LDL cholesterol level was 123 mg/dl (<100).

Case 2: A 65-year-old female patient underwent liver transplantation from a cadaver on 12/09/2019 due to toxic hepatitis and on 25/09/2019 due to hepatic vein thrombosis after transplantation. Receiving tacrolimus and mycophenolic acid treatments after transplantation, she developed refractory dyslipidemia after the second transplant. Tests performed in February 2020 showed levels

of Triglyceride 474 mg/dl (<150), LDL-Cholesterol 512 mg/dl (<100), Total Cholesterol 815mg/dl (<200) and HDL cholesterol 11 mg/dl (>50). Pravastatin 1 × 40 mg was initiated in February 2020 and intermittent lipid apheresis was performed. In April 2020, ezetimibe 1 × 10 mg was added to her treatment. In May 2020, LDL level was determined 186 mg/dl.

Discussion: Maintaining or improving allograft function after transplantation and reducing cardiovascular risk are main objectives during follow-up. Interventions for dyslipidemia have the effect of reducing cardiac events in clinical studies specific to transplant population.

Objective: Primary hyperparathyroidism (PHPT) is the most common cause of hypercalcemia. A group of patients who were followed up with a diagnosis of PHPT had normal calcium levels with high parathyroid hormone (PTH) levels. For the diagnosis of normocalcemic PHPT, secondary causes of hyperparathyroidism such as vitamin D deficiency should be excluded. In this study, the data of 318 PHPT patients who were operated were retrospectively analyzed, and biochemical and clinical characteristics of hypercalcemic and normocalcemic patients were compared.

Methods: The data of patients who were admitted to our hospital’s endocrinology clinic between January 2012 and January 2019, diagnosed with PHPT and operated according to guidelines (all symptomatic patients and asymptomatic patients with at least one operation indication) were retrospectively evaluated. A total of 318 patients were divided into two groups as hypercalcemic and normocalcemic according to the corrected calcium level. The two groups were compared according to clinical and biochemical properties.

Results: Female gender was dominant in both groups (P = 0.07). The mean age was similar in both groups (P = 0.36), while it was 54.0 ± 10.3 in the hypercalcemia group, and 55.4 ± 12.8 in the normocalcemia group. As expected, serum corrected calcium (Ca), PTH levels and urinary Ca excretion were higher in the hypercalcemia group (P < 0.01). While phosphorus (P) level was lower in the hypercalcemia group (P < 0.01), urinary P excretion was similar between the two groups (P = 0.77). There was no difference between the two groups in alkaline phosphatase, creatinine, and vitamin D levels. Percentage of localization with preoperative ultrasonography and mean adenoma size were similar. Also, there was no difference in adenoma features (echogenicity, cystic appearance) and localization, thyroid nodules and thyroiditis prevalence on ultrasonography. The positive result obtained on neck MRI and MIBI scanning was similar. There was no difference between the two groups in terms of stone incidence and osteoporosis prevalance (P = 0.72 and P = 0.08, respectively).

Conclusion: In our cohort, corrected Ca and PTH levels and urinary Ca excretion were high in the hypercalcemic group, as expected. But, the phosphorus level was significantly lower in the hypercalcemia group. In the normocalcemic group, the PHPT phenotype was found to be similar to the hypercalcemic group. These findings suggest that the frequency of surgical indications is similar

in normocalcemic PHPT patients to that in hypercalcemic PHPT patients.

Introduction: Hypercholesterolemia may develop due to primary and secondary causes. Diabetes mellitus, hypothyroidism, nephrotic syndrome and liver diseases are among the most common causes of secondary hyperlipidemia. Here, we will present a case with severe hyperlipidemia due to primary sclerosing cholangitis(PSC).

Case: A 36-year-old male patient was admitted to our outpatient clinic due to severe hypercholesterolemia. It was learned in his history that he had increased liver enzymes for 3 years. He was diagnosed with PSC 4 months ago and liver transplantation was planned. The patient was using ursodeoxycholic acid 2x500 mg treatment. On physical examination, blood pressure was 120/70 mmHg, heart rate was 78 beats/minute and he had icteric appearance. Xanthoma, xanthelasma, arcus cornea was not observed. In laboratory tests, AST, ALT, ALP, GGT, total bilirubin, total cholesterol, LDL, triglyceride, VLDL, HDL were 111 U/l, 108 U/l, 1037 U/l, 301 U/l, 17 mg/dl, 574 mg/dl, 499 mg/dl, 348 mg/dl, 70 mg/dl, 5 mg/dl, respectively. The patient had no other comorbid diseases other than PSC. There was no history of early cardiovascular disease or sudden death in family members. It was learned that the patient’s LDL value was 102 mg/dl 5 years ago. The cause of hypercholesterolemia in the patient was considered depending on the PSC. Statin therapy was not considered due to impaired liver function tests. We planned to start cholestyramine 12 grams per day.

Conclusion: PSC is a liver disease with biliary obstruction. Lipid disorder due to biliary obstruction is associated with lipoprotein X (LpX). LpX is a abnormal low density lipoprotein. It is unable to exert negative feedback on the cholesterol synthesis rate limiting enzyme hydroxymethyglutaryl coenzyme A (HMGCoA) reductase. In contrast, the presence of LpX increases the activity of HMG-CoA reductase in the liver with increased hepatic cholesterol synthesis. Patients with biliary obstruction have increased LDL and decreased HDL. Hypercholesterolaemia improves with removal of obstruction or liver transplantation. LDL apheresis, statins and cholestyramine decrease

cholesterol levels in patients with PSC.

Background: Cardiovascular complications of Cushing’s syndrome (CS) include; hypertension, left ventricular hypertrophy, and myocardial ischaemia. Also, CS can cause structural and functional changes in the heart, leading to dilated cardiomyopathy in rare cases. Here, we present a case with dilated cardiomyopathy related to Cushing’s syndrome.

Case: A 31-year-old male patient applied to the cardiology department with shortness of breath that worsened with exertion for a year. Globally advanced hypokinetic and globally dilated heart was found in echocardiography with ejection fraction (EF) 20%. His medical treatment was arranged by cardiology department and referred to endocrinology clinic due to the 25 kg weight gain in one year, increased appetite and purple striae on the abdomen and shoulder. Laboratory tests revealed that; ACTH was <5 pg/ml, cortisol: 24.3 mg/dl, night cortisol: 24.7 mg/dl. After 1 mg dexamethasone suppression test (DST) and, 2 day 2 mg DST cortisol levels were found 18.9 mg/dl and 31.79 mg/ dl, respectively. Because these findings suggest the CS, abdominal MRI was performed and revealed that a mass lesion (adenoma?) with a smooth contour, 37 × 28 mm in size, showing heterogeneous signal loss in the outer phase in the left adrenal gland. No pathological finding was found in pituitary MRI. With these findings, the patient was diagnosed with adreanal Cushing Syndrome. Viral myocarditis, lupus or autoimmune myocarditis was ruled out by negative

viral respiratory panel, and negative autoimmune panel respectively. Absence of hilar adenopathy excluded sarcoidosis. Cardiac MRI conducted for cardiac exclusion of mixoma and revealed no findings that were consistent with the mixoma. After the exclusion of other reasons of cardiomyopathy the patient was diagnosed with dilated cardiomyopathy. In the control echocardiography 2 months after heart failure treatment, EF was found 40%. Metyrapone therapy was started gradually to lower the risk of surgery by lowering the patient’s preoperative cortisol load. The cortisol level was found to be 17.4 mg/dl, 2 hours after the first metyrapone treatment. 10 days after metyrapone treatment, when the cortisol level decreased by 14.8 mg/dl, left adrenal gland

excision was performed. Postoperative cortisol was found to be 1.8 mg/dl and 3.2 mg/dl. Pathology result was compatible with nodular diffuse hyperplasia.

Conclusion: Dilated cardiomyopathy and left ventricular failure are rare presentations of CS. Since cardiomyopathy can be reversed following successful treatment of Cushing’s syndrome it is important to consider this diagnosis in patients with both heart failure and signs of CS.

Background: Pheochromocytomas are rare tumors originating from chromaffin cells and characterized by excessive catecholamine synthesis. They are usually benign lesions. Hypertension(HT), tachycardia, sweating and headache are frequently observed. We aimed to present a high malignancy suspected pheochromocytoma case diagnosed in a young age female.

Case presentation: A 20-year-old female patient was admitted to the emergency department due

to high blood pressure, tinnitus and headache. The patient was hypertensive (220/110 mmHg) and had tachycardia (130/bpm). For the etiology of HT, renal doppler USG was performed. An extra-renal solid mass lesion (pheochromocytoma?) was reported. She was referred to our clinic. Surrenal MRI revealed a lesion in the left paraaortic area with 40 × 37 mm enhancement in the area corresponding to the adrenal region. 24-hour urinary normetanephrine and metanephrine levels were found 10 times higher than upper limit of the reference range. Laparoscopic partial adenomectomy was performed by the urologist. After surgery, blood pressure was return to normal range without any medication. In histopathology, Ki 67 proliferation index was reported as 20%. Periadrenal adipose tissue invasion, atypical mitosis, lymphovascular invasion and capsule invasion were found positive. Calculated PASS score was reported 6/21 and it was evaluated as high suspicion of malignancy. Genetic analysis (VHL, MEN, SDH) result was negative. The patient had an identical twin. Pheochromocytoma symptoms of the identical twin were not present. In the literature some cases of identical twins which have concominant pheochromocytoma were reported.

We performed pheochromositoma screening tests for identical twin and no pathology was found.

Conclusion: Although pheochromocytoma is most common in the 4th and 5th decades, it can be seen in all age ranges. The majority of patients are sporadic, there are also hereditary forms. Genetic background should be investigated in patients diagnosed with pheochromocytoma at the young age. Although our case was diagnosed with pheochromocytoma at a young age, her genetic tests was not

showed any mutation.

Objective: There is limited clinical data available on bilateral adrenal masses (BAM). Here we present a case with BAC and adrenal insufficiency. The patient’s lesions disappeared after steroids, re-grew in the follow-up, allowing a biopsy.

Case: A 60-year-old male patient presented with abdominal pain, nausea, and weakness to another hospital. Hyponatremia and hyperkalemia accompanied by hypotension were detected. Abdominal tomography revealed, “irregularly demarcated hyperdense mass lesions, 60 × 44 mm in the right and 75 × 26 mm in the left adrenal.” Upon referral to our hospital, we employed PET-CT, which demonstrated “mass lesions of 49 × 52 × 71 mm in the right and 56 × 57 × 75 mm in the left adrenal as well as pathological hypermetabolism in multiple foci in the skeletal system.” After diagnosing adrenal insufficiency, we initially gave the patients intravenous hydrocortisone, followed by oral maintenance. There were no pathological findings in tuberculosis tests, viral and autoimmune panel, and malignancy screening. Urine and plasma catecholamine and 17-hydroxy progesterone levels were normal. CT-guided biopsy of the adrenal mass revealed fat necrosis. After 45 days, we attempted a repeat biopsy without success due to almost wholly regressed adrenal masses. Also, bone lesions could not be visualized. Adrenal MRI showed “14 mm lesion on the right and, only diffuse thickening on the left adrenal.” A control PET-CT was obtained. “Evident decrease in the size of the adrenal lesions, in addition to the fairly reduced metabolic activity of adrenal masses and bone lesions.” We performed a biopsy from the most active bony lesion; however, it was inadequate. Two months after the initial presentation, he was admitted with abdominal pain. His lesions had progressed. In CT he had, 70 × 41 mm right adrenal mass invading liver and IVC, 56 × 38 mm left adrenal mass, and numerous metastasis in his liver and lungs. Adrenal biopsy, this instance was compatible with “CD20 + B cell lymphoma infiltration.” Patient died of cerebrovascular incident, whilst awaiting biopsy results.

Conclusion: Primary adrenal lymphoma is a rare etiological cause of BAM with only a handful of reported cases. Adrenal lesions vanishing after steroids should raise the suspicion of adrenal lymphoma. The shrinkage of tumors may lead to diagnostic difficulties such as our patient.

Background: Cytochrome P450 oxidoreductase (POR) deficiency is an autosomal recessive steroidogenesis disorder similar to combined deficiencies of 17α-hydroxylase, 17,20-lyase, 21-hydroxylase. POR deficiency (PORD) is a very rare type of congenital adrenal hyperplasia(CAH) characterized by sexual development disorders and skeletal anomalies. We present a case that was evaluated with a prediagnosis of nonclassical CAH and was found to have a heterozygous mutation in the POR gene.

Case report: A 23 years old male patient applied to our clinic with complaint of excessive hair. These symptom had started on her arms and legs at 6 years old, appeared on her back at 8 years old, then spread to all over the body. He has reached his final adult height at about 15 years old. He had no history of chronic illness, his 47 years old mother and 56 years old father were consanguineous. On physical examination, his blood pressure was 120/80mm/hg, height was 161cm, the length of the penis was 9.5cm and testicular volume was 20 ml. Laboratory tests were as follows; glucose 89 mg/dl (70−99), sodium 138 mEq/l (132−146), potassium 4.7 mEq/l (3.5−5.5), cortisol 20.3 mg/dl (5.2−22.4), ACTH 37.8 pg/ml (<46), TSH 1.6 mU/l (0.55−4.78), sex hormone binding globulin 7 nmol/l (10−57), FSH 3.2U/l (1.4−18.1), LH 6.9U/l (1.5-9.3), progesterone 1.26 mg/l (0.28−1.22), total testosterone 383 ng/dl (164−753), dehydroepiandrosteronesulfate 698.72 mg/dl (34.5−568.9), 17-alpha-hydroxyprogesterone (17-OHP) 1.22 ug/l, free testosterone 26.6 pg/ml (15−50), androstenedione 13.5 nmol/l (2.1−10.8). Maximum 17-OHP was 3.36 mg/l after ACTH-stimulation. Abdominal magnetic resonance imaging showed normal adrenal glands. Scrotal ultrasonography was normal. Bone age was 18 years. Genetic testing revealed that the patient was heterozygote for c.461A > T(p.Asp154Val) mutation in exon 5 of POR gene while CYP21A2, CYP17A1, CYP11B1, HSD3B2, STAR genes were normal. Subsequent genetic testing of parents showed that his mother also had POR(NM_000941.3):c.461A > T(exon5) heterozygote mutation, while there was no mutation in his father.

Conclusion: A great number of POR variants affecting more than 130 amino acids in the POR protein have been reported. There is clinical heterogeneity in patients with POR gene mutations, making the diagnosis difficult. Considering that the POR gene mutation shows ethnic differences, we think that the determination of variant cases in our society will clarify its importance in this case in the future

Aim: It is known that serum thyroglobulin (TG) can increase after fine-needle biopsy of thyroid nodules. We aimed to determine whether TG is increased after ultrasonography guided fine needle capillary biopsy (FNC) of suspicious cervical LNs in thyroidectomized patients and investigate the

possible association between change in TG and cytology results.

Material and methods: Data of 188 patients who underwent FNC of suspicious cervical LNs were

retrospectively evaluated. Demographical features, radioactive iodine (RAI) treatment status, thyroid-stimulating hormone (TSH), TG, anti-TG antibody and ultrasonography features of LNs were noted. TG levels before FNC (TGb-FNC), after FNC (TGa-FNC), TGa-FNC/TGb-FNC ratio and the number of patients with increased TG were determined. Patients were grouped as benign, nondiagnostic, suspicious for malignancy and malignant according to the cytological results.

Results: The age, gender, clinical diagnosis, history of RAI treatment and TSH levels were similar in different cytological groups. TGa-FNC, Tgb-FNC/Tga-FNC, and rate of patients with increased TG were significantly higher in malignant cytology group than other groups (P<0.001)(Table). The optimal cut-off level of TG increase that was predictive for malignancy was 7.6% with a sensitivity of 73.7% and specificity of 85.2%. TG increase was not associated with age, sex, TSH level, antiTG positivity and US features of LNs while signficantly lower in patients who received RAI treatment.

Among 31 patients with positive anti-TG, TGb-FNC/TGa-FNC, and rate of patients with increased TG were higher in malignant compared to benign and nondiagnostic cytology groups.

Conclusions: Serum TG increment and rate of patients with increased TG after FNC of suspicious cervical LNs were higher in patients with malignant cytology than with all other cytology results both in all study group and in subgroup of anti-TG positive patients. Increase in TG after FNC might be an additional tool for determining LN metastasis.

Table. Demographical, clinical and ultrasonography features and thyroglobulin levels in patients with respect to the cytological results of lymph nodes

Quantitative and categorical variables are summarized by median (IQR: 25^th -75^th percentiles) and frequency (%), respectively.

^1,2,3The same numbers indicates that the corresponding groups are significantly different from each other.

Objectives: Adherence to treatment is one of the most important parameters that affect the success of the treatment in hypothyroidism. We aimed to evaluate the use and adherence to treatment and determine the factors that are related to adherence in patients on levothyroxine therapy.

Materials and Methods: Patients older than 18 years old and using levothyroxine for hypothyroidism were recruited. Demographical, sociocultural and clinical statuses of patients were determined. The practices of using levothyroxine and compliance were evaluated through a questionnaire. Thyroid hormones and antibodies were obtained from medical records. Those who answered the frequency of not using/skipping the drug as never/rarely, sometimes and frequently/often were grouped as high, medium and low adherence, respectively. Data of high, medium and low adherence patients were compared.

Results: A total of 335 patients - 282 (84.18%) female and 53 (15.82%) - male were included. Mean age was 47.36±12.50. 330 (98.50%) patients were taking levothyroxine in the morning and 332 (99.10%) were taking fast. The period between the drug and meal was 15 min in 66 (19.88%), 30 min in 170 (51.20%), 45 min in 25 (7.53%), at least 1 h in 63 (18.98%) patients, while 8 (%2.41) patients were taking it just before or during the meal. Among 145 (45.03%) patients who use a medication that may interfere with the absorption of levothyroxine, 66.66% were using it in less than 2 h of levothyroxine. There were 218 (65.08%) high, 98 (29.25%) medium and19 (5.67%) low adherence patients. Drug adherence was not associated with sex, age, marrital and working status, smoking, alcohol use, the cause and duration of hypothyroidism, presence of comorbid disease and thyroid hormones. The rate of patients graduated from primary school was higher in low adherence and rate of patients graduated from university was higher in high adherence groups (P = 0.008). Familial history of thyroid disease was associated with high adherence (P = 0.013).

Conclusion: We showed that drug adherence is medium or low in 34.92% of hypothyroid patients, and education level and familial thyroid disease were related with high adherence. Although majority of patients take levothyroxine at fast, 22.29% eat less than 30 min after taking the drug. In addition, a considerable amount of patients using medications that inhibits the absorption of levothyroxine did not leave required time between two medications. For effective treatment of hypothyroidism, it is important to increase drug compliance and inform patients about hypothyroidism and levothyroxine.

Background: Diabetic ketoacidosis (DKA) is one of the most serious complications of diabetes. It is characterised by the triad of hyperglycemia (blood sugar >250 mg/dl), ketosis and metabolic acidosis (arterial pH <7.3 and serum bicarbonate <18 mEq/l). Rarely these patients can present with blood glucose (BG) levels of less than 200 mg/dl, which is defined as euglycemic DKA.

Case: A 22-year-old female patient applied to the primary care physician with tingling and numbness in the hands. Fasting blood glucose was 205 mg/dl with normal renal and liver function tests in the first laboratory evaluation and then suggested to apply to the endocrinology clinic. After learning about high blood sugar level, she avoided foods containing carbohydrates and followed a ketogenic diet. She is 160 cm tall and 45 kg heavy. The patient referred to the endocrinology clinic with nausea two weeks later. Her plasma glucose level was 86 mg/dl with an HbA1C of%10.3. HbA1C measurement was repeated and confirmed to be high. She was diagnosed with diabetes. Her laboratory assessments revealed an elevated anion gap of 20.9, increased urinary and plasma ketones, and metabolic acidosis. Low hCG values excluded pregnancy The diagnosis of euglycemic DKA was made, and treatment with intravenous fluids and insulin was initiated, then the patient improved.The C-peptide level was 0.42 mg/l (n:0.81-3.85 low normal). Anti-glutamic acid decarboxylase and anti-insulin antibodies were negative, while the anti-islet cell antibody was positive. There was no one with diabetes in her family. She was screened for liver diseases and glycogen storage diseases, and no pathological condition was detected.

Conclusion: We present a type 1 diabetic patient diagnosed with euglycemic DKA. The possible aetiology of euglycemic DKA includes decreased caloric intake, heavy alcohol consumption, the recent use of sodium-glucose cotransporter 2 inhibitors, chronic liver disease and glycogen storage disorders. DKA in pregnancy has also been reported to present with euglycemia. Our patient had euglycemic DKA triggered by the ketogenic diet. Euglycemic DKA can be missed or inadequately treated in patients presenting with euglycemia on initial presentation. Recognising this condition in newly diagnosed patients can also be a challenge for physicians.

Background: Immune checkpoint inhibitors, including anti-programmed cell death-1 (PD-1) antibodies, have become promising treatments for a variety of advanced malignancies. Nivolumab, an anti-PD-1 monoclonal Ab, is an effective treatment of unresectable metastatic melanoma, non-small cell lung cancer, renal cell carcinoma, head and neck cancer, Hodgkin lymphoma, and gastric cancer. These medicines can cause immune-related adverse events (irAEs), including endocrinopathies. Thyroid dysfunction (TD) is a common irAE induced by nivolumab. The TD includes hypothyroidism and thyrotoxicosis, which are generally mild to moderate. The most common endocrine adverse event with anti-PD-1 therapy is hypothyroidism (around 5.9% cases). Thyrotoxicosis is related to destructive thyroiditis in most of the cases. Patients with TgAbs or TPOAbs are prone to develop destructive thyroiditis after initiation of nivolumab treatment. The development of hyperthyroidism owing to Graves’ disease is virtually very rare, with only 4 cases reported so far. Here we aimed to present the 5th case of Graves’ disease after Nivolumab therapy.

Case presentation: A 75-year-old woman with primary malignant urethral melanoma received three courses of nivolumab at a dose of 240 mg every two weeks. Laboratory tests performed before the 4th course due to the patient’ palpitation. Thyroid- stimulating hormone (TSH), free triiodothyronine and free thyroxine level were < 0.015 (normal range [NR]: 0.55-4.78) mU/l, 7.44 (NR: 2.3-4.2) ng/l and 2.4 (NR: 0.89-1.76) ng/dl, respectively. Her thyroglobulin (Tg-Ab) and thyroid peroxidase antibody (TPO-Ab) were both positive, while TSH receptor antibody (TRAb) was negative. Thyroid ultrasonography showed enlargement of both thyroid lobes with low echogenicity and increased vascularity. Thyroid scintigram showed an increased and diffuse uptake. She had been diagnosed with Graves’ disease approximately eight years ago and treated medically. Tg-Ab and TPO-Ab were both positive, and TRAb was negative like now. After medical treatment was over, the patient was euthyroid in follow-up and even before PD-1 treatment.

Conclusion: While antibody positivity often causes destructive thyroiditis, differently caused Graves’ disease in this case. Also, this is the first case-reported that nivolumab therapy induced a relapse of Graves’ Disease.

Background: Although high levels of calcitonin suggest neoplastic proliferations such as medullary thyroid carcinoma, C cell hyperplasia and some neuroendocrine tumors, systemic diseases and drugs may also elevate calcitonin. Although calcitonin is not as effective as PTH, it has got a role in calcium hemoastasis. Supraphysiological calcitonin level can lead to hypocalcemia.

Case presentation: A 57-year-old male patient was diagnosed with epilepsy with complaints of contraction in the body at the age of 16. Phenytoin therapy was started. He had no epileptic seizures for 13 years. Basal ganglia calcification was detected in brain CT which had been taken when he had muscle contractions  while he had been hospitalized for measles in 1992. Calcium: 6.9 mg/dl phosphorus: 5.3 mg/dl albumin: 4.7 g/dl, parathormone: 499 pmol/l (219-659) calcitonin: 145 (0-50) was measured and hypoparathyroidism was diagnosed. Calcitriol and calcium carbonate treatment had been started. In another medical center it was thought that he had pseudohipoparathyroidism, because calcium was normal, vitamin D and parathormone were high while he was not taking calcium replacement treatment. He came to outpatient clinic in 2018 while he was taking 2000 mg oral calcium carbonate treatment. Calcium: 8.9 mg/dl (8.7-10.4) phosphorus:3.5 mg/dl albumin:4.5 g/ dl, parathormone: 41 ng/l (18-80), 25-OH vitamin D: 41 ng/ml (25-80), 1,25OH vitamin D: 24.1 pg/ml (18-64) kalsitonin:117 ng/l (<8.4) was measured. Pseudohipoparathyroidism wasn’t considered with clinical findings. The control calcitonin value was 144, and the highest calcitonin value was 323. Thyroid USG and CEA levels were normal. He had no medullary thyroid carcinoma history in the family. CDKN1B, RET, menin gene analysis were normal. 24-h urinary calcium was 55 mg/day. The heterophile antibody examined by the PEG precipitation method and heterophile antibody-coated tube was negative. No pathological lesions were detected in GA-68 DOTA peptide imaging performed for possible neuroendocrine tumor.

Conclusion: In cases of hypercalcitoninemia, C cell neoplasms should be investigated primarily. In this case, medullary thyroid carcinoma was not considered with the current findings. Due to the coexistence of hypocalcemia and endogenous hypercalcitonemia, the possibility of autosomal dominant hypocalcemia was considered in which calcium sensing receptor activation is playing a role. However, hypocalcuria was interpreted against this possibility. In case of low/normal parathormone in the etiology of hypocalcemia, it is also suggested to measure the calcitonin level.

Background: Fine needle aspiration biopsy (FNAB) and Bethesda System for Reporting Thyroid Cytopathology (TBSRTC) have proven to be the most valuable diagnostic procedure for preoperative discrimination of benign and malignant thyroid nodules. Thyroid surgery may cause regional scarring and some degree of fibrotic process which may result in problems when collecting FNAB samples and evaluating the cellular abnormalities. In this study, we aimed to determine whether the Bethesda classification system in thyroid nodules is reliable in patients with a history of thyroid surgery.

Methods: We retrospectively examined outcomes of 130 patients with 260 nodules who underwent a thyroidectomy for recurrent goiter (Group 1) and compared them with 2821 patients with 5890 thyroid nodules who underwent first thyroidectomy (Group 2) in our center between 2007 and 2014.

Result: Malignancy rate was significantly lower in group B (24 (18.5%) patients) compared to group A (911 (32.3%) patients) (P = 0.016). The most frequent operation indications in group A may explain the hight rate ofmalignancy in this group, that were giant nodule and suspicious cytology results in group B and group A respectively (P = 0.001). Hypothyroidism was significantly higher in group B and result by a hight ratio of gaint nodules (P = 0.001). Although a relationship between giant nodule and higher malignancy rate was reported in previous studies, we did not find a correlation between giant nodules and malignancy rate of patient in group B. Diagnostic value of Bethesda was determined in patients with primary and reoperative thyroid surgery. Benign cytology was considered negative and suspicious for malignancy and malignant cytologies were considered positive. Sensitivity, specifity, PPV, NPV and accuracy of Bethesda classification in patients with primary thyroid surgery were 74.50%, 98.18%, 83.38%, 96.92% and 95.60%, respectively. In patients with reoperative thyroid surgery, sensitivity was 62.50%, specifity was 98.91%, PPV was 71.43%, NPV was 93.38% and accuracy was 97.39%.

Table 1. Diagnostic value of Bethesda classification in patients who underwent primary and reoperative thyroid surgery.

Conclusion: FNAB is known to be the most accurate and cost-effective method that provides avoidance of unnecessary surgery in 25% of patients with benign thyroid disease. A lower frequency of malignancy was observed in patients/nodules with reoperative thyroid surgery compared to patients/nodules with primary thyroid surgery in this surgical series. Sensitivity and PPV of Bethesda were affected negatively by previous thyroid surgery. This might be considered in these patients while deciding for a recurrent surgery which has a higher risk of complications.

Background: Alstrom syndrome is a rare autosomal recessive genetic disorder characterised by vision loss, hearing loss, childhood obesity, insulin resistance and hyperinsulinemia, type 2 diabetes, hypertriglyceridemia, cardiomyopathy, and progressive pulmonary, hepatic, and renal dysfunction. Hyperinsulinemia develops early, and pancreatic islets show beta-cell proliferation, thus suggesting that both insulin resistance and increased insulin secretion might contribute to glucose intolerance. Increased triglyceride levels, steatosis in  the liver and pancreas can also amplify the insulin resistance.

Case presentation: A 20-year-old male patient was diagnosed with congenital amaurosis at the age of 6, diabetes mellitus and hypothyroidism at the age of 8, and hearing loss at the age of 9. Then mutations in ALMS1 detected and Alstrom syndrome was diagnosed. No pathology was detected in bone marrow biopsy for pancytopenia in 2015, and follow-up planned. Chronic liver disease and esophageal varices were detected in 2017. He was admitted to our Endocrinology outpatient clinic with high blood sugar. The serum level of FPG, HbA1c, insulin (fasting), and c-peptide were 148 mg/dl, 10.5%, 63.1 mU/l (3-25) and 5.31 mg/l (0.81-3.85), respectively. Anti-GAD, anti-islet antibody and anti-insulin antibody were negative. He was hospitalised for blood glucose regulation. His height was 155 cm and body weight was 55 kg. On admission, he received 15 units/day insulin glargine and 25 units/day insulin aspart. The total daily insulin requirement increased to 216 units and blood glucose was in the range of 150-300 mg/dl. Due to cirrhosis, the recommendation of pediatric metabolic disease doctors was taken, and then metformin and pioglitazone treatment were started while sodium benzoate treatment was continuing. Liver decompensation did not develop at follow-up and insulin requirement gradually decreased to 160 units/day and blood glucose decreased to 90-190 mg/dl.

Conclusion: In diabetes mellitus types with insulin resistance such as Alstrom syndrome, drugs that increase insulin sensitivity such as metformin and glitazone come into prominence. Due to cirrhosis of our case, metformin and pioglitazone treatment was started cautiously. There was a significant decrease in insulin requirement and improvement in the brittle blood glucose profile without any side effects.

Objective: Primary hyperparathyroidism (PHPT) is a clinical condition characterized by hypercalcemia-specific symptoms and signs caused by excessive secretion of parathormone. After the evaluation of blood calcium measurements within routine tests, the frequency of hyperparathyroidism increased and there is a marked decrease in the frequency of classical symptoms and signs. Recently, most PHPT cases are detected in the asymptomatic period, and which of these asymptomatic patients will go to surgery, is individually evaluated. In this study, it was investigated whether there is any feature that can be taken into account in the diagnosis and follow-up by considering the calcium course in the period until the development of hypercalcemia.

Methods: The biochemical records of patients who were operated with the diagnosis of PHPT and whose histopathological diagnosis was parathyroid adenoma were reviewed from our database. We evaluated patients who had at least 2 consecutive albumin corrected calcium levels before the time of first hypercalcemia were detected, during the preoperative period. The date when the first hypercalcemia detected, first hypercalcemic value, normocalcemic values and dates, and the intervals between them were recorded. We determined delta change and percentage changes within the patients who had at least 1 year of periyod between normocalcemia values.

Results: In this study,18(94.7%) female and 1(5.3%) male,19 patients with PHPT were included and the mean age was 52.21 ± 10.9. The median time to develop hypercalcemia after the last normocalcemia time was 5 months (0.5-36 months). Median hypercalcemia level was 10.3 mg/dl (10.1-10.9),median for last normocalcemia was 9.8 mg/dl (9.3-10.0). It was found that the development time of hypercalcemia was decreasedas the normal calcium level increased (P = 0.044). A higher hypercalcemic value was found as the time between normocalcemia and hypercalcemia increased (P = 0.049). The course of increase in calcium levels over time was statistically significant (P = 0.0). For the course of changes in normocalcemic values determined in these 19 patients until hypercalcemia was detected, delta change and percentage changes of 12 patients with 2 normocalcemic values at least 1 year intervals before the development of hypercalcemia were calculated.

Conclusion: Recently, some patients with primary hyperparathyroidism who are asymptomatic at the time of admission are treated surgically and some of them are followed up. Individualized treatment is applied in this regard, according to the guidelines some of the patients recommended surgery are followed, some of those recommended for follow-up are also operated. More information about the natural course of untreated primary hyperparathyroidism can help resolve this imprecise situation.

Aim: While the histopathological diagnosis is parathyroid adenoma in majority of patients with primary hyperparathyroidism (PHPT),parathyroid hyperplasia, atypical parathyroid adenoma or parathyroid carcinoma can be seen in others. Although it is known that serum calcium (Ca) and parathyroid hormone (PTH) levels are higher in patients with parathyroid carcinoma, there are not any cut-off value for serum Ca, phosphorus (P) and PTH levels defined for different histopathological parathyroid lesions. In this study, we aimed to determine cutoff levels for serum Ca, P and PTH in different histopathological PHPT lesions.

Materials and Methods: The data of 392 patients operated for PHPT were evaluated retrospectively. Patients were grouped as parathyroid hyperplasia, parathyroid adenoma and atypical parathyroid adenoma according to histopathological results. Three way ROC analysis was used to evaluate the performance of serum Ca, P and PTH to determine the three groups. It was shown that Volume Under Surface (VUS) higher than 0.17 was giving information beyond chance. Cut-off levels and correct classification rates (CCR) were calculated when the VUS value was significantly higher than 0.17.

Results: There were 19 patients with parathyroid hyperplasia, 343 with parathyroid adenoma and 31 with atypical parathyrod adenoma. Serum Ca, P and PTH levels were significantly different between groups (P = 0.026, P = 0.003 and P ≤ 0.001, respectively). Serum Ca was significantly lower in parathyroid hyperplasia group compared to other two groups (P = 0.032 and P = 0.036, respectively). Serum Ca was similar in patients with parathyroid adenoma and atypical parathyroid adenoma (P = 0.999) (Table 1). The performance of serum P and PTH to determine groups were not sufficient significantly (P >0.05). In determining the groups, only the VUS value of serum Ca was statistically significantly higher than 0.17 (P = 0.005). The cut-off values for the variable

were determined as C₁ = 10.73 mg/dl and C₂ = 11.40 mg/dl, respectively.

Conclusion: In this study, we found that serum Ca levels can be predictive for the histopathological diagnosis in patients with PHPT. Serum Ca lower than 10.73 mg/dl, 10.73–11.40 mg/dl and >11.40 mg/dl were determined to predict parathyroid hyperplasia, parathyroidadenoma and atypical parathyroid adenoma, respectively.

Table 1. Serum calcium, phosphorus and parathyroid hormone in patients with primary hyperparathyroidism according to histopathological diagnosis

Introduction: Primary hyperparathyroidism (PHPT) is a common endocrine disorder that is characterized by hypercalcemia and elevated or normal levels of parathyroid hormone (PTH). Most PHPT cases are incidentally discovered when routine laboratory analysis reveals hypercalcemia. PHPT should be considered in any person with elevated serum calcium (Ca) levels and no clear evidence of malignancy. Serum phosphorus (P) is low due to the phosphaturic effects of PTH and mostly in the lower half of the normal range. As serum Ca and P are inversely related in PHPT, we examined the diagnostic value of the serum Ca/P ratio in the diagnosis of PHPT.

Method: A total of 364 patients followed at our clinic with a diagnosis of PHPT were retrospectively analyzed. As a control group, we selected 98 patients who attended the clinic in the same time period, presenting serum PTH, Ca and P within the normal range. The main outcome measures were: serum Ca, P, albumin, PTH, 25-OH vitamin D and creatinine. Both patients with normocalcemic PHPT and hypercalcemic PHPT were included. The diagnostic accuracy of Ca/P was investigated using receiver operator characteristic (ROC) curve analysis. The resultant cut-off was verified using the independent set of data containing 100 patients and 50 control cases.

Results: There were 317 (87%) females and 47 (13%) males in patients group, and the mean age of the cohort was 53.9 ± 11.4 years (range: 20–82 ). Ca and PTH were significantly higher in PHPT than in controls (P < 0.0001). The Ca/P ratio was also significantly higher in PHPT than in controls (P < 0.0001). ROC curves analyses identified a cutoff value as 3.23 (mg/dl) for Ca/P ratio with a sensitivity and specificity of 94% and 93%, respectively (P < 0.0001). This cut-off value was confirmed by an independent group of cases (100 PHPT and 50 control cases) with 91% sensitivity and 80% specificity.

Conclusion: Ca/P is a precious predictor for the diagnosis of PHPT and it can be used instead of evaluating serum Ca and P levels solely. As Ca/P ratio is easily accessible and inexpensive, it will be useful for PHPT diagnosis and provide simplicity especially for the practitioners with limited resources.

Introduction: Primary hyperparathyroidism (PHPT) is a prevalent endocrinologic disease and the most common cause of hypercalcemia. PHPT usually affects the elderly. PHPT younger than 40 years of age is less frequent. In young patients especially for ones younger than 30 years of age, screening for familial syndromes such as MEN 1 and MEN 2A is recommended. However, in most of the cases genetic tests are negative and evidence for other endocrine components are absent. Herein this study we retrospectively evaluated the data of 322 patients with asymptomatic PHPT patients who were operated and compared the biochemical and clinical features of young patients (<40 years old) with older ones.

Method: This study had a retrospective design. We evaluated the data of the patients who admitted to our university hospital’s endocrinology clinics and diagnosed with PHPT between September 2015-may 2018. According to the clinical guidelines all symptomatic patients and asymptomatic ones who had

at least one indication for surgery were operated. There were 346 adenomas belonging to 322 patients in total. The patients were classified into 2 groups regarding age (<40 years or >40 years old as Group 1 and 2, respectively). Two group was compared according to clinical, biochemical and histopathologic features.

Results: There wasn’t any statistically significant difference between groups according to histopathology (adenoma, hyperplasia and carcinoma) (P = 0.065). In both groups there was female predominance, but number of male patients was significantly higher in Group 1 compared to Group 2 (P = 0.004). Serum Ca levels were similar whereas PTH level was higher in Group 1. According to ultrasonographic features, Group 2 had higher prevalence of accompanying thyroid nodules or thyroiditis (P <0.001).Interestingly T scores on femur and total vertebra and prevalence of osteoporosis were similar in between two groups. The percentage of preoperative localization with US and mean size of adenomas were similar. However positive result on MIBI scan was higher in Group 2. median Urinary Ca excretion was higher in Group 1 despite similar vitamin D levels (P = 0.0012).

Conclusion: The phenotype of PHPT in young adults is different from older patients. In our cohort number of male patients, serum PTH, urinary Ca excretion were higher in younger patients.

Introduction: Denosumab is a monoclonal antibody, which is used to prevent bone-related

outcomes in patients with solid tumor bone metastasis and reduces the transfer of calcium from

bone into the blood. It rarely causes severe hypocalcemia as a side effect. Here we present a case of

severe hypocalcemia lasting 8 months after administration of a single dose of denosumab given for

diffuse bone metastasis. The patient’s concomitant surgical hypoparathyroidism has also contributed

to the development of hypocalcemia.

Case: A 57-year-old female patient who underwent left mastectomy for breast cancer in 2002 and

received chemotherapy and radiotherapy was operated for multinodular goiter in 2013.

Histopathological diagnosis was multifocal papillary thyroid carcinoma and it was in complete

remission. In April 2018, she was diagnosed with postoperative hypoparathyroidism and her serum

calcium levels were in normal ranges with calcitriol 0.5 mcg/day and calcium carbonate 1000

mg/day. In December 2018, she was given denosumab 60 mg subcutaneously and capecitabine

treatment due to disseminated bone metastasis of breast cancer detected in 18F-FDG-PET

examination. Although her serum calcium was 9.3 mg/dL a few days before denosumab, four days

after injection her serum calcium was 6.9 mg/dL. Her calcitriol and oral calcium supplementation

doses were increased in course of time in another clinic. At the second month of denosumab, she

was consultated to our clinic due to weakness, tingling in the body and numbness and a serum

calcium was 6.2 mg/dl (8,7-10,4), phosphorus was 4.3 mg/dL (2,4-5,1), albumin was 36 g/L

(32-48) and parathyroid hormone was 28.0 pg/mL (18,5-88) despite treatment with calcitriol 2

mcg/day and oral calcium 5000 mg/day. She was hospitalized and intravenous calcium infusion was

given with oral active vitamin D and calcium supplementation. Since the patient had low calcium

values with calcitriol, treatment was replaced by alphacalcidol. During hospitalization, intravenous

calcium infusions were repeated and oral vitamin D and calcium supplementation doses were

increased. Her serum calcium could be maintained between 7.5-8 mg/dl with high doses of vitamin

D and calcium. She was on 3 mcg/day alphacalcidol, 8000 mg/day calcium carbonate and she had a

serum calcium of 7.6 mg/dl when she was discharged at the 25th of hospitalization. She was

followed weekly and then every 15 days in the outpatient clinic and vitamin D and calcium

supplementation doses were reduced, gradually. Finally at the 8th month of denosumab injection,

the treatment doses of alphacalcidol and calcium carbonate could be reduced to basal levels which

were 0.5 mcg/day and 1000 mg/day, respectively.

Conclusion: Hypocalcemia is a known side effect of denosumab, however it is usually mild. In the

case of coexisting hypoparathyroidism, severe and prolonged hypocalcemia that needs to be treated

with intravenous calcium and very high doses of vitamin D and oral calcium supplementation may

occur.

Background: It is known that 85-90% of the parathyroid adenomas (PA) are found in usual locations while

5-10% can be located ectopically in the thymic band or mediastineum. PAs are visualized as oval and

hypoechoic lesions generally parallel to the thyroid gland in two dimensional ultrasonography (US) images.

However, adenomas with atypical locations can be in different forms in the three dimentional plane. The

most common form is the bean grain type. In this report we present four cases of atypical PA with different

US features and locations.

Case-1: A 41-year old patient was referred to emergency service with hypercalcemia crisis. His calcium (Ca)

and intact parathyroid hormone (iPTH) levels were 14.24 mg/dl and 735 pg/ml respectively. His biochemical

parameters were shown in table. Since Ca level did not decrease with intravenous hydration and loop

diuretics, hemodialysis was performed and his Ca level decreased to 11 mg/dl. There was no lesion

compatible with PA in his first neck US. Technetium-99m-sestamibi was compatible with PA. No adenoma

was found in the second US evaluation also. But when the US probe was changed from 13-5 MHz to 10-5

MHz and the tissue penetration was also changed, a giant PA isoechoic with the thyroid gland was seen

inferior to the right thyroid lobe starting from the lower end extending to the cervical vertebrae. PA was

removed successfully with minimally invasive procedure (MIP) and the histopathological diagnosis was

atypical PA.

Case 2: A 52-year old woman was referred to our clinic because of hypercalcemia. Her biochemical

parameters were shown in the table. US revealed a hypoechoic lesion (compatible with PA) with

macrocalcific areas, fibrous bands and partial cystic changes in the inferior posterior part of the right thyroid

gland. She underwent MIP and atypical PA was detected histopathologically.

Case-3: A 35-year old woman admitted to emergency clinic due to the hypercalcemia crisis (biochemical

parameters were shown in table). A giant PA lesion in the right thyroid gland starting from the middle part to

the inferior part was detected in neck US. It was iso-hypoechoic and had partial cystic areas. After the

removal of the PA, her Ca level was normalized and histopathologically atypical PA was observed.

Case-4: A 82-year old man was referred to our outpatient clinic due to hypercalcemia. His US finding was

consistent with PA located superior to the right thyroid gland. It was isoechoic and had partial cystic areas.

He underwent MIP and Ca levels decreased to normal levels. The histopathological diagnosis was atypical

PA.

Conclusion: The common US findings of these four atypical PAs were either the anteroposterior diameter

was longer than the transvers diameter (in all of the four cases) or the PA was larger than the longest

diameter of the thyroid gland (case 3 and 4). Our findings suggest that the location and the size of atypical

PAs may also be atypical.

Table. Biochemical features and Technetium-99m-sestamibi results of the patients and sizes of the

parathyroid adenomas and the longest diameter of the thyroid gland

Variables Case 1 Case 2 Case 3 Case 4

Calcium (mg/dl) 14.24 13.4 15.3 12.3

Albumin (gr/dl) 4.82 4.5 4.61 4

Phosphorus (mg/dl) 2 1.9 2.5 1.8

Creatinine (mg/dl) 1.35 0.8 0.75 1.2

Alkaline phosphatase

(IU/L)

66 159 290 132

Parathyroid hormone

(pg/ml)

735 270 998 387

25-hydroxy vitamin D

(µg/L)

16.4 23.3 5.1 8.13

Parathyroid adenoma size

(mm)

Anteroposterior 40 25.8 21 30

Transvers

Longitidunal

18.5

38.7

18.9

33.5

12.9

49.7

25

40

Technetium-99m-

sestamibi scintigraphy

positive positive negative positive

Longest diameter of the

thyroid gland (mm)

40 45 45 35

Introduction: Chronic kidney disease-mineral and bone disorder (CKD-MBD) is frequently seen in

advanced stages of chronic kidney disease. These patients are at high risk of fracture. Denosumab,

an injectable human monoclonal antibody with affinity for nuclear factor-kappa ligand, is an

effective treatment for osteoporosis in postmenopausal women and men. In contrary to the

bisphosphonates, the pharmacokinetics and pharmacodynamics of denosumab are not influenced by

the renal function and are being increasingly used for patients having CKD-MBD with low bone

mineral density to reduce the risk of fragility fractures. Hypocalcemia is a known side effect of this

drug along with compensatory increase in parathyroid hormone (PTH). Here, we present a patient

with grade IV renal failure who developed severe symptomatic hypocalcemia and dramatic increase

in PTH following denosumab therapy.

Case: A 84 years old female patient with coronary heart disease, essential thrombocytosis,

hypothyroidism and chronic renal disease was consultated to our clinic for osteoporosis. She had

stage IV chronic renal disease for 7 years. Her serum creatinine, urea, glomerular filtration rate

(GFR), calcium, phosphorus, albumin and PTH were 1,8 mg/dl, 58 mg/dl, 25 ml/min/1.73 m 2 , 9.3

mg/dl, 4.7 mg/dl, 3.4 mg/dl, and 65 pg/ml, respectively. Dual energy X-ray absorptiometry revealed

a femoral neck t score of -3.7 and lumbal vertebra t-score of -3.3. She was given vitamin D 7500

IU/day for 8 days and then denosumab 60 mg subcutaneously. Ten days after injection, her serum

calcium was 6 mg/dl, albumin was 3.6 mg/dl, phosphorus was 2.5 mg/dl and PTH was 669 pg/ml.

She had mild numbness and tingling in her fingers but no other symptoms of hypocalcemia,

however Chvostek and Trousseou signs were positive. She was initially managed with intravenous

calcium and then oral calcium supplementation and calcitriol. One week after therapy serum

calcium was 8 mg/dl, albumin was 3.8 mg/dl and PTH was 569 pg/ml. She was managed as an out-

patient with close monitoring of calcium homeostasis. Three weeks after therapy serum calcium

was 8,4 mg, albumin was 3,8 g/dl, phosphorus was 3,3 mg/dl, and PTH was 380 pg/ml.

Conclusion: Denosumab is increasingly used to prevent skeletal-related events related with

osteoporosis and metastatic bone disease. Hypocalcemia is a known side effect of denosumab but it

is generally mild and can be avoided by simultaneous vitamin D and calcium supplementation.

Patients with a low baseline GFR are at significantly increased risk for developing hypocalcemia.

Clinicians should ensure special attention in recognizing patients at risk of developing this serious

adverse effect, so that prompt treatment and preventive strategies can be implemented.

Introduction: Poorly differentiated thyroid carcinomas (PDTC) are a rare subtype of thyroid

carcinomas that are biologically situated between well-differentiated thyroid carcinomas (WDTC)

and anaplastic thyroid carcinomas. Even a minor poorly differentiated component of only 10% of a

given carcinoma significantly affects patient prognosis. Here we present a 63-year-old female

patient who presented with diffuse bone pain and thyrotoxicosis, and diagnosed with PDTC and

diffuse bone metastasis.

Clinical course: A 63 years old female patient with nodular goitre was suggested thyroidectomy 20

years ago, but she has declined the operation. She presented with back and hip pain which

intensified in the last two months and could not be relieved with nonsteroidal anti-inflammatory

drugs. In laboratory examination she had thyrotoxicosis and methimazole was started. Technetium-

99m scintigraphy revealed a hypoactive nodule in the right thyroid lobe. The sacroiliac magnetic

resonance imaging showed a 45x36 mm lesion in the right half of the sacrum. In 18F-FDG PET

scan, a 65x60 mm lesion with calcifications and necrotic areas filling the right thyroid lobe and

isthmus of the neck, extending into the upper mediastinum at the inferior, narrowing the trachea at

this level, with borders that cannot be clearly distinguished from neighbouring anatomical structures

was observed. Additionally, there were mediastinal lymph nodes and metastatic foci in the right

lung, left scapula, T5 vertebrate, right sacrum, left ischium and right femur. Bone biopsy from the

left scapula resulted in WDTC metastasis. Since her thyroid functions were not normalized despite

60 mg/day methimazole treatment, total thyroidectomy and lymph node dissection were performed

after 3 days of plasmapheresis. Histopathologically, a 60 mm tumoral tissue in the right thyroid lobe

was detected. Approximately 20% of the tumor was composed of poorly differentiated cancer cells

including trabecular, solid and insular pattern. The remaining areas were morphologically WDTC.

There were also capsular and lymphovascular invasion. An additional follicular variant papillary

carcinoma of 3 mm was observed in the same lobe. Four central lymph nodes were excised and all

were reactive. At the 6th day of surgery, her serum TSH was &lt;0.008 uıU/ml (0.55-4.78), free

thyroxine was 0.60 ng/dl (0.89-1.76) and free triiodothyronine was 2.47 pg/ml (2.3-4.2) and

methimazole treatment was stopped. The patient was discharged with radioactive iodine treatment

planned.

Conclusion: PDTC patients have worse outcomes than patients with WDTC. There is no difference

in the outcomes of PDTC and WDTC with poorly differentiated component. In our case;

approximately 20% of the tumor was composed of poorly differentiated cancer cells and at the time

of diagnose patient had bone metastasis without cervical LAP metastasis.

Introduction: In our country, some health institutions are allowed to constitute additional service

buildings/centers in order to increase the accessibility to outpatient services and decrease the

crowdiness in hospitals. We aimed to investigate the satisfaction of the patients evaluated in our

endocrinology and metabolism diseases center-ENDOOTEM (Endocrinology-Nuclear Medicine-

Diabetes-Obesity-Osteoporosis-Thyroid Diagnosis and TreatmentCenter)- which serves as a part of

our university hospital since 2007.

Methods: Patients who were examined in our center between September 2018-January 2019 were

asked to participate in satisfaction survey. ‘Satisfaction surveys application guide’ published by

Ministry of Health of our country, satisfaction survey recommended by ‘American Association of

Family Physicians-AAFP’ and PQ8-18 survey developed in 1994 were modified to create our own

satisfaction survey.

Results: 1387(58.6%) female and 979 (41.4%) male patients completed the questionnaire. The

question of ‘Are you satisfied with our center in general?’ was answered as yes by 1374 (58.1%),

partially by 625 (26.6%) and no by 353 (14.9%) patients. There were 1526 (64.5%) patients who

thought that the doctor spent enough time for his/her illness and 368 (15.6%) patients who thought

he/she partially spent enough time. Whether the doctor was polite and respectful was answered as

yes by 1800 (76.7%), partially by 335 (14.3%) and no by 213 (9.1%) patients. There were 1930

(82.0%) patients who were completely or partially pleased with the attitude of the staff and 1988

(84.5%) patients who stated that his/her personal privacy was taken care of. Waiting rooms were not

enough according to 1406 (59.4%) and not comfortable according to 1140 (48.2%) patients. The

main problems were defined as difficulty of making appointment by 990 (41.8%), waiting for a

long time for evaluation of results by 1056 (44.6%), waiting for a long time for examination dates

by 734 (31.0%), difficulty in transportation and car parking by 573 (24.2%) and not being able to

make appointment for the same doctor by 472 (19.9%) patients. 1695 (72.2%) patients declared that

they wanted to continue the follow-up in our center.

Conclusion: Majority of patients were satisfied with the services, the physicians and the staff

working in our center. However, the difficulty in making appointments and physical conditions

seem to be the most important problems. These results suggest that specialized centers may increase

the quality of health services and the number of such centers should be increased. Nevertheless, it is

important to provide the proper physical conditions before opening a specialized health center.

Introduction: Familial Mediterranean Fever (FMF) is an autosomal recessive hereditary disease

characterized by fever and inflammation of serous membranes. The most important complication of

FMF is amyloidosis which has significant role in the prognosis. It is unclear how endocrine system

hormones are affected in FMF. We present adrenal insufficiency in a an FMF patient without

amyloidosis.

Case: A 39 years old male patient who had been diagnosed with FMF at the age of 14 years

admitted to the emergency department with the weeklong complaints of cough, fatigue, fainting and

abdominal pain. He had started colchicine treatment at the diagnosis but was not using it regularly.

He had a personal history of hospitalization in the intensive care unit with the diagnosis of

pericardial effusion and FMF attack 6 years ago. His blood pressure was 80/50 mm/hg, body

temperature was 36.88? ?C. In laboratory examination, his blood glucose was 40 mg/dl, sodium was

133 mmol/l, potassium was 6.1 mmol/l, calcium was 8.2 mg/dl, phosphorus was 3.0 mg/dl and

albumin was 4.0 g/dl. Cortisol and adrenocorticotrophic hormone were 0.326 ug/dl and 324.4

pg/ml, respectively.

He was hospitalized with the diagnosis of adrenal insufficiency and glucocorticoid and

mineralocorticoid therapies were started. 24 hour urine protein excretion was 265.1 mg/day which

was suggestive for lack of renal amyloidosis. The size of the kidneys was normal in the abdominal

ultrasonography. Abdominal magnetic resonance imaging showed aplastic/hypoplastic right adrenal

gland that could not be distinguished and a small left adrenal gland. His complaints regressed with

hydrocortisone, fludrocortisone and colchicine treatments.

Conclusion: The most common cause of adrenal insufficiency in developing countries is

tuberculosis while its most common cause in developed countries is autoimmune adrenalitis. Lack

of proteinuria and presence of hypoplastic adrenal glands were suggestive for the absence of

amyloidosis in our patient. Coexistent FMF and Addison’s disease in a patient might be associated

with the immunopathogenic mechanisms or just a coincidence rather than amyloid involvement of

adrenal glands.

Aim: Radioactive iodine (RAI) is one of the treatment approaches in Graves and toxic nodular or

multinodular goiter (TNG/TMNG) with low cost and high efficacy. In this study, we aimed to

evaluate ultrasonographical and cytological features of thyroid nodules in patients who were treated

with radioactive iodine for hyperthyroidism years ago.

Methods: Patients who had a history of RAI treatment for hyperthyroidism and had thyroid nodules

that were evaluated with fine needle aspiration biopsy (FNAB) were included in the study.

Ultrasonographical features, and cytological and histopathological results of nodules were obtained

from the records.

Results: There were 27 patients (22 female and 5 male) with a mean age of 59.3±13.5. The

indication for RAI treatment was Graves in 5 (18.6%), TNG/TMNG in 16 (69.2%) and unknown in

6 (22.2%) patients. A total of 48 thyroid nodules were evaluated with FNAB and cytological

diagnosis were benign in 24 (50.0%), nondiagnostic in 15 (31.2%), atypia of undetermined

significance in 5 (10.4%), suspicous for malignancy in 2 (4.2%) and malignant in 2 (4.2%) nodules.

Mean duration between RAI treatment and FNAB was 76.4±63.1 months. Thyroidectomy was

performed in 10 patients and 5 were benign (50.0%) and 5 (50.0%) were malignant

histopathologically. FNAB result was benign in 1 (20.0%), atypia of undetermined significance in 1

(20.0%), suspicious for malignancy in 1 (20.0%) and malignnt in 2 (40.0%) nodules with malignant

histopathology. Ultrasonography features of 31 cytologically/histopathologically benign and 5

cytologically/histopathologically malignant nodules were compared. Rates of nodules with

anteroposterior/transverse diameter ratio higher than 1, solid structure, presence of peripheral halo,

marginal irregularity and microcalcification were similar in benign and malignant nodules

(P=0.303,P=0.684, P=0.829, P=0.973 and P=0.621, respectively). There were 1 (20.0%) isoechoic,

1 (20.0%) hypoechoic and 3 (60.0%) iso-hypoechoic nodules among malignant nodules, while 24

(77.4%) of benign nodules were isoechoic, 3 (9.7%) were hypechoic and 4 (12.9%) were

isohypoechoic (P=0.025). Macrocalcification was observed in 4 (80.0%) of malignant and 10

(32.3%) of benign nodules (P=0.042).

Conclusion: In patients treated with RAI due to hyperthyroidism, thyroid nodules with suspicious

ultrasonography features, particulary hypoechoic appearence and presence of macrocalcification,

should be evaluated with FNAB irrespective of the period after RAI treatment. Atypia related with

previous RAI treatment might cause diagnostic problems in cytological evaluation.

Aim: Although nonsecretory parathyroid carcinoma is relatively more frequent, nonsecretory

parathyroid adenoma was also reported. It is thought to precede functioning parathyroid adenoma.

Case report: An iso-hypoechoic 6.5x9.5x16.1 mm thyroid nodule with irregular borders in the

superior-posterior part of right thyroid lobe was observed in ultrasonography in a 44-year-old

female euthyroid patient. Fine-needle aspiration (FNAB) biopsy resulted with non-diagnostic

cytology (degeneration of follicular epithelial cells, colloidal material). A second FNAB was

recommended but she admitted five years later. There was subclinical hypothyroidism with positive

thyroid autoantibodies and normocalcemia in laboratory examination. The nodule in the superior-

posterior part of right thyroid lobe was well circumscribed and hypoechoic with diameters of

5.4x13.2x18.1 mm. The ultrasonographical apperarence was found to be suspicous for an

intrathyroidal parathyroid adenoma. Serum calcium was 8.99 mg/dL, albumin was 4.6 g/dL,

parathyroid hormone was 70.22 pg/mL and 25-OH Vitamin D3 was: 6.52 ng/mL. Parathyroid

hormone decreased to 37.94 pg/mL after replacement of vitamin D. The lesion was evaluated with

FNAB and the cytological result was again nondiagnostic (small amount of colloidal material, a few

epithelial cells). Parathyroid hormone washout was &gt;5000 pg/mL in fine-needle aspiration fluid.

24-hours urinary calcium excretion was 210 mg. In Tc99m-sestamibi SPECT/CT revealed persistent

activity at superior-posterior part of upper pole of the right thyroid lobe. There was increased

echogenity compatible with crystalloid in urinary system ultrasonography. Z score was within the

expected range for age in bone mineral density. Surgical excision of the lesion was performed and a

parathyroid adenoma was confirmed histopathologically.

Conclusion: Parathyroid hormone washout should be considered in a lesion with suspicion of

intrathyroidal parathyroid adenoma even when primary hyperparathyroidism can not be shown

biochemically. If surgery is not performed, patients should be followed for possible development of

primary hyperparathyroidism.

Introduction: 80-90% of insulinomas are smaller than 2 cm, equally located in the head, body and

tail of pancreas. Computer tomography (CT) is 75%, magnetic resonance imaging (MRI) is 55-

90%, endoscopic ultrasonography (EUS) is 85-95% and selective arterial calcium stimulation test

(SACST) is 95-100% sensitive in the diagnosis of insulinomas. Here, we presented two cases of

insulinoma which could not be located by conventional methods and evaluated with SACST.

Case 1: A 29-year-old male who described hypoglycemic symptoms especially after exercise in the

last 4 months was admitted to the hospital for a prolonged fasting test. At the 8th hour of the test,

laboratory results were as follows; blood glucose 36mg/dl, insülin 21 uIU/dl, c-peptide 4 ng/dl,

proinsulin 22 pmol/l and cortisol 18 ug/dl. Blood ketone and anti-insulin antibody were negative.

No pathology was observed in the abdominal CT and EUS. Abdominal MRI revealed a 10 mm

diameter nodular lesion in the posterior medial of the stomach which was suspicious for insulinoma.

It was seen only in T2A sequence in the venous phase in contrast-enhanced examination. Galium-

68 Dotatate scintigraphy showed no involvement in the pancreas. SACST was performed. A ten-

fold increase in insulin levels was observed in the splenic artery and distal pancreatectomy was

performed.

Case 2: A 41-year-old woman who had episodes of hypoglycemia for 3-4 months was referred with

a pre-diagnosis of insulinoma. The patient underwent a prolonged fasting test. At the time of

hypoglycemia (blood glucose 45 mg/dl), serum insülin was 7.8 uIU/dl, c-peptide was 2.2 ng/dl,

proinsulin was 8 pmol/l and, serum ketone and anti-insulin antibody were negative. There was no

contrast enhancement in the pancreas in the abdominal MRI, but a suspicious hyperintense area of

10 mm diameter was seen in T2A sequence. There was no pathology in abdominal CT and EUS. In

SACST, a five-fold increase in insulin levels was detected in the mesenteric artery which was

suggestive for an insulinoma lesion in the head of pancreas. Surgical excision was recommended

but the patient refused.

Conclusion: Although the biochemical diagnosis of insulinomas are usually not complicated, the

localization might be problematic. Because of the low sensitivity of non-invasive methods in tumors

smaller than 2 cm, invasive methods can be used for the localization like in our cases.

Table 1: 29 year-old man patient’s(case 1) selective arterial calcium stimulation test results

Gastroduodenal

artery

SMA (superior

mesenteric

artery)

Splenic artery Gastric artery

0.second 22,51 uIU/ml 3,31 uIU/ml 2,014 uIU/ml 31,83 uIU/ml

20.second 25,58 uIU/ml 3,88 uIU/ml 19,8 uIU/ml 17,18 uIU/ml

40.second 28,22 uIU/ml 4,42 uIU/ml 33,42 uIU/ml 23,34 uIU/ml

60.second 19,23 uIU/ml 6,24 uIU/ml 23,53 uIU/ml 23,7 uIU/ml

Table 2: 41 year-old woman patient’s(case 2) selective arterial calcium stimulation test results

SMA Proximal splenic

artery

Gastroduodenal

artery

Distal splenic

artery

0.second 17,54 uIU/ml 21,54 uIU/ml 19,8 uIU/ml 20,69 uIU/ml

20.second 18,49 uIU/ml 30,37 uIU/ml 20,01 uIU/ml 15,5 uIU/ml

40.second 84,93 uIU/ml 21,22 uIU/ml 20,52 uIU/ml 16,83 uIU/ml

60.second 110,3 uIU/ml 24,03 uIU/ml 22,36 uIU/ml 20,24 uIU/ml

Aim: Contradictory results in limited number of studies were reported about the effects of Ramadan

fasting on thyroid hormones. We aimed to evaluate the thyroid functions in Ramadan, and compare

late evening or pre-sahour use of levothyroxine in patients being treated for hypothyroidism.

Methods: Patients taking levothyroxine for hypothyroidism who were seen in the last one week

before Ramadan (8-15 May 2018) and had normal thyroid functions were recruited. Patients were

offered to take levothyroxine at 22.30-23.00 pm before sleep (Group-1) or between 01:30 and

03:00 am at least 30 min before sahour (Group-2).

Results: Basal thyrotophin (TSH) was 2.01? ?1.05 mIU/ml and significantly increased at the end of

Ramadan (3.09? ?3.38 mIU/ml, P=0.008). Free-triiodothyronine (FT3) decreased while free-

thyroxine (fT4) increased (P&lt;0.001, P=0.028). Eighteen patients were in Group-1 and 44 were in

Group-2. There was unsignificant increase in TSH and FT4 in Group-1 (P=0.160, P=0.425), while

both increased significantly in Group-2 (P=0.022, P=0.008). FT3 decreased in Group-1 and 2

(P=0.016, P&lt;0.001). At the end of Ramadan, TSH increased in 39(%63.9), decreased in 22

(%36.1) and did not change in 1 patient. Anti-thyroid peroxidase antibody was positive in 65.5% of

patients with increased TSH and in 35.3% of patients with decreased TSH (P=0.047).

Conclusion: Although mean TSH increased significantly,about one third of patients had lower TSH

indicating for the need to evaluate every patient individually and follow closely during this month.

Use of levothyroxine in late evening seems to maintain more stable thyroid hormones compared to

pre-sahour. Clinical studies with larger sample sizes will be helpful to determine the optimal time

for levothyroxine use during Ramadan.

Introduction: Subacute thyroiditis is an iflammatory disease of the thyroid gland characterized by

pain, tenderness and swelling in the neck. Less frequently, it may present with painless or silent

thyroiditis that occurs spontaneously or in the postpartum period. In a few studies in the literature,

urinary iodine was reported to be high in patients with postpartum thyroiditis, but it was not

evaluated in patients with subacute thyroiditis. We aimed to evaluate urinary iodine in patients with

subacute thyroiditis and determine whether it might have any role in the differential diagnosis.

Materials and methods: Patients diagnosed with subacute thyroiditis between April 2018 and

January 2019 were included in the study. Patients younger than 18 years old, with a history of

exposure to iodinated contrast media and pregnant or lactating women and patients with postpartum

thyroiditis were excluded. Demographic features, thyroid functions, thyroid autoantibodies, serum

thyroglobulin, erhytrocyte sedimentation rate (ESR), C-reactive protein (CRP), urinary iodine,

thyroid ultrasonography and Tc99m pertechnatate scintigraphy results were evaluated.

Results: There were 23 patients (16 female and 7 female) with a mean age of 38.65? ?7.99. At the

time of diagnosis, median serum thyrotrophin was 0.140 mIU/mL (minmax: 0.001-0.25) (normal

levels: 0.27-4.2 mIU/mL), mean serum free triiodothyroxine and free thyroxine were 8.29? ?3.53

pg/mL (normal levels: 1.8-4.6 pg/mL) and 3.56? ?1.34 ng/dL (normal levels: 0.9-1.7 ng/dL),

respectively. There was 1 (4.3%) patient with positive antithyroid peroxidase and 6 (26.1%) patients

with positive antithyroglobulin. Median serum thyroglobulin was 116 ng/mL (min-max: 2.7-500)

(normal levels: 0-78 ng/mL), mean ESR was 52.24? ?25.47 mm and median CRP was 63 mg/L (min-

max: 4.2-188) (normal levels: 0-5 mg/L). Ultrasonographically, thyroiditis was observed in 22

(96.7%) patients and 5 (21.7%) patients had thyroid nodules. Median urinary iodinewas 441 mcg/L

(min-max: 255-1843) and it was higher than 250 mcg/L in all patients. Thyroiditis was controlled

with nonsteroidal antiinflammatory drugs and beta blockers in 13 (54.5%) patients, while additional

corticosteroid treartment was required in 10 (45.5%) patients.

Conclusion: In patients with subacute thyroditis, urinary iodine was very well above normal limits.

This might be helpful in the differential diagnosis and follow up of the disease. While, high iodine

levels may be a consequence of thyroid follicle epithelial cell damage, the possibility of being an

etiological factor should not be ignored. Large-scale prospective studies are required to determine

the role of iodine in subacute thyroiditis

Introduction: The aldosterone-to-renin ratio (A/R) is the most frequently used screening test for

primary hyperaldosteronism (PH) and a confirmation test is recommended when it is high.We

aimed to determine the frequency of PH in patients with high A/R and investigated possible clinical

features that might help to prevent unnecesary confirmation tests.

Method: Patients who underwent saline infusion test because of high A/R (&gt;3.8) were

retrospectively reviewed. PH was diagnosed in patients with plasma aldosteron &gt;10 ng/dl after 4

hours of saline infusion. Patients with postinfusion aldosteron level between 5-10 ng/dl and with &lt;5

ng/dl were defined as indeterminate and not to have PH, respectively. Patients with and without PH

were compared.

Results: There were 38 patients (27 female and 11 male) with a mean age of 55.18? ?10.13. Mean

serum potassium (K) was 4.01? ?0.69 mmol/l and aldosteron was 30.24? ?14.61 ng/dl. Median renin

and A/R were 2.015 ng/l and 12.913, respectively. After saline infusion test, the diagnosis of PH

was confirmed in 17 (43.6%) and excluded in 11 (28.2%) patients. Indeterminate results were

obtained in 10 (25.6%) patients. There were 9 female and 8 male patients with PH, while all 11

patients without PH were female (P=0.007). 16 (94.1%) patients with PH and 7 (63.6%) without PH

were hypertensive (P=0.040). The age, presentation, adrenal imaging findings, sodium and renin

were similar in patients with and without PH. Mean serum K were 3.57? ?0.65 mmol/l and 4.31? ?051

mmol/l in patients with and without PH, respectively (PZ0.003). Mean aldosteron and median A/R

were higher in patients with PH, however the differences were not statistically significant [For

aldosteron; 36.67? ?15.38 ng/dl vs 25.14? ?13.02 ng/dl, P=0.050, for A/R 16.27 (4.90-264.50) and

7.36 (3.97-53.84), P=0.051]. Median aldosteron after saline infusion was 19.40 ng/dl (10.26-64.35)

in patients with PH and 3.70 ng/dl (1.50-4.83) in patients without PH (P&lt;0.001).

Conclusion: Confirmation of PH in less than half of patients with high A/R is suggestive for high

false positivity of this screening method. It may be rational to repeat measurements before

confirmation tests in women, patients without HT and without hypokalemia. However, male sex,

presence of HT and hypokalemia seem to be stronger clinical findings that requires confirmation

tests in patients with

high A/R.

Aim: Familial hypercholesterolemia (FH) is an autosomal dominant genetic disease characterized

by increased levels of low density lipoprotein cholesterol (LDLchol). Despite relatively high

prevalance and significant association with increased mortality, the awareness of physicians and

patients is low and it is an underdiagnosed and undertreated disease. We aimed to detect patients

with FH and determine treatment status and compliance.

Materials and methods: Patients &gt;18 years old and have a serum LDL-chol? ?250 mg/dL between

January 2010-December 2016 were identified from the database of our hospital. A survey was

performed by reaching patients via phone. Demographic features, smoking status, use of alcohol,

exercise, presence of cardiovascular disease (CVD), use of medication for dyslipidemia, CVD and

high cholesterol levels in the family were questioned. Patients with a serum

thyrotrophin10? ?mIU/mL, patients with glomerulonephritis and nephrotic syndrome, patients with

high liver enzymes and patients with serum triglyceride &gt;400 mg/dL were excluded. DUTCH lipid

diagnostic criteria was used to classify patients.

Results: LDL-chol was ? ?250 mg/dL in 1918 measurements. When repeated measurements were

excluded, 1365 patients were identified. Patients that could not be reached by phone and who

refused to interview were excluded and data of 367 patients were analyzed. There were 248 (67.6%)

female and 119 (32.4%) male patients and mean age was 50.5? ?11.66. LDL-chol was ? ?330 mg/dL in

50 (13.6%) and 250-329 mg/dL in 317 (86.4%) patients. Mean DUTCH score was 6.36? ?1.63. 40

(10.9%) patients were classified as definite, 181 (49.3%) as probable and 146 (39.8%) as possible

FH. Among patients with definite or probable FH, 84 (38.0%) had CVD. DUTCH scores were

8.09? ?1.54 and 6.74? ?1.31 in patients with and without CVD, respectively. Considering all patients,

42% were taking medication for dyslipidemia. Among 213 patients that were not on antilipidemic

treatment, 162 (76.1%) stated that medication was never recommended previously, 30 (14.1%) had

stopped medication him/herself and 21 (9.8%) had stopped medication with the advice of the

physician. 49 (58.3%) definite or probable FH patients with CVD was taking antilipidemic

treatment.

Conclusion: A significant proportion of patients with LDL-chol? ?250 mg/dL were not taking

antilipidemic drugs and other cardiovascular risk factors were not under control. Similar with many

other countries, diagnosis and treatment rates of FH patients were very low in our country. Further

national studies are required to increase awareness of the disease in both physicians and patients

Aim: It has been reported that thyrotrophin receptor antibody (TRAb) is associated with frequency

and aggressiveness of thyroid cancer in patients with Graves disease (GD). However, there is not

any data regarding the effects of TRAb on cytology and histopathology results of patients with

nodular GD. Thus, the aim of the present study is to evaluate the effects of TRAb on cytology and

histopathology results in patients with nodular or multinodular thyroid disease on the basis of GD.

Materials and Methods: Clinical data of patients with GD who had thyroidectomy and

preoperative TRAb levels were reviewed retrospectively. The cytology and histopathology results

of 548 nodules from 598 patients with GD were evaluated for the present study.

Results: Of 598 patients, 189 (31.6%) were men and 409 (68.4%) were women. However 352

patients did not have nodular disease on preoperative thyroid ultrasound, 74 had only one nodule

and 172 had ≥2 nodules. 517 (86.5%) patients had benign and 81 (13.5%) had malignant final

histopathology. In malignant group, 77 (95.1%) patients had papillary throid carcinoma, 2 (2.5%)

had follicular thyroid carcinoma, 1 (1.2%) had thyroid tumor of uncertain malignant potential, and

1 (1.2%) had hurthle cell thyroid carcinoma. However, TRAb was detected as positive in 359 (60%)

patients, it was found as negative in 239 (40%) patients. There were 185 nodules in TRAb positive

group and 363 nodules in TRAb negative group, and there was no significant difference in cytology

results between groups (p=0.181) (Table 1). Malignancy was detected in 48 (13.4%) and 33

(13.8%) patients with TRAb positive and negative patients, respectively (p=0.878), and there was

not any difference in histopathology results between groups (p=0.161) (Table 1). Furthermore, there

was no difference in features of carcinoma such as capsular, vascular, and lymphatic invasions

between TRAb positive and negative groups (p&gt;0.05).

Conclusion: In the present study, it was found that malignancy rate was similar in TRAb positive

and negative patients. Contrary to literature, TRAb positivity was not associated with increased

malignancy rate and also had no effect on cytology and histopathology results in patients with GD.

Table 1. Comparison of the cytology and histopathology results of Thyrotrophin receptor antibody

positive and negative patients with Graves Disease

TRAb Positive TRAb Negative p

Cytology (n,%) n=185 n=363

Nondiagnostic 52 (28,1) 81 (22,3) 0,181

Benign 113 (61,1) 258 (71,1)

Atypia of undetermined

significance/ Follicular

lesion of undetermined

significance

13 (7,0) 19 (5,2)

Follicular neoplasia/

Suspicious for follicular

neoplasia

1 (0,5) 1 (0,3)

Suspicious for malignancy 4 (2,2) 3 (0,8)

Malignant 2 (1,1) 1 (0,3)

Histopathology (n,%) n=48 n=33

Papillary thyroid carcinoma 47 (97,9) 30 (90,9) 0,161

Follicular thyroid carcinoma 0 2 (6,1)

Thyroid tumor of unceratin

malignant potential

0 1 (3,0)

Hurthle cell thyroid

carcinoma

1 (2,1) 0

Aim: Although thyroid nodules located in isthmus were less frequent, papillary thyroid cancer in

this location was reported to be more aggressive in some studies. Our aim was to evaluate

hormonal, ultrasonographic, and cytopathologic features of nodules located in isthmus (isthmic

nodules).

Material and methods: Data of patients who underwent thyroidectomy between 2006-2014 were

reviewed retrospectively. Hormonal, ultrasonographic, and cytopathologic features of patients with

isthmic and with lober (non-isthmic) nodules were compared.

Results: Patients with isthmic nodules (Group-1) and non-isthmic nodules (Group-2) consisted of

260 and 2171 patients, respectively. Age and gender distributions were similar. AntiTg positivity

was higher in Group-1 (28.6% vs 21.2%; P=0.018). Subsequently, 268 isthmic (10.7%) and 5347

non-isthmic (89.3%) nodules were compared. Although ultrasonographical features such as

presence of microcalcification and halo, nodule diameters, echogenicity, texture, margin, and

vascularity were similar between groups, macrocalcification rate was lower in isthmic nodules

(19% vs 27%; P=0.004). Furthermore, cytologic results were also similar. However, malignancy

rate was lower in isthmic nodules (6.0% vs 11.4%; P=0.006), type of thyroid cancer was similar in

isthmic and non-isthmic nodules. When malign isthmic (n=16, 2.6%) and malign non-isthmic

nodules (n=605, 97.4%) were compared, diameter and type of tumor, lymphovascular and capsular

invasion, extrathyroidal extension and multifocality rates were statistically insignificant. Malign

isthmic nodules (n=16, 6%) had smaller size [10.05(4.00-34.50) mm vs 20.05(8.40-74.10)mm;

P=0.002], higher hypoechogenity (31.2% vs 5.6%, P&lt;0.001) and exophyticity rates (28.6% vs

4.9%; P=0.007) compared to benign isthmic nodules (n=251, 94%).

Conclusion: Although isthmic nodules had lower malignancy rate compared to non-isthmic ones,

histopathologic features were similar in isthmic and non-isthmic nodules. Relatively small,

hypoechoic, and exophytic nodules located in isthmus should be evaluated immediately for

malignancy.

ABSTRACT

Aim: Anti thyroid peroxidase (AntiTPO) and antithyroglobulin (AntiTg) Ankara Yildirim

Beyazit University, School of Medicine, Endocrinology and Metabolism Diseasesare known to

be positive in 75-90% and 35-50% of patients with Graves disease, respectively. Although

studies investigating the association between thyroid cancer and Hashimoto thyroiditis (HT) -in

which AntiTPO is an important hallmark of the disease- reported controversial results, studies

showing higher risk in HT outweigh. However, the association between AntiTPO and thyroid

cancer in patients with Graves disease was not studied. We aimed to investigate whether

AntiTPO or AntiTg positivity have any effect on malignancy risk in these patients.

Methods: Graves patients operated in our center was recruited for the study retrospectively. The

clinical features, operation indications and thyroid autoantibodies (AntiTPO, AntiTg and TSH

receptor antibody) were recorded. Patients were grouped as benign and malignant according to

histopathological diagnosis.

Results: Data of 602 patients were analyzed. There were 410 (%68.1) female and 192 (%31.9)

male patients with a mean age of 43.65±12.69. Preoperative ultrasonography revealed no nodule

in 286 (%47.5), single nodule in 63 (%10.5) and multiple nodules in 253 (%42.0) patients.

There were 400 (66.4%) patients with positive AntiTPO and 279 (46.3%) with positive AntiTg.

Histopathological diagnosis was benign in 512 (85%) and malignant in 90 (15%) patients. Age,

sex and TSH receptor antibody positivity did not differ between benign and malignant patients.

267 (52.1%) patients in benign and 19 (21.1%) patients in malignant group had no nodule in

preoperative ultrasonography (p&lt;0.001). There was significant difference in operation

indications between benign and malignant patients (p&lt;0.001). AntiTg was positive in 48.2% of

benign and 35.6% of malignant patients (p=0.026). AntiTPO was positive in 356 (69.5%) of

benign and 44 (48.9%) of malignant patients (p&lt;0.001). With multiple regression analysis,

association between AntiTg positivity and benign histopathology was lost (p=0.600), while

association between AntiTPO positivity and benign histopathology remained (p=0.016).

Conclusion: In accordance with the literature, the presence of nodule in Graves patients

increased malignancy risk in our study. Additionaly, for the first time we showed that AntiTPO

positivity might play a protective role against thyroid cancer in patients with Graves disease.

ABSTRACT

Background: Targeting better HbA1c and blood pressure (BP) goals may endanger older adults

with type 2 diabetes mellitus (T2DM) for a number of risks. Overtreatment of T2DM and

hypertension (HTN) is a trending issue but awareness and attitudes of physicians need to be

explored.

Objective: To assess the rates and predictors of overtreatment and undertreatment of glycemia

and blood pressure in older adults with T2DM. Treatment deintensification or intensification by

the physicians were also investigated.

Method: Data from older adults (≥65 years) enrolled in a large nationwide T2DM survey in

2017 across Turkey were analyzed. Overtreatment was defined as HbA1c &lt;6.5% plus use of ≥2

oral hypoglycemics or insulin, and systolic BP &lt;120 mmHg or diastolic BP &lt;65 mmHg plus use

of ≥2 drugs). Undertreatment was defined as HbA1c &gt;9% at all, and SBP &gt;140 mmHg or DBP

&gt;90 mmHg plus use of &lt;3 drugs. Deintensification or intensification rates were calculated

according to treatment modification by the physicians.

Results: A total of 1276 patients were included. The overtreatment rates for glycemia and BP

were 9.8% and 5.9%, whereas undertreatment rates were 14.2% and 17.7%, respectively. In the

adjusted model, use of oral hypoglycemics only (OR:3.1, 95% CI:1.9-5.3) and follow-up at a

private clinic (OR:2.2, 95% CI:1.2-3.9) were the predictors of glycemia overtreatment. Presence

of microvascular complications (OR:2.0, 95% CI:1.1-3.5) was the only predictor of BP

overtreatment. The deintensification and intensification rates for glycemia were 25% and 75.7%

respectively, and for the BP 10.9% and 9.0% respectively.

Conclusion: The overtreatment rates of diabetes and BP in Turkish older adults with T2DM

were consistent with the previous studies, while the undertreatment rates were much higher.

Doctors seem to feel more comfortable to intensify glycemic management and largely ignore BP

control. The results warrant enforced measures to improve care of older adults with T2DM.

ABSTRACT

Introduction: Pretibial myxedema is a rare manifestation of Graves’ disease caused by local autoimmune attack of the connective tissue probably mediated by anti TSH receptor autoantibodies (TRab). Its prevalence changes between 0.4 and 5% in Graves ‘patients and usually is accompanied by opthalmopathy. The diagnosis requires physical examination and clinical suspicion and in doubtful cases biopsy may be performed.

Case 1: Sixty four years old female patient who has been taking methimazole treatment with the diagnosis of Graves’ disease for eight months came to the endocrinology clinic with the complaint of a lesion on the anterior face of lower third of right leg. At the dermatological examination, a plaque with a shiny surface, measuring five centimeters, looking like an orange peel was observed. Upon palpation, it presented a firm and non-depressible consistency. Patient had a history of active moderate orbitopathy and received iv steroid therapy (4.5 gr prednisolone in divided doses). The patient was euthyroid at the time of evaluation with methimazole 2 tb/day and Trab was 1.3 IU/l (at the time of diagnosis it was 135 IU/l). Histopathological incisional biopsy was performed and histopathology revealed accumulation of mucin in reticular dermis leading to separation of collagen bundles. Dermopathy was successfully treated topical corticosteroids.

Case 2: Thirty seven years old female patient admitted to the clinics with symptoms of palpitations, excessive sweating and weight loss. She was diagnosed to have Graves’ disease. Radioactive iodine uptake of the thyroid was increased and TRab was three times higher than the upper limit of normal range. She had reddish edema on the distal tibia and was referred to the dermatology clinics. Pretibial myxedema diagnosis was made clinically and the lesion disappeared completely with topical steroids.

Conclusion: Graves’ dermopathy is typically asymptomatic, they are rarely pruritic or painful. In severe cases, associated with acropathy, bone pain may result from an underlying periosteal reaction. In patients with high TRab levels and orbitopathy, we should make a proper physical examination and refer the patient to a dermatologist if the patients has a lesion and the diagnosis is equivocal.

ABSTRACT

Introduction: Acromegaly is an acquired disorder related to excessive production of growth hormone (GH) and insulin-like growth factor-1 (IGF-1). It is characterized by progressive somatic disfigurement and systemic manifestations. Empty sella (ES) is an anatomical condition comprising sella turcica that is partially or completely filled with cerebrospinal fluid mainly due to intrasellar herniation of subarachnoid space. Primary ES may be associated with endocrine dysfunction and intracranial hypertension. Primary ES has to be distinguished from secondary ES, which has been linked to iatrogenic factors (surgery, radiation, medical treatment) or may be due to pituitary tumor apoplexy or autoimmune hypophysitis. Here, we describe a patient who presented with clinical and biochemical features of acromegaly and who had an empty sella on pituitary MRI.

Case: A 73-year-old male patient was consulted to our clinic for acromegalic phenotype while planning to be operated due to colorectal adenocarsinoma. The patient noticed gradual enlarging of his hands, feet, lips, and nose for 30 years, but never consulted to any clinician for this reason. Physical examination revealed typical acromegalic features. Visual field defect was not detected. Laboratory data showed elevated serum growth hormone (GH; 20.6 ng/ml)(normal <3 ng/ml) and insulin-like growth factor-1 (IGF-1; 531 ng/ml)(normal, 69-200 ng/ml). An oral glucose tolerance test (OGTT) showed no suppression of GH values. Serum levels of prolactin (PRL), adrenocorticotropic hormone (ACTH), cortisol (CS), thyroid-stimulating hormone (TSH), follicle-stimulating hormone (FSH), andluteinizing hormone (LH) were normal. T1-weighted magnetic resonance imaging (MRI) revealed an empty sella. Thorax computed tomography (CT), abdomen CT and 18F-FDG PET-CT did not have any finding consisted with ectopic GH secretion. Adenoma releasing growth hormone releasing hormone (GHRH) was not considered as GHRH was in the normal range (<100 mg/dl). He was treated with Octreotide LAR 20 mg per 28 days. At 6th month evaluation, serum GH and IGF-1 levels were decreased to 5.45 ng/ml and 274 ng/ml (normal, 69-200 ng/ml), respectively.

Conclusion: The mechanism underlying the association of acromegaly and empty sella remains unclear. However, our patient did not have a history of pituitary apoplexy, we should keep in mind that apoplexy on existing pituitary adenoma and then formation of necrosis can proceed empty sella. Yet, we have not found any reason for secondary empty sella in our patient. So, he has probably primary empty sella.

ABSTRACT

Introduction: Prolactinoma is a type of pituitary tumor that produces excessive amount of the hormone prolactin. It is the most common type of hormonally-active pituitary tumor. These tumors can result in ocular complications such as vision loss and visual fields (VF) defect. In this study, we aimed to evaluate thicknesses of chorioretinal layers in patients with prolactinoma.

Material and method: We enrolled 21 prolactinoma patients (13 females, 8 males and mean age: 40.7G 8.1 years) and 18 age and gender matched healthy controls. All participants underwent complete hormonal and ophthalmological examination including thicknesses of chorioretinal layers and VF test. We used the Spectralis spectral domain optical coherence tomography for evaluation of chorioretinal layers in an outpatient setting. The seven layers were retinal nerve fiber layer (RNFL), ganglion cell layer (GCL), inner plexiform layer (IPL), inner nuclear layer (INL), outer plexiform layer (OPL), outer nuclear layer (ONL), and retinal pigment epithelium (RPE). Additionally, we calculated the mean thickness of two combined layers: inner retinal layer (IRL) and photoreceptor layer (PL). The results of prolactinoma patients were compared with the control group.

Results: There were no statistically significant differences in median right-left and mean RNFL, GCL, IPL, INL, OPL, ONL, and IRL measurements between prolactinoma and control groups (PO0.05 for each). Median right and mean RPE were significantly low in the prolactinoma group (PZ0.018 and PZ0.028, respectively). Median right-left PL was similar in two groups, while mean PL was significantly lower in patients with prolactinoma compared to control group (PZ0.04) None of the patients had VF defect. When we compared two subgroups of prolactinoma patients (active/inactive), we found that the thicknesses of layers were not significantly different between the groups.

Conclusion: To our knowledge, this is the first study that evaluates thicknesses of chorioretinal layers in patients with prolactinoma. Thicknesses of many layers were similar with control group, while mean RPE and PL were lower in prolactinoma group.

ABSTRACT

Introduction: Multiple endocrine neoplasia type 1 (MEN 1) is associated with neoplasia and hyperfunction of the parathyroid and pituitary glands, pancreatic islet cells, and neuroendocrine cells of the gut. Many authors advocate routine subtotal or total parathyroidectomy and autotransplantation for these patients. Here we demonstrate negative MEN1 and MEN4 gene mutation analysis in a case with prolactinoma and a large parathyroid adenoma that could not be localized with preoperative imaging techniques.

Case: A 21-year-old man applied with a 8 years history of recurrent renal stones and increased serum calcium (11.25 mg/dl [Normal-9-10.5mg/dL]), alkaline phosphatase (147 U/L [Normal-30-120U/L]), serum parathyroid hormone (137 pg/l[Normal-10-60pg/mL]) and low phosphorus (2.1 mg/dl [Normal 3-4.5mg/dL]). Localization studies by imaging techniques (neck ultrasonography, Computed tomography and Tc-99m MIBI scintigraphy) failed to determine the number and location of diseased parathyroid glands. In addition, laboratory studies demonstrated elevated serum prolctine (246, Normal - 4.79-25.3 ng/mL). Other pituitary hormones were normal. Pituitary magnetic resonance imaging revealed 7.5 mm pituitary adenoma. He was started on cabergoline. Germ-line mutation analysis for MEN1 and Multiple endocrine neoplasia type 4 (MEN4) genes were negative and he had no familial history of endocrine tumors. Intraoperative parathyroid exploration demostrated a 3 cm paratyhroid adenoma. Histopathpolohical diagnosis was compatiel with parathyroid adenoma. There was no hypocalcemia or recurrence with a follow-up of 14 months.

Conclusion: Coexistence of hyperparathyroidism and prolactinoma in a young patient might not be always related to MEN1. A careful intraoperative exploration by an experienced parathyroid surgeon can be the best approach when hyperparathyroidism is diagnosed biochemically despite negative localization. 

ABSTRACT

Introduction: Amyloid accumulation in the thyroid gland leading to a clinically detectable mass is a rare clinical entity. The diagnosis of thyroid amyloidosis can be confused clinically as well as cytologically with both colloidal goiter or neoplastic processes of the thyroid. We report a case of thyroid amyloidosis that was initially misinterpreted as medullary thyroid carcinoma (MTC) clinical and cytological examination.

Case: A 24 years old man with chronic renal failure admitted to our hospita with rapidly progressive enlargement of a neck mass. He was suffering from renal failure for at least 10 years secondary to nephrolithiasis and was on 3 day/week hemodialysis after the rejection of renal transplantation 2 years before. He had dysphagia and dyspnea for about 5 months. Further workup demonstrated multinodular goiter with compressive symptoms and substernal extension. He had multiple nodules with the largest diameter of 80 mm in ultrasonography. Serum TSH was 1.68mIU/L (0.27-4.2), free T4 was1.01ng/dL (0.9-1.7), free T3 was2.84ng/dL (1.8-4.6) and thyroglobulin was 758 ng/mL (0-78). Anti-thyroglobulin and antithyroid peroxidase antibodies were negative. His calcitonin level was high which was suggestive for possible diagnosis of MTC (12.6 pg/mL normal:2-8 pg/mL). Fine needle aspiration cytology of the largest nodule displayed MTC. 24 hour urine catecholamine levels were within the normal range and computerized tomography of adrenal glands revealed no pathology. Total thyroidectomy was performed and the final histopathological diagnosis was thyroid amiloidosis.

Conclusion: Although amyloid deposition in thyroid is a well known fact in MTC, it should be remembered that it is not a histological finding exclusive of this disease. In patients with a rapidly enlarging thyroid gland presenting with dysphagia, dyspnea, or hoarseness, amyloid goiter should be included in the differential diagnosis particularly when the patient has a chronic disease that might be associated with amyloidosis.

ABSTRACT

Introduction: Papillary thyroid carcinoma(PTC) and medullary thyroid carcinoma(MTC) have always been considered different tumors. Concomitant presence of MTC and PTC in the same patient is a rare clinical event.

Case report: A 43 year-old woman admitted with fatigue, a serum thyrotropin of 4.6 uIU/ml and a 15!11 mm thyroid nodule in right lobe detected in another center. Fine needle aspiration(FNA) of the nodule was consistent with MTC. In family history, her mother had thyroid cancer but the type was unknown. Repeat thyroid ultrasonography revealed a 14!11.8!18.4 mm solitary thyroid nodule in right lobe. There were also suspicious lymph nodes in right level VI and IV and left level IV. FNA along with tyroglobuline and calcitonin wash-out was performed to lymph nodes and thyroglobulin levels were 8423, 373.3 and 0.3 ng/ml respectively while calcitonin wash-out results were O2000 pg/ml in all lymph nodes. FNA cytologies were atypia of undetermined significance for the right and nondiagnostic for the left lymph nodes. Serum calcitonin was 655 pg/ml (!5 pg/ml) and carcinoembryonic antigen(CEA) was 45.1 ng/ml (0-3.4 ng/ml). Evaluation for concomitant primary hyperparathyroidism and pheochromocytoma revealed no pathology. Total thyroidectomy with right lateral, left lateral and bilateral central lymph node dissection was performed. Pathology of the nodule was reported as 17!14 mm mixed medullary and papillary thyroid carcinoma’. Immunhistochemistry was positive for TTF-1 and calcitonin, and in focal areas thyroglobuline, CK-19 and HMBE-1 stainings were positive. One right lateral and three right central lymph node were tumour positive. The patient received 150 mCi radioactive iodine ablation therapy. Stimulated thyroglobuline was 4.2 ng/ml and a focal activity uptake in thyroid location was seen in postablative whole body scanning. Serum calcitonin and CEA regressed to 20.0 pg/ml and 2.7 ng/ml, respectively. The patient was heterozygote for C2410GOA (VAL804MET) mutation in RET protooncogene analysis. 26-year old daughter of the patient was also heterozygote for C2410GOA (VAL804MET) while other daughter had no mutation. Mutation carrier daughter of patient preferred active surveillance rather than prophylactic thyroidectomy. 

Conclusion: Our patient is one of the rare cases of mixed medullary and papillary thyroid carcinoma that was evaluated completely both clinically and genetically. Mixed medullary and papillary thyroid carcinoma is a rare clinical entity but merits consideration in differential diagnosis of thyroid nodules particularly in patients with a family history of thyroid malignancy.

ABSTRACT

Introduction: Lithium is the preferred and most efficacious therapy for acute and maintenance therapy of bipolar depressive disorder. Lithium use is associated with an increased incidence of hyperparathyroidism (4.3-6.3%) and have a female preponderance. Bilateral neck exploration was the most common surgical approach while a few patients were managed medically. The initial management of Lithium-associated hyperparathyroidism (LAH) is medical intervention which includes discontinuation of lithium or use of an alternative treatment such as atypical antipsychotics and calcimimetics. Here we demonstrate improved psychiatric symptoms after cessation of lithium and successful treatment of hypercalcemia by cinacalcet in a geriatric patient with LAH.

Case: 81-year-old woman with a history of bipolar disorder treated with lithium carbonate for more than 10 years presented with nocturia and polyuria. Her serum calcium was 11.58 mg/dl (Normal - 9-10.5 mg/dl), alkaline phosphatase 175 U/L (Normal - 30-120 U/l)), serum parathyroid hormone 380 pg/ml (Normal - 10- 60 pg/ml) and phosphorus 2.1 mg/dl (normal 3-4.5 mg/dl). No definite parathyroid lesions were identified by neck ultrasonography and Sestamibi/SPECT scans. Lithium treatment was stopped after consultation with psychiatrist. More than 3 months later, she had persistent hypercalcemia and depressive symtomps recurred. Cinacalcet (30 mg once daily) was started. After 2 weeks of treatment serum calcium level decreased to 9.5 mg/dl and PTH level was 160 pg/ml.Cinacalcet was well tolerated and the patient’s psychiatric symptoms improved without any need for lithium or other antidepressant drug.

Conclusion: Cinacalcet is known to be effective in primary hyperparathyroidism but our observations also support the use of this calcimimetic agent in lithium-induced hyperparathyroidism as a potential alternative to surgery in geriatric patients. Treatment of hypercalcemia might help to resolve depressive symptoms in these patients. Cinacalcet could represent an important pharmacological intervention in MEN1-associated primary hyperparathyroidism before surgery and in postsurgical recurrences.

ABSTRACT

Introduction: Many recent studies have shown that detection of an incidental thyroid cancer among patients operated for a toxic thyroid disease is not infrequent. We aimed to compare cytology and histopathology results of cold, warm and hot nodules in patients who had thyroidectomy due to toxic multinodular goiter (TMNG).

Methods: The cytology, histopathology and scintigraphy records of 1069 thyroid nodules from 413 patients who had operation with TMNG were reviewed in this study. The nodules were categorized as hypoactive (cold), normoactive (warm) and hyperactive (hot) groups according to scintigraphy. 0f 1069 nodules, 560 with undetermined scintigraphic activity were excluded. The cytology and histopathology results were compared.

Results: Of these 413 patients (118 men, 295 women), 23 (5.6%) had malignant and 390 (94.4%) had benign histopathology. In malignant group, 16 patients had papillary thyroid carcinoma (PTC), 3 had follicular thyroid carcinoma (FTC), 1 had an undifferentiated thyroid cancer (UTC), and 3 had thyroid tumors of uncertain malignant potential (TT-UMP). The 509 thyroid nodules were grouped as normoactive [nZ23 (4.5%)], hypoactive [nZ122 (24.0%)], and hyperactive [nZ364 (71.5%)] according to scintigraphy. Cytological evaluations of 23 normoactive nodules were as follows: 7(30.4%) nondiagnostic (ND), 15(65.2%) benign, 1(4.3%) suspicious for follicular neoplasia (SFN). The cytology of 122 hypoactive nodules were ND in 25(20.5%), benign in 86(70.5%), atypia of undetermined significance (AUS) in 5(4.1%), follicular lesion of undetermined significance (FLUS) in 3 (2.5%), SFN in 1(0.8%), and finally suspicious for malignancy (SM) in 2 (1.6%). The 364 hyperactive nodules were determined as ND, benign, AUS, FLUS, SFN, SM, and malignant in 80 (22%), 259(71.2%), 10(2.7%), 7(1.9%), 2 (0.5%), 2 (0.5%) and 4 (1.1%), respectively. There were no differences according to cytological results between groups (PZ0.616). Histopathology of normoactive nodules were PTC in 1(4.3%) nodule and benign in 22 (95.7%) nodules. However, 7 (5.7%) nodules had PTC and 1 (0.8%) nodule had FTC, 114 (93.4%) nodules had benign histopathology in hypoactive group. Histopathologies of the hyperactive group were as follows; 8 (2.2%) nodules with PTC, 2(0.6%) with FTC, 1(0.3%) with UTC, 3 (0.8%) with TT-UMP, and 350 (96.1%) nodules with benign pathology. There were no differences according to histopathological results between groups (PZ0.905).

Conclusion: Recently, incidental papillary carcinomas originating from hot nodules have been reported. Contrary to conventional knowledge, we demonstrated similar malignancy rates in hot nodules when compared with cold and warm nodules.

ABSTRACT

Aim : In this study, we aimed to evaluate ABO blood groups and Rh factor in patients with thyroid cancer. We also assessed whether the ABO/Rh factor had any effect on prognosis, agressive features and advanced stage of thyroid malignancies.

Methods: Medical records of patients who underwent thyroidectomy between December 2006 and September 2014 were evaluated retrospectively. Demographical and clinical features, cytological results (according to Bethesda classification), ABO blood groups and Rh factor status of patients with benign and malignant thyroid disease were compared. Additionaly, in malignant group, histopathological features were compared in patients with different ABO blood groups, and Rh positive and negative patients.

Results: Histopathological diagnosis was benign in 1299 (63.5%) and malignant in 744 (36.5%) patients. There were no significant difference in age, sex, thyroid autoantibody positivity and ABO blood groups in benign and malignant patients (PO0.05 for each). Ratio of Rh positive patients was significantly higher in malignant compared to benign group (91.8% vs 88.1%, P<0.046). In all subgroups of cytology, malignancy rates were similar in different ABO blood groups, and Rh positive and negative patients. Considering malignant patients, extrathyroidal extension and advanced stage (3-4) were more prevalant in patients with B compared to non-B blood groups (PZ0.028 and PZ0.042, respectively). Patients with O blood group had lower rate of capsular invasion than patients with non-O blood groups (PZ0.018). ABO blood groups or Rh status were not associated with thyroid cancer in this study. However, patients with B blood group had higher risk of extrathyroidal extension and advanced stage compared to patients with non-B blood group.

Conclusion: For the first time in our study, we evaluted the association of Rh factor status and thyroid cancer, and found no significant relation. ABO blood groups also did not increase malignancy risk in thyroid nodules. In malignant patients, extrathyroidal extension and advanced stage were higher in B compared to non-B blood groups. Our findings can be considered as a preliminary to investigate ABO blood groups and Rh status as factors that can identify patients with higher risk.

ABSTRACT

Aim: We aimed to investigate the relation between preoperative serum thyrotrophin (TSH) and clinicopathological features in patients with papillary thyroid carcinoma (PTC) and microcarcinoma (PTMC).

Methods: Patients who underwent thyroidectomy and diagnosed to have benign nodular disease or PTC/PTMC in our clinic were evaluated retrospectively. Patients with a previous history of thyroid surgery, patients using antithyroid medications or thyroid hormone and patients with tumors known to be unresponsive to TSH were excluded. Histological variants of PTC were classified as nonaggressive (classical/conventional and follicular variants), aggressive (tall cell, diffuse sclerosing and columnar variants) and other variants.

Results: Data of 1632 patients were analyzed. Histopathological diagnosis was benign in 969 (59.4%) and malignant in 663 (40.6%) patients. Preoperative median serum TSH was significantly higher in malignant compared to benign group (1.41 IU/dl vs 0.98 IU/dl, P<0.001). Malignancy risk increased gradually as going from hyperthyroidism to euthyroidism and hypothyroidism (20, 40.6 and 59.1%, respectively, P<0.05). Serum TSH was lowest in benign nodular disease, higher in PTMC and highest in PTC (P<0.001). This was also true when patients with positive antithyroid peroxidase/antithyroglobulin and with lymphocytic thyroiditis were excluded from the analysis (P<0.001). Serum TSH was higher in patients with bilateral tumor, capsular invasion and lymph node metastasis (LNM) compared to patients with unilateral tumor, without capsule invasion and without LNM, respectively (PZ0.036, PZ0.002 and PZ0.001, respectively). Patients with aggressive variant PTC had higher serum TSH than nonaggressive ones (P<0.05).

Conclusion: Preoperative serum TSH was associated with increased risk of thyroid cancer and LNM regardless of autoimmune thyroid disease. With the present study, for the first time, we showed higher preoperative TSH in aggressive variants of PTC compared to nonaggressive ones.

ABSTRACT

Introduction: Malignant insulinoma is a rare functional endocrine tumor of the pancreas. Therefore, there are few data regarding their optimal therapy and long term prognosis. Malignancy is defined by the presence of metastases, mostly in lymph nodes or the liver. Generally these patients present with severe hypoglycemia and require multiple therapies. Here, we described the management of a patient with malignant insulinoma.

Case: A41-year-old womanwith symptomatic and proven hypoglycemia, presented with a 11x10 mm hypodense cystic lesion and a 16!14 mm hyperdense lesion in the tail of the pancreas, and multiple liver metastases following a computerized tomography (CT) scan. Distal pancreatectomy, splenectomy and biopsy from the metastatic liver lesions were performed. Pancreatic resection showed evidence of tumor infiltration into the peripancreatic adipose tissue and extense perineural and lymphovascular invasions. 4 of the 15 resected lymph nodes were evaluated as metastatic. The ki-67 proliferation index of the insulinoma was 7.8%. After surgery, the patient was treated with 120 mg lanreotide autogel/28 days, and with 100 mg of diazoxide two times a day. Dexamethasone therapy was started with 4 mg daily and progressively increased to 16 mg daily. Selective internal radiation therapy with yttrium-90 (Y-90) was administered to treat liver metastases. But the patient did not have benefit from radiation therapy. The patient was evaluated for the liver transplantation because Ga68 scintigraphy showed metastases only in the liver. Although dexthamethasone, lanreotide and diazoxide therapies, hypoglycemic episodes reappeared and she was rehospitalised for persisted hypoglycemia and diuretic resistant edema. Diazoxide was stopped after 6 weeks. Intravenous glucose (10-20% dextrose) infusion and subcutaneous glucagon average 1-2 ampules/day administration were performed. Oral everolimus at a dose of 10 mg/day was also started. Hypoglycemia did not resolve and then parenteral nitrution was performed. Chemotherapy was planned but general status of the patient was deteriorated and patient had respiratory distress due to probably infection or drug associated pneumonitis. Brochoscopy was planned but general status of the patients did not permit the procedure. She died from acute respiratory distress syndrome(ARDS) 3 months after the initial diagnosis.

Conclusion: Refractory hypoglycemia in patients with metastatic insulinoma is an important cause of morbidity and mortality. Surgery is the only curative treatment but does not mostly solve the hypoglycemia caused by malignant insulinomas. For our patient, although hypoglycemic episodes were controlled with aggressive medical treatment, she died due to respiratory distress.

ABSTRACT

Aim: Multiple endocrine neoplasia-1 (MEN-1) is described in patients as presence of clinical two or more primary MEN-1 associated tumors or patients who have MEN-1 clinics and also have family members with MEN-1 associated tumors. It is associated with loss of activation genetic mutation in a tumor suppressor gene called Menin. MEN-1 is associated with tumors involving the parathyroid glands, anterior hypophysis, and pancreatic islet cells. Primary hyperparathyroidism (PHPT) is the most common feature of MEN-1. In this study, we aimed to evaluate the frequency of MEN-1 associated mutation in patients with PHPT.

Materials and methods: We scanned the medical records of 361 patients with PHPT who were followed up in our department between January 2010- December 2017. We presented the data of 14 patients who had genetic analysis due to suspicious clinical findings. 

Results: Totally 14 patients (two men, 12 women; median age 31.2G5.7 years) with PHPT were evaluated in genetic analysis. Menin gene mutation was found in 3 (21.4%) patients. In overall patients with PHPT (nZ361), frequency of MEN-1 (nZ3) was evaluated as 0.83%. Genetic analysis of three patients with menin mutation were as follows:

Case 1: A 37-year-old man presented with a history of recurrent nephrolithiasis during 14 years. He was diagnosed as PHPT after biochemical analysis. Genetic analysis was reported as MEN-1:c.643_646delACAG (p.Thr215Serfs*13) heterozygous. Other tumoral components of MEN-1 were not found in physical and laboratory examinations.

Case 2: A 35-year-old man was diagnosed as PHPT and prolactinoma. Genetic analysis was reported as MEN-1: c.654C1GOA heterozygous. He did not have other MEN-1 associated tumors.

Case 3: A 26-year-old woman who had hypoglycemia, hyperammonemia, hyperinsulism,partial empty sella and hyperprolactinemia in her medical history was evaluated. Genetic analysis was associated with heterozygous genomic changes as c984cOa in MEN-1 gene on 7th exon.

Conclusion: MEN-1 frequency in PHPT patients is estimated as 1-18%. The diagnosis of PHPT is usually made in second decade in MEN-1 patients. So, the guidelines mostly recommend scanning for PHPT before 30 years of age. In our study population, two patients are between ages of 30 and 40 years. It must be kept in mind that the estimated penetrance of 100% is present up to 40-50 years of age in an individual harboring the MEN-1 gene.

ABSTRACT

Background: Gestational diabetes insipidus (DI) is a rare complication of pregnancy, usually developing in the last trimester and resolves spontaneously 4-6 weeks postpartum. It is mainly caused by excessive vasopressinase activity, an enzyme expressed by placental trophoblasts which metabolises arginine vasopressin (AVP). However in some cases, it can develop in a patient who had limited reserve of ADH and marginal central DI prior to pregnancy and may not resolve after delivery. Herein we represent a case of DI developed in pregnancy and consisted after delivery due to ectopically located neurohypophysis.

Case: 24 year old female patient admitted to our clinics with the complaints of polyuria and polydipsia. The amount of daily consumed water was 18 l. The complaints were started in the last 2 months of pregnancy and did not resolve in 2 years after delivery. She did not have any previously diagnosed psychiatric illness such as obsessive compulsive disorder, somatization or depression. She did not have history of head trauma or symptom or sign of any pituitary hormone deficiency.  She was not using any drugs which could be related with DI. In the basal biochemistry, the serum Na level was 143 mmol/l, serum osmolarity was 293 mosm/l. The urine osmolarity was 93 mosm/l. Anterior pituitary hormone levels were normal except mildly elevated prolactin (29 ng/ml). She was hospitalized for water deprivation test. During the test, urine osmolarity did not change with water deprivation but became %200 concentrated after vasopressin which was compatible with cental DI. In the pituitary MRI neurohypophyseal T1- bright spot situated ectopically in the infundibulum. Desmopressin nasal sprey was started and the symptoms resolved immediately.

Conclusion: Gestational DI is a rare complication of pregnancy occurring in two to four out of 100,000 pregnancies. It usually develops at second half of pregnancy and remits spontaneously 4-6 weeks after delivery. Serum and urine osmolality are required for the diagnosis, but other tests such as serum sodium, glucose, urea, creatinine, liver function may be informative. The water deprivation test is normally not recommended during pregnancy because it may lead to significant dehydration, and should be dane in the post partum priod. After delivery pituitary MRI should be performed at some point to exclude lesions in the hypothalamo-pituitary region.

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Aim: In this study, we aimed to evaluate the vitamin D and calcium treatments adherence in patients with hypoparathyroidism after surgery. 

Materials and methods: To elucidate the medication adherence, we performed a questionnaire survey using the six item Morisky Medication Adherence Scale for medication of patients with postoperative hypoparathyroidism. These 6 questions were as follows; 1) Do you sometimes have problems remembering to take your medications? 2) Do you pay attention to take medications at exact time? 3) Do you sometimes leave your medication when you feel yourself well? 4) Do you stop sometimes your medication if you feel yourself bad and think that it is associated with medication? 5) Do you know long term benefits of taking your drugs? 6) Do you forget to being prescribed your medications when the prescription time comes? The answers were evaluated as Yes/No. In addition to these six questions, three more questions were added concerning to have worry about side effects of drugs.

Results: Totally 64 patients (12 men, 52 women; median age 48.6G11.6 years) who had postoperative hypoparathyroidism were included in our study. Average duration from diagnosis to evaluation time was 73.0G72.6 months. Average calcium and vitamin D dosages were 1388.39G897.92 mg and 0.61G0.39 mg, respectively. However, in evaluation of calcium usage, motivation level was low in 16 (26.2%) patients and information level was low in 12 (19.7%) patients. Moreover, for vitamin D usage, motivation and information levels were low in 8 (13.3%) and 4 (6.7%) patients, respectively. We found that motivation score of calcium usage was significantly low compared to vitamin D usage (P!0.001) Calcium motivation score was found as decreasing significantly with increasing disease time (rZK0.256 and PZ0.046). 38 (59.4%) patients had worry about side effects of calcium treatment. Of these, 10 (15.6%) patients left medication due to this feeling. 55.5% of patients had worry about renal problems such as nephrolithiasis and renal toxicity. 21 (32.8%) of patients declared that they were using lower doses of both drugs than recommended.

Conclusion: In this study, we found that one third of the patients had low motivation for calcium usage and more than half of patients had worry about side effects. We think that these patients must be informed about side effects and convinced about regular and careful follow-up of treatment associated side effects especially in patients who are under calcium treatment.

ABSTRACT

Introduction: Parathyroid carcinoma (PC) mediated hypercalcemia is often severe and more resistant to medical treatment. 18F-Fluorocholine PET/CT is a new technique used for determining the localization of parathyroid lesions. Denosumab, novel antiresorbtive agent, has been shown to have a useful role in hypercalcemia treatment. We report a male patient in long-term follow-up of PC who had refractory hypercalcemia due to pulmonary metastases revealed with 18-Fluorocholine PET/CT and who was successfully treated with denosumab.

Case: A 49-year-old man with recurrent PC initially presented in July 2007 with diffuse bone pain at lower extremities and hypercalcemia A neck ultrasound and CT scanning revealed a 3.9x3x3.5 cm solid lesion adjacent to the lower pole of the left thyroid lobe that was shown to represent a single hyperfunctioning parathyroid lesion on 99mTc-sestamibi (MIBI) parathyroid scintigraphy. The patient underwent a left parathyroidectomy along with en-bloc left thyroid lobectomy and left lateral lymph node dissection. Histological examination revealed parathyroid carcinoma. Due to postoperatively increased calcium and PTH levels, the patient was re-operated two times during the follow-up period for local recurrences. Afterwards, local radiotherapy was applied. One year later, laboratory investigations showed significantly raised calcium and PTH levels. Intravenous bisphosphonate as zolendronic acid 4 mg/28 days was started. For last 3 years, he did not take the medication due to social problems. He had admitted to our department with severe hypercalcemia 10 years later the initial operation at June 2017. He had hypercalcemia (16.8 mg/dl). He was screened for local recurrence or metastases. In 18F-FDG PET/CT diffuse nonhomogeneous hypermetabolism in medullary bones mostly associated with metabolic bone disesase was detected. His serum calcium levels were not decreased to !14 mg/dl levels with standard therapy such as aggressive saline rehydration, intravenous bisphosphonate, hemodialysis, oral cinacalcet. He had also acute pancreatitis in hospitalised period. For detection of local recurrence, 18-Fluorocholine PET/CT which revealed high uptake on pulmonary nodules was performed. Subcutaneous denosumab of 60 mg/28 days was given. After 3 doses of denosumab, total calcium was measured as 11.4 mg/dl.

Conclusion: As in this case, imaging with 18F-fluorocholine PET/CT is feasible inrecurrent/metastatic parathyroid carcinoma. In our patient, 18F-fluorocholine PET/CT seems superior to FDG-PET/CT for detection of metastases. Denosumab is a good choice in treatment of hypercalcemia in patients who are resistant to other therapies such as hemodialysis, bisphosphonates and calcimimetics.

ABSTRACT

Introduction: Bisphosphonates are the most commonly used drugs for the treatment of osteoporosis and have been shown to improve bone mineral density and reduce fractures. However, approximately a decade ago, atypical femoral shaft fractures were found to be a rare complication of bisphosphonate treatment. Atypical Femoral Fractures (AFF) represent fractures located between the lesser trochanter and the supracondylar flare of a femur. An increasing pool of evidence supports their association with the prolonged use of bisphosphonates, even though a direct correlation has not been proven yet. In this report, we describe a patient who developed atypical femoral fractures after prolonged use of bisphosphonates.

Case: A 42-year-old man was referred to our out-patient clinic after operation for bilateral femoral fractures by orthopedists. The patient had the history of mild trauma. Her medical case history revealed that, for the past 6 years, he had received 70 mg/week alendronate as treatment for osteoporosis. Plain radiographs showed a transverse fracture in the bilateral femur, and cortical thickening was observed at the fracture site. His bone mineral densities (BMD) at the baseline dual-energy X-ray absorptiometry (DEXA) scan were as follows; femoral neck: 0.76 g/cm2 (T scoreK1.2), femoral total: 0.79 g/cm2 (T ScoreK1.6), and lumbar total: 0.70 g/cm2 (T Score K3.7). Blood tests indicated that his serum calcium, phosphate, and alkaline phosphatase levels were in the normal ranges. Any reason for secondary osteoporosis was not determined. The patient was diagnosed as bilateral atypical femoral fractures. The patient discontinued his alendronate regimen. The patient was treated with teriparatide 30 mg/day for osteoporosis for 18 months. After this treatment, lumbar total T-score was reduced to K2.9 (0.77 g/cm2).

Conclusion:  Bisphosphonates are one of the most widely prescribed drugs for the treatment osteoporosis and the reduction of fracture risk. In this report, we presented a patient with atypical fractures associated with long-term bisphosphonate treatment. The correlation between the long-term bisphosphonate use and atypical fractures has not been conclusively established. However, the drug holiday is suggested to reduce the risk of atypical fracture after prolonged bisphosphonates use. This case confirmed that teriparatide had a rapid bone anabolic effect on unhealed atypical fractures associated with chronic bisphosphonate use.

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Aim: The aim of this study is to correlate the histopathological cell types and morphologic features of parathyroid neoplasms with ultrasound(US) images and laboratory findings, and also gain more information about the clinical importance of these results.

Materials and methods: The parathyroid lesions of 57 patients who were operated for hyperparathyroidism were sampled on saggital plane. The slides were scanned on high resolution

and digital whole slide images were formed. The system was consisted of motorized microscope, motorized table, robotic slide loader, and a high resolution camera. The slide on the motorized table was automatically scanned with the chosen objective and a high resolution image was formed. This image was opened with the help of an interface and then examined. These images can be archived. The US and the slide images were matched by the manufacturer software program.

Results : Forty three patients were female (73.7%). The ages of the patients were between 21-48 years and the median was 53. The study population had 47 adenomas, 7 atypical adenomas, 2 carcinomas. The median of parathormone (PTH) was 194 pg/ml (min-max: 53-2800), median of the tissue area was 96.29 (min-max: 16.01-576.05). Hypoechogenic areas on ultrasound(US) were matched with chief cells in 21 (55.3%), oncocytic cells in 2(5.0%), cyctic morphology in 8(20.0%) cases. There were less chief cells and more connective tissue in hyperechogenic areas (P!0.05). Hyperechogenic areas had less clear cells than isoechoic areas (P!0.05). Lipoic tissue ratio was significantly less in hypoechoic areas than hyperechoic areas (P!0.05). There was no significant difference between echogenicity, oncocytic cells, and haemorrhagia. There was a significant positive correlation between PTH and total neoplasm area (rZ0.377, PZ0.004). There was no significant difference between cyctic area ratio and chief cell amount in atypical and other cases(PO0.05). A moderate positive lineer relationship was found between serum calcium levels and cyctic area ratio and percentage (rZ0.416, PZ0.048).

Conclusion: The morphologies of parathyroid neoplasms taken from the digital whole slide images were compared to US projections in the study. However, hypoechogenic areas of US images were matched with chief cells, hyperechogenic areas were compatible with connective and adipose tissues in histopathology. The positive lineer relationship between serum calcium levels and cyctic areas was open to new researches. Results of this study may guide the evaluation of the clinic outcomes of detailed morphometric studies with digital whole slide method

ABSTRACT

Introduction: Ectopic adrenocorticotropic hormone (ACTH) secretion is a less common cause of Cushing syndrome(CS) and is seen in 5 to 10% of patients with endogenous hypercortisolism. The most common types are bronchial carcinoids and small cell lung carcinoma. However, in approximately 10-20% of the cases, overt tumor cannot be found. Here, we described two patients with catastrophic hypercorticolism associated with ectopic CS and who were treated with bilateral adrenalectomy.

Case 1: A 47-year-old female patient had a history of a total abdominal hysterectomy and bilateral salpingo-oopherectomy operation due to clear cell ovary carcinoma 7 months ago. She was treated with chemotherapy. After 3rd dose chemotherapy, she had been hospitalized and treated due to sepsis associated with urinary tract infection. During the follow-up period in oncology, hypokalemia was detected and she was referred to our department due to severe muscle weakness in lower extremities and hypokalemia (serum K: 2.2 mEq/l). 24-h urinary free cortisol, ACTH measurement, dexamethasone suppression test (DST) demonstrated an ACTH dependent hypercortisolism. The inferior petrosal sinus sampling was indicative for an ectopic ACTH secretion. CT-scans of the thorax and abdomen, FDG-PET/CT scan and Ga68 DOTATATE PET/CT scans, were unable to demonstrate malignancy. Previous ovarian pathology was screened for ACTH secretion and evaluated as negative. Antifungal and metyrapone were started and then bilateral adrenalectomy was performed.

Case 2: A 71-year-old male patient who had a medical history of metastatic prostate carcinoma was referred to our department due to severe hypopotasemia, muscle weakness, refractory hypertension, peripheral edema. He had a history of second operation 3 months ago due to tumoral enlargement at the base of the urinary bladder and it was evaluated as infiltration of the prostate carcinoma. 24-h urinary free cortisol, ACTH measurement, DST demonstrated an ACTH dependent hypercortisolism. CT-scans of the thorax and abdomen, FDG-PET/CT scan and Ga68 DOTATATE PET/CT scans, were negative for malignancy. Medical therapy was started. But refractory hypertension, parenteral potasium infusion need were not suspended. Bilateral adrenalectomy was perfomed. He died due to pulmonary embolism 2 months after adrenalectomy.

Conclusion: Common treatmant options of Cushing syndrome consist of tumor management, somatostatin analogs, steroidogenesis inhibitors. Bilateral adrenalectomy is a highly effective treatment for patients with severe hypercortisolism if rapid control of hypercortisolism is desired. Mortality is high especially in patients with severe co-morbidities and mostly it depends on the prognosis of the underlying malignant tumor.