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
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<0.001). There was significant difference in operation
indications between benign and malignant patients (p<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<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.
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
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 <6.5% plus use of ≥2
oral hypoglycemics or insulin, and systolic BP <120 mmHg or diastolic BP <65 mmHg plus use
of ≥2 drugs). Undertreatment was defined as HbA1c >9% at all, and SBP >140 mmHg or DBP
>90 mmHg plus use of <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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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
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.
Introduction: Upper gastrointestinal (UGI) symptoms are frequently encountered in patients with
primary hyperparathyroidism (PHPT). Some of these symptoms may improve after PHPT treatment,
while hypercalcemic state may also cause permanent effects. We aimed to evaluate UGI symptoms, UGI
endoscopic and pathologic features and determine the relationship between these features with serum
chromogranin A (CgA) and gastrin in PHPT patients.
Methods: Seventy-one patients diagnosed with PHPT were included in the study after exclusion of
patients who refused UGI endoscopy, had an UGI surgery or used drugs that affect serum chromogranin
A or gastrin. Patients were questioned regarding UGI symptoms. Serum CgA and gastrin were measured.
Endoscopy was performed and gastric biopsy specimens were taken to evaluate atrophic gastritis.
Results: There were 60 females and 11 males, and median age was 52 years. Mean serum CgA and
gastrin levels were 134.10±19.43 ng/ml (28-620) and 219.39±48.6 pg/ml (14-2255), respectively.
Dyspepsia, epigastric pain and weight loss were the most common symptoms and presented in 61, 51.7
and 46.6% of patients, respectively. Endoscopy was normal in 25(35.2%) patients. Erosive antral gastritis,
atrophic gastritis, gastric ulcers, duedonal ulcers, reflux gastritis and nodular gastritis were present in 14
(19.7%), 12 (16.9%), 6 (8.5%), 5 (7%), 4 (5.6%) and 4 (5.6%) patients, respectively. Intestinal
metaplasia, gastric atrophy, gastric neuroendocrine tumor and Helicobacter pylori infection were detected
in 29.2, 20, 1.4 and 66.2% of patients, respectively. Serum CgA was similar in patients with and without
atrophic gastritis, while serum gastrin was higher in patients with atrophic gastritis (P=0.024). Presence of
intestinal metaplasia and Helicobacter pylori infection did not affect serum CgA and gastrin levels.
Conclusion: Dyspeptic symptoms are common in patients with PHPT. The frequencies of atrophic
gastritis and peptic ulcers are increased. We think that patients with PHPT should be questioned for UGI
symptoms and evaluated with UGI endoscopy when needed.
Introduction: Musculoskeletal system is widely affected in acromegalic patients which might cause
difficulties in the diagnosis and treatment of inflammatory rheumatological diseases. Here, we report
coexistent rheumatoid arthritis (RA) in three acromegalic patients presenting with continuing joint and
back pain although acromegalic state was in remission.
Case 1: A 64 years old female patient with acromegaly and macroadenoma had undergone
transsphenoidal surgery 11 years ago and radiosurgery 7 years ago because of clinical and laboratory
evidence of disease. The patient got into remission 3 years after radiosurgery. Because she had morning
stiffness and symmetrical pain and swelling in interphalangeal joints, she was consultated with
rheumatology and diagnosed as seronegative RA. Her complaints improved dramatically at the second
month of methotrexate, prednisolone and indomethacin treatment.
Case 2: A 62 years old female had undergone transsphenoidal surgery for acromegaly 12 years ago. She
had been treated with conventional radiotherapy and radiosurgery 4 and 10 years after diagnosis,
respectively because remission could not be achieved by medical treatment which had been stopped about
a year after radiosurgery. She had symmetrical pain, swelling and deformities in interphalangeal and
metacarpal joints. Seronegative RA was diagnosed and methotrexate and prednisolone were started.
Case 3: Acromegaly had been detected 13 years ago in a 57 years old female. Because she had refused
surgery, she had been treated with conventional radiotherapy and cure had been achieved in a year. She
complained morning stiffness, back pain and pain and swelling in hand joints. She was diagnosed to have
seropositive RA and treated with methotrexate, sulfosalazine and indomethasine.
Conclusion: Symptoms related with RA might be confused with musculoskeletal symptoms seen in
acromegaly. Detailed rheumatological physical examination and immunological evaluation might be
helpful to display concomitant rheumatological disease in acromegalic patients with ongoing
musculoskeletal complaints despite achievement of treatment targets.
Introduction: Parathyroid surgical therapy differs because the glands are small and of variable number
and location. Although localization studies have improved greatly, we may not reliably determine the
number and location of all diseased glands preoperatively. Ultrasonography (US) is the most widely used
imaging method. In this study, we aimed to demonstrate how the surgical outcomes change when the
surgeon accompanies the endocrinologist during preoperative ultrasonography examination.
Methods: This prospective study included 50 patients with primary hyperparathyroidism (PHPT) who
underwent a minimally invasive parathyroid adenomectomy under local anaesthesia at our institution
from January 2014 to December 2015. The patients were divided in two groups. In group A, all patients
underwent neck US performed by an experienced endocrinologist and the surgeon on the day of operation
and the location of the lesion was specified by the surgeon. Group B patients were operated according to
the previous US performed by the endocrinologist only.
Results: There were 25 patients in Group A and 25 patients in Group B. The two groups were similar in
regard to demographical features, biochemical and hormonal parameters. Postoperative parathyroid
hormone (PTH), calcium and phosphorus levels didn’t differ between the groups. In group A operation
duration was significantly shorter compared to Group B (25.7 min vs 45 min, P=0.00).
Conclusion: Preoperative detection of hyperactive parathyroid glands is useful for minimizing the extent
of surgical intervention, reducing operation time and decreasing the risk of perioperative complication.
Introduction: Thyroid carcinoma is common in young women. Radioactive iodine (RAI)
therapy has been confirmed as a useful treatment in the management of differentiated thyroid
carcinoma (DTC). For women with DTC, the effect of RAI therapy on gonadal and reproductive
function is an important consideration. We aimed to evaluate effects of RAI therapy on ovarian
Method: Women younger than 40 years old and diagnosed with thyroid cancer that required
RAI treatment were enrolled in this study.Patients with ovarian insufficiency were excluded.
Early follicular phase serum follicle stimulating hormone (FSH) and anti-müllerian hormone
(AMH) levels were measured before and 3-6 months after RAI therapy. Friedman test is used to
detect changes in FSH and AMH levels by RAI therapy with time.
Results: Eighteen patients with a mean age of 31.9±4.9 years were enrolled in this study.
Median AMH levels were 4.2 (2.96-17.42) ng/ml, 2.21 (0.84-3.69) ng/ml, 2.08 (0.86-6.12)
ng/ml before and 3-6 months after RAI therapy, respectively. Median FSH levels were 5.5
(3.78-15.5) mIU/ml, 5.32 (4.19-35.36) mIU/ml, 6.07 (4.24-13.69) mIU/ml before and 3-6
months after RAI therapy, respectively. AMH levels before RAI were higher than after RAI
(P=0.021).AMH levels after RAI at 3 and 6 months were not different. FSH levels were similar
before and after RAI.
Conclusion: Anti-müllerian hormone (AMH) is considered an important marker of ovarian
reserve. Ovarian reserve decreases in first 6 months after RAI therapy. Further large prospective
studies are necessary to determine its predictive interest for post-treatment residual fertility.
Introduction: ‘Artificial intelligence’ is an information-processing technology developed and inspired
by the information processing technique of human brain. Artificial intelligence applications are used
with an increasing ratio in medicine; particularly in the fields of breast cancer, radiology, cardiology,
health management and drug effects analysis. There is not any study concerning thyroid diseases and
artificial intelligence applications in the literature. In this study, we aimed to use an artificial
intelligence application - CHAID (Chi-Squaered Automatic Interaction Detection) algorithm- to
predict malignancy risk in thyroid nodules with Bethesda III -atypia of undetermined
significance/follicular lesion of undetermined significance (AUS/FLUS)- cytology.
Methods: Data of 3300 patients (6863 nodules) evaluated by our multidisciplinary council and
operated between 2005-2016 were analysed retrospectively. There were 364 patients with 385 nodules
with AUS/FLUS cytology in. 65 parameters including clinical, laboratory, ultrasonographical,
cytological and histopathological features of each nodule were evaluated. The diagnostic value of
CHAID algorithm was determined considering histopathological diagnosis as the reference method.
Results: There were 75 male (20.6%) and 289 female (79.4%) patients. Histopathological diagnosis
was benign in 282 (73.2%) and malignant in 103 (26.8%) nodules. Analysis with CHAID algorithm
revealed that presence of thyroiditis/chronic thyroiditis ultrasonographically, and presence of nuclear
groove and intranuclear inclusions cytologically were predictive for malignancy. This algorithm had a
sensitivity of 49.5%, specifity of 96.8%, positive predictive value of 85%, negative predictive value of
16% and accuracy of 84.15%.
Conclusion: The main issue in thyroid nodules is to differentiate benign and malignant lesions. While
doing this, clinician should try to avoid unnecessary ultrasonography examinations, fine needle
aspiration biopsy and surgical approach. Superfluous interventions cause increased economical burden
for both the patient and the country. Use of artificial intelligence applications in clinical practice might
help to reduce unnecessary diagnostic procedures and surgical interventions in thyroid nodules with
Introduction: True risk evaluation is important in the management of thyroid cancer. We aimed to
evaluate patients with differentiated thyroid cancer (DTC) according to the different staging systems.
Method: Data of patients diagnosed with DTC between 2007 and 2014 at our institution were
analysed retrospectively. TNM, MACIS, EORTC, AMES, De Groot, ETA, LATS, and ATA staging
systems were applied to patients according to their original description. In
ATA risk classification system, we classified patients into four categories considering inappropriate
postoperative thyroglobulin levels.
Results: There were 983 patients (218 male and 765 female) with a mean age of 49.4±12.5 and a
mean follow-up of 42.6±24.3 months. Distribution of patients according to the staging systems were as
follows; TNM: 81.1%, 4.7%, 12.7%, 1%, 0.3%, 0.2% of patients in stage I, II, III, IVA, IVB, IVC
respectively; MACIS: 91%, 5.9%, 2.2%, 0.8% of patients in group 1-4 respectively; EORTC: 39.4%,
36.7%, 19.8%, 4%, 0.1% of patients in group 1-5 respectively; AMES: 82.2% of patients in low risk
and 17.8% in high-risk group; De Groot: 81.6%, 4.7%, 13.3%, 0.4% of patients in stages 1-4
respectively; ETA: 35.5%, 25.9%, 12.4%, 26.1% of patients in very low, low, high and undetermined
risk groups respectively; LATS: 35.5%, 26.7%, 17.7%, 20.1% of patients in very low, low, high and
undetermined risk groups respectively. According to ATA, distribution of patients in low,
intermediate, high and undetermined risk groups were respectively 26.4, 8.7, 40.8 and 23.6% in
category 1, 39.7, 12.9, 23.8 and 23.6% in category 2, 46.7, 15.2, 14.5 and 23.6% in category 3, and
3.9, 19.2, 3.3 and 23.6% in category 4.
Conclusion: Variable scoring systems with variable risk assessments were suggested for DTC in the
literature. A standardized categorization is required to overcome confusion and help clinicians during
management of these patients.
Introduction: Although malignancy rate is low in thyroid nodules with nondiagnostic (ND) cytology,
it is reported as higher in persistent ND nodules. We aimed to determine the role of ultrasonography
(US) features and Thyroid Imaging Reporting and Data System (TIRADS) in the prediction of
malignancy in patients with persistent ND cytology.
Methods: 246 patients who underwent thyroidectomy with an indication of at least two ND cytologies
were included in this study. Suspicious US features (solid component, hypoechogenicity, irregular
margin, microcalcification, and taller-than- wide shape) and TIRADS categories (TIRADS category 3,
4a, 4b, 4c and 5) of each nodule were obtained from medical records.
Results: Of the 246 patients, 218 (88.6%) had benign and 28 (11.4%) had malignant final
histopathology. Of these 28 patients with malignant histopathology, 25 (89.3%) were evaluated as
papillary thyroid carcinoma, 1 (3.6%) as follicular thyroid carcinoma, 1 (3.6%) as medullary thyroid
carcinoma, and 1 (3.6%) as undifferentiated thyroid carcinoma. Frequencies of taller-than- wide shape,
solidity, hypoechogenicity, microcalcifications, and irregular margins were similar in benign and
malignant groups (P>0.05, all). TIRADS categories of 246 nodules with ND cytology were as follows;
12 (4.9%) TIRADS 3, 53 (21.5%) TIRADS 4a, 104 (42.3%) TIRADS 4b and 77 (31.3%) TIRADS 4c.
There was not any nodule with TIRADS 5 category. Malignancy rates of categories 3, 4a, 4b, and 4c
nodules were 0, 13.2, 9.6 and 14.3%, respectively. No significant differences were found in TIRADS
categories between benign and malignant nodules (P>0.05, all).
Conclusion: In the present study, malignancy rate was found as 11.4% in nodules with persistent ND
cytology. There was not any suspicious US feature that was predictive for malignancy in ND nodules.
Thyroid nodules in TIRADS 4a, 4b and 4c categories had higher malignancy rates than estimated risk
of malignancy reported by the Bethesda system in ND cytology.
Aim: Lithium bicarbonate is a drug used in the initial treatment of bipolar disorders. Lithium is an
element of alcali metal group and besides being a causative agent for goiter and hypothyroidism
primarily, it has also some antithyroid effects. Rarely, lithium may cause hyperthyroidism secondary
to thyroiditis or probably autoimmune mechanisms. The association between lithium and thyroid
cancer is very little known subject. In this case series, we presented differentiated thyroid cancer in 5
patients using lithium for the treatment of bipolar affective disorder
Cases: 3 of patients were female and 2 were male. 3 patients had hypothyroidism and were using
levothyroxine and 2 patients were euthyroid. There was a solitary thyroid nodule in 2, while multiple
nodules were present in others. Preoperatively, thyroid fine needle aspiration biopsy was performed in
all patients and cytological results were suspicious for malignancy in 3, atypical cells in 1 and atypia
of undetermined significance in 1 subject. Histopathologically, 1 patient had minimal invasive
follicular carcinoma, 2 had papillary thyroid carcinoma, and 2 had concomitant papillary thyroid
carcinoma and papillary thyroid microcarcinoma. All patients were given radioactive iodine ablation
Conclusion: Thyroid dysfunctions can be observed in patients using lithium due to various
mechanisms. Among these, thyroid cancers are the least known and patients with nodular goiter on
lithium therapy should be evaluated carefully for the risk of development of thyroid cancer.
Introduction: Hysterosalphingography (HSG) is the radiographic examination of uterine cavity and
fallopian tubes. It is generally used during evaluation of infertility and radioopaque contrast is injected
through cervical duct during the procedure. Lipiodol which is the most commonly used contrast media
in HSG is a fatsoluble iodinated contrast media. This iodine is progressively cleared from the body in
a period ranging from a few weeks to a few months. Here, we present a 6 week pregnant woman who
underwent HSG 9 months ago and has very high urinary iodine excretion.
Case: A 31 years old woman at the 6th week of pregnancy was consultated for high blood glucose.
She was evaluated for infertility for 2 years, and HSG was performed 9 months before conception.
There was no history of drug or nutritional supplement use that has high iodine content and that might
affect iodine status. Iodine excretion was 10087 mcg/L (100-700 mcg/L) in random urine sample and
>450 ug/L in 24 hour urine. Her serum TSH was 2.19 uIU/mL, fT4 was 1.32 ng/dL and fT3 was 1,32
pg/mL. Thyroid autoantibodies were negative and thyroid ultrasonography was normal.
Conclusion: The optimal time for normalization of body iodine stores after exposure of iodinated
contrast media is not known exactly. Thyroid dysfunctions in the form of both hypothyroidism or
thyrotoxicosis can develop in euthyroid subjects after use of iodinated contrast media during HSG. In
our case, thyroid functions were normal but urinary iodine was very high even several months after
HSG. This suggests that females at reproductive age who underwent HSG might have excess iodine
concentration for a prolonged time and should be carefully evaluated for development of thyroid
Aim: In this study we aimed to evaluate the oxidative stress via evaluating changes in dynamic thiol-
disulphide status in euthyroid patients with Hashimoto’s thyroiditis (HT).
Methods: Fifty euthyroid patients with HT and 50 healthy individuals were enrolled in this study.
Thyroid function tests (free triiodothyronine (fT3), free thyroxine (fT4), thyrotropin (TSH)), acute phase
reactants (C-reactive protein (CRP), high sensitive CRP (hs-CRP)) and thiol-disulphide parameters were
evaluated. Native thiol (-SH), total thiol (-SHC- S-S- ), disulphide (-S- S-) levels, calculated
disulphide/native thiol (-S- S-/- SH), disulphide /total thiol (-S- S-/- SHC-S- S-), native thiol/total thiol (-
SH/-SHC- S-S- ) ratios were compared between groups.
Results: Mean age was 38.3±10.4 years in the patient group and 37.2±10.1 years in the control group.
There were 43 (86%) females and 7 (14%) males in the patient group while there were 39 (78%) females
and 11(22%) males in the control group. Median TSH level was significantly higher in the patient group
compared to controls (P=0.04). However, fT3 levels were similar statistically between groups (P=0.347),
free T4 was significantly lower in the patient group (P=0.01). Mean native thiol and total thiol levels were
significantly higher in the patient group compared to the control group (P=0.04 and P=0.036,
respectively). There were not any statistically significant differences between groups regarding calculated
disulphide/native thiol (-S- S-/- SH), disulphide /total thiol (-S- S-/- SH+-S- S-), native thiol/total thiol (-SH/-
SH+-S- S-) ratios. The association between acute phase reactants and thiol-disulphide parameters were
evaluated and no significant correlation was found. Similarly, there was no significant correlation
between antibody positivity and thiol-disulphide parameters.
Conclusion: To our knowledge, our study is the first one that evaluated the association between HT and
thiol-disulphide status according to Erel and Neselioglu method. In conclusion native and total thiol levels
were detected to be increased in euthyroid HT patients, these results were not consisted with the literature
data using different methods.
Introduction: Although, familial medullary thyroid cancer is a known condition, familial papillary
thyroid cancer (PTC) is a rare and less well described clinical entity. While some studies suggest more
aggressive features in familial PTC, some do not support these findings. We aimed to compare
ultrasonographical,cytopathological and histopathological results of patients with familial and sporadic
Methods: Data of 194 patients diagnosed with PTC histopathologically between 2007-2016 were
retrospectively reviewed. PTC in ≥2 members of the family was defined as familial PTC. Thyroid
functions, ultrasonography features, cytological and histopathological findings were compared in familial
and sporadic PTC.
Results: There were 35 tumor foci in 20 familial and 253 foci in 174 sporadic PTC patients. Gender,
thyroid functions, thyroid autoantibody positivity, mean nodule number, thyroidectomy indications and
surgical approach were similar in two groups. Preoperative ultrasonography features were available in 20
familial and 112 sporadic nodules. There was not any difference in mean nodule diameter, echogenity,
texture, microcalcification, macrocalcification, presence of hypoechoic halo, taller than wide shape,
margin irregularity and vascularization pattern. Cytological results were distributed similarly in two
groups (P=0.433). In histopathological examination, mean tumor number was 1.79±0.98 in familial and
1.46±0.77 in sporadic patients (P=0.09). Mean tumor diameters were 6.26±4.10 mm and 9.87±11.62 mm
in familial and sporadic tumors, respectively (P=0.074). Multifocality, microcarcinoma rate, variants of
invasion and extracapsular extension were similar (P=0.155, P=0.239, P=0.094, P=0.617 and P=0.743,
respectively). Capsular invasion was significantly increased in sporadic group (19.8% vs 5.9%, P=0.049).
Conclusion: Whether familial PTC is more aggressive than the sporadic form of the disease is
controversial. Clinical, ultrasonographical, cytological and most of the histopathological features of
familial and sporadic PTC were identical in our study. Early detection of cases other than index patients
might cause diagnosis at an earlier stage of the disease in familial form.
Introduction: Prolactinomas are the most common hormonally active pituitary tumors that account for
40-60% of all pituitary adenomas and are usually successfully treated with dopamine agonists. Surgery or
radiotherapy is reserved for drug intolerance/resistance or in neuro-ophthalmological emergencies. We
present a patient with refractory microprolactinoma with empty sella treated by transsphenoidal surgery.
Case: 42-year- old female patient admitted with a 14 years history of prolactinoma being treated with
dopamine agonists for ten years. At the end of the tenth year, the tumor was resistant to high dose
cabergoline (4 mg/week). Magnetic resonance imaging (MRI) revealed a partial empty sella with 6.5X3.5
mm pituitary adenoma. She underwent transsphenoidal surgery. Histopathologically, a pituitary adenoma
with rare mitotic figures, Ki-67 index of 2%, no expression of p53 and no other features of atypia was
identified. Immunohistochemistry showed expression of prolactin by majority of the cells. Postoperative
MRI demonstrated empty sella (height of the gland was 2 mm) and no residual mass. After operation,
cabergoline was restarted because of high prolactin levels and amenorrhea. Despite a substantial increase
in dosage there was no clinical improvement in amenorrhea and galactorrhea and there was not any
biochemical response. Her other anterior pituitary hormones were normal while serum prolactin was 255
ng/ml (4.79-25.3 ng/ml) in her last visit.
Conclusion: A minority of patients, ranging from 10-20% in different series does not achieve
normoprolactinemia and/or tumor shrinkage despite treatment with high doses of dopamine agonists.
Those tumors are usually macroadenomas with cavernous sinus invasion and rarely microadenomas.
Resistance can be documented by demonstrating the absence or poor expression of D2 receptors on the
membrane surface of tumor cells, or abnormalities at a postreceptor level. However, molecular biology
studies cannot be routinely performed in our center. Exchange of cabergoline with bromocriptine was
successful in few cases in the literature.
Introduction: Ectopic adrenocorticotrophic hormone (ACTH) syndrome is associated with variable
tumor groups most commonly originating from neuroendocrine cells. Here, we reported a patient
considered to have nonconvulsive status epilepticus initially due to neurological symptoms and
diagnosed as neuroendocrine tumor with ectopic ACTH syndrome.
Case: A 85 years old woman with regulated hypertension admitted with partial loss of conciousness.
She had cachectia and body mass index was 16.7 kg/m 2 . There was no acute pathology in cranial
imaging. Because electroencephalography revealed findings compatible with nonconvulsive status
epilepticus, levatiresatam was started. In laboratory examination she had hypokalemia (2.5 mg/dL)
resistant to replacement. Her serum cortisol was 126 mcg /ml (5-20 mcg/ml) and ACTH was 331.7
pg/mL (0-60 pg/mL). Hypophysial MRI showed a 6x3 mm lesion in right hypopysis. She did not any
physical signs of Cushing syndrome. In thoracal CT, a 16 mm solid irregular lesion extending to the
parencyma and costal pleura in right lung was observed. Abdominal CT revealed a 125 mm
heterogenous mass and satellite lesions in the liver and hypertrophic adrenal glands. A tru-cut biopsy
from the lesion was reported as metastasis of neuroendocrine tumor. The lesion was diffusely positive
for TTF-1, cytokeratin 7, synaptophysin and chromagranin. Ki67 proliferation index was 10-15% and
primary tumor was suggested to be atypical carcinoid tumor of lung according to the
immunohistopathological findings. The patient died at the 20 th day of intensive care unit due to sepsis.
Conclusion: Ectopic ACTH syndrome is a rare cause of ACTH dependent Cushing syndrome. It can
be easily included in the differential diagnosis in a patient with classical signs of Cushing syndrome
and without adenoma in hypophysis. However, like ours, well-known physical appearance and signs
of Cushing syndrome might not be seen in all patients, and the only clinical presentation might be
Introduction: Parathyroid carcinoma (PC) is a rare endocrine malignancy which accounts for 0.005%
of all cancers and less than 1% of primary hyperparathyroidism cases. This uncommon tumor usually
occurs during the fifth decade of life, with equal frequency in both sexes, and has an indolent but
progressive course. It’s frequently symptomatic and patients may have high values of serum calcium
and parathyroid hormone (PTH) with a palpable cervical mass. PC generally occurs as a sporadic
disease, and less frequently in the setting of genetic syndromes such as hyperparathyroidism-jaw
tumor syndrome and multiple endocrine neoplasia. In this study we present five different PC cases
followed in our clinic.
Cases:There were 2 female and 3 male patients with PC. The mean age of the patients was
50.4±13.7(38-65). They had presented with weakness, headache, nausea and vomiting, and widespread
bone pain. One of the patients had bone fracture and one other patient had nephrocalcinosis.The mean
serum calcium, phosphorus and PTH levels were 15.3±2.7 mg/dL (ranging between 11.6 and 18.9
mg/dL), 2.4±0.8 mg/dL and 869.4±991.9pg/mL (ranging between 87pg/mL and 2500pg/mL),
respectively. Histopathologically, mean tumor size was 29.2±11.1 (15-44) mm. Plasma calcium,
phosphorus and PTH levels were in the normal range and 36 months after surgery in 2 patients. Local
recurrence was observed in 2 patients and reoperation was performed. One other patient withlung and
bone metastasis had still high serum Ca and PTH levels despite recurrent surgeries for six times.
Conclusion. PC is usually that of a slowgrowing neoplasm and indicates progressive end-organ
damage from disturbed calcium homeostasis. While some patients present with mild increases in
serum calcium and PTH levels, some might have very severe hypercalcemia and hyperparathyroidism.
Similarly, prognosis varies from cure to life threatening unresectable and metastatic disease depending
on the presentation and surgical success.
Introduction: Hepatic dysfunction in hyperthyroidism may occur due to high thyroid hormones,
medications or associated autoimmune liver disease. Autoimmune hepatitis or primary biliary cirrhosis
(PBC) has rarely been reported in Graves’ disease. We report a patient presenting with pruritus and
diagnosed as accompanying PBC and Graves’ disease.
Case: A 50 years old female patient applied with progressive pruritus for at least 4 months.
Laboratory investigations showed normal alanine aminotransferase and aspartate aminotransferase.
Serum alkaline phosphatase (ALP) was 125 IU/l (≤105 IU/l), gamma glutamyl transferase (GGT) was
132 IU/l (≤42), and total serum bilirubin and conjugated bilirubin were within normal ranges. She had
low TSH (<0.005 U/l) and high serum free T4 (4.6 ng/dl) and free T3 (14.71 pg/ml). Thyroid
peroxidase antibody and thyroid stimulating hormone receptor antibody were also positive. She was
afebrile and had regular pulse rate of 110/min and normal blood pressure. There was no exophthalmus,
goiter, hepatomegaly or splenomegaly in physical examination. Ultrasonographically, the thyroid
gland was enlarged with increased vascularity. Technetium-99m scintigraphy showed increased
activity throughout the gland with cold nodules in an enlarged thyroid gland. She was started on
methimazole and propranolol. After a week of treatment, her ALP and GGT levels raised to 160 and
151, respectively that we discontinued methimazol. Serology tests for viral hepatitis, human
immunodeficiency virus and cytomegalovirus were negative; laboratory tests excluded copper, iron-
related metabolic disorders and autoimmune liver diseases. Anti-mitochondrial antibody was found
positive and PBC was diagnosed with clinical and laboratory findings. She was started on
ursodeoxycholic acid and underwent bilateral total thyroidectomy.
Conclusion: PBC is often associated with other autoimmune diseases. When a cholestatic pattern of
liver enzymes is observed during follow-up for Graves’ disease, PBC should be considered in the
Aim: Atypia/follicular lesion of undetermined significance(AUS/FLUS) is a category of thyroid
cytology with features that are neither definitely benign or malignant. We aimed to determine whether
specific cytologic or architectural features are associated with malignancy in AUS/FLUS category of
Bethesda system according to subgroups.
Methods: The specimens of patients who underwent surgery with preoperative thyroid fine neeedle
aspiration (FNA) biopsies of Bethesda Category III (AUS/FLUS) were reanalyzed. An experienced
cytopathologist who blinded to original cytology and final histopathology was reevaluated the
specimens and numerated the cytology from 1 to 7 according to Bethesda system as follows; Group 1:
cells producing microfollicles, Group 2: containing predominantly Hurthle cells with rare cells and
colloid, Group 3: difficulty in evaluation of atypia due to smear artifacts, Group 4: cellular smears
containing benign Hurthle cells, Group 5: focal cells with nuclear changes like papillary carcinoma but
generally benign appearance, Group 6: cells with atypic features but generally benign appearance,
Group 7: rare follicular cells with nuclear enlargement and frequently apparent nucleoli.
Results: Specimens of one hundred and ninety five patients (153 females, 42 males) with a mean age
of 47.87±12.18 years were included to the study. Of these 195 patients, 148 had AUS and 47 had
FLUS cytology. Nuclear groove formations are found as higher in malignant group in overall study
population and in also AUS subgroup (P=0.005 and P=0.023, respectively), but not in FLUS subgroup
(P=0.164). Nuclear enlargement, overlapping, elongation, inclusions, and papilleroid features were
similar between malignant and benign groups in all patients, AUS and FLUS subgroups. Furthermore
cytologic groups distributions are similar between benign and malignant groups in all patients, and in
AUS and FLUS subgroups (P>0.05, for all).
Conclusion: Patients in Bethesda Category III particularly in AUS subgroup with cytologic
interpretation of nuclear grooves are at higher risk of malignancy and should undergo surgery.
Introduction: Adrenocortical carcinoma (ACC) is a rare disease with poor prognosis. About 42% to 57% of patients with ACC present with symptoms of hormonal excess such as Cushing syndrome or virilization. Non-functional tumors usually present with abdominal or flank pain, varicocele and renal vein thrombosis. In addition, a growing proportion of these patients (>15%) is initially diagnosed incidentally. Here we report 3 ACC cases with different clinical presentations.
Case 1: A 38-year-old female patient admitted to our clinic with low back and abdominal pain, weight loss, and hirsutism. On physical examination, her body mass index was 17.3 kg/m2 and Ferriman-Gallwey score (FGS) was 10. She had a history of vena cava inferior (VCI) thrombosis and a filter was put in another center 6 months ago. Abdominal ultrasonography (US) revealed invasion and thrombosis in VCI and multiple metastatic lesions with the biggest diameter of 58 mm in the liver. In computerized tomography (CT), a 200x95 mm lesion in the left adrenal gland was observed. Basal cortisol and ACTH levels were 11.4 mcg/dL and 4.6 mcg/dL, respectively. Overnight 1 mg and 2 days 2 mg dexamethasone suppression tests (DSTs) showed no suppression in the morning fasting cortisols. DHEAS was 907 mcg/dl (normal limits: 0-340 mcg/dl) (Table 1). The percutaneous biopsy of metastatic mass in the liver revealed ACC and the patient was evaluated as inoperable.
Case 2: A 57-year-old female patient admitted to internal medicine clinic with fatigue, abdominal pain and high blood pressure. She was referred to our clinic due to low potassium (3.1mEq/L) concentration. In further laboratory examination, basal cortisol was 11.8 mcg/dL, ACTH was 2.6 mcg/dL, DHEAS was very high (1000 mcg/dl) and plasma aldosteron/renin ratio was normal. Abdominal CT revealed a 110x88 mm mass in the right adrenal gland. There was no suppression in overnight 1 mg and 2 days 2 mg DSTs (Table 1). Patient underwent right adrenalectomy and pathology was consistent with ACC.
Case 3: A 52-year-old female patient admitted to our clinic with hirsutism in the last 6 months. On physical examination, her body mass index was 31 kg/m2 and plethora, moon face, abdominal obesity, abdominal blue-purple striae, and buffalo hump were present. Basal cortisol and ACTH were 23.0 mcg/dl and 1.0 pg/ml, respectively. DHEAS was 884 mcg/dl. Overnight single dose of 1 mg and 2 days 2 mg DSTs showed no suppression (Table 1). Adrenal Cushing’s syndrome was diagnosed. A 80x60 mm mass in the left adrenal gland was observed in abdominal CT. Right adrenalectomy was performed and the histopathological diagnosis was ACC.
Conclusion: ACC is seen more commonly, diagnosed at a younger age and more often functional in females compared to males. The clinical presentation varies in a wide spectrum ranging from asymptomatic/mild disease as in case 3 to symptoms related with hormone overproduction as in case 2 and to severe life threating metastasis as in case 1.
Table 1. Clinical, laboratory and radiological findings of patients
Abdominal pain, weight loss, hirsutism, inferior vena cava thrombosis
Fatigue, abdominal pain high blood pressure, hypokalemia
Hirsutism, moon face, blue-purple striae, buffalo hump
Basal cortisol (mcg/dl)
Overnight DST (mcg/dl)
Low dose DST (Liddle) (mcg/dl)
8 mg DST (mcg/dl)
24 hour urinary catecholamines
17-OH progesterone (0.27-1.99) (ng/ml)
200x95 mm heterogeneous necrotic hypodense solid lesion in the left adrenal gland, metastatic lesions (max 58 mm) in the liver
110x88 mm heterogeneous necrotic solid lesion in the right adrenal gland
80x60 mm heterogeneous solid lesion in the left adrenal gland
ACTH: Adrenocorticotrophic hormone, DST: dexamethasone suppression test
Introduction: The adrenal gland is considered as an exceptional localization of a hydatid cyst. Adrenal hydatid cysts are usually secondary to generalized echinococcosis. The reported incidence of adrenal hydatid cysts is 0.5%. We present here a case of an adrenal hydatid cyst mimicking a malignant tumour in the imaging techniques such as magnetic resonance imaging (MRI) and positron emission tomography (PET)- computerized tomography (CT).
Case: A 70-year-old woman was admitted to our hospital for abdominal pain. She had undergone surgery for liver hydatid cysts 4 years ago. No hypertension was present in medical history. In her physical examination; blood pressure, temperature, and heart rate were 130/90 mmHg, 36.9ºC, and 88/min, respectively. Tenderness in the epigastrium and right hypochondrium were observed on palpation. Other physical examination findings were normal. Blood tests revealed leukocytes and eosinophils within normal values except anemia (Hb:11.2 gr/dL). Erythrocyte sedimentation rate was 93 mm/h. Abdominal ultrasonography revealed 71x91 mm and 61x65 mm hypoechoic masses containing internal cystic components in the liver. Abdominal MRI showed that there were cystic masses with 8 cm and 9 cm in diameter in the right lobe of the liver, and a 65x40 mm heterogenous probably malignant mass with internal cystic components in the right adrenal localisation which was showing diffusion limitation and contrast enhancement in early and delayed phases (Figure 1). Indirect hemaglutination test of echinococcus granulosus was positive. Renin, aldosterone, plasma metanephrine and normetanephrine, fractionated urinary catecholamine and dehydroepiandrosterone sulfate levels were normal. One mg dexamethasone suppression test was evaluated as negative. In PET-CT, increased 2-[fluorine-18]-fluoro-2-deoxy-D-glucose (FDG) involvement was observed in the right adrenal mass (SUVmax 8.3), and cystic lesions of liver (SUVmax 4.8). She underwent an open laparotomy, and drainage of hepatic cysts and right adrenalectomy were performed. Histopathological examination revealed a cuticular layer and germinative membrane.
Conclusion: Hydatid cystic disease of the adrenal glands is rarely observed in clinical practice. Most hydatid cysts arising from the adrenal gland are part of a disseminated disease. These are mostly asymptomatic and found incidentally by imaging or during surgery for other abdominal pathologies. Treatment of adrenal hydatid cysts is mostly surgical (pericystectomy or resection of the entire adrenal gland). The adrenal cyst hydatids can mimic malignant adrenal lesions in imaging techniques as in our case. Adrenal hydatid cysts should be considered in patients with incidentally discovered adrenal masses especially with a history of hydatid cystic disease.
Keywords: adrenal gland, liver, hydatid cystic disease, imaging techniques
Objective: Recent studies concerning fine needle cytology of lymph node (FNCLN) have shown that
non-aspiration (NAS) technique is superior to aspiration (AS) in terms of obtaining easily
interpretable material without significant difference between two methods. We aimed to compare NAS
and AS technique in evaluation of FNCLN in point of cytological diagnositicity.
Method: Of 134 patients, 123 LNs in 75 patients who underwent NAS- and AS-FNCLN in the same
visit were evaluated in this retrospective study. Ultrasonographic and cytopathologic features of all
LNs were noted. Cytopathologic results were categorized in 5 groups as insufficient, benign, atypia of
undetermined significance (AUS), suspicious for malignancy, and malign. However, all of results
except insufficient cytology were accepted as diagnostic, the insufficient results were categorized as
Results: The numbers of LNs located in Level (L) 1, L2, L3, L4, L5, L6, and L7 were 2, 28, 29, 26, 6,
30, and 2, respectively. Median LN volume was 0.41(0.07-20.08) ml. Ultrasonographic features of
LNs were heterogen echogenicity in 82.8%, solid texture in 82.9%, presence of
micro/macrocalcification in 29.3 %, spheric shape in 11.5%, coalescence feature in 6.5%, absence of
hilum in 74.8%, and presence of irregular hilum in 5.7%. The rates of malignancy were 13.8% in AS
vs 16.3% in NAS technique, whereas benign cytology was detected in 32.5% and 43.1%, respectively.
The diagnositicity rates were 56.9% in AS and 74.8% in NAS technique (p<0.001) (Table 1).
Conclusion: Diagnositicity rate in NAS-FNCLN was significantly higher than AS-FNCLN. Lesser
degree of cellular trauma and degeneration, and better maintained architecture because of the lack of
vacuum pressure may be the reasons of increase in the rate. To reduce non-diagnostic cytology results,
we suggest NAS-FNCLN technique which is easier to perform and causes less worry in the patient.
Objective: Biological aggressivity, and recurrence and mortality rates of thyroid cancer are known to
be higher in geriatric patients. We aimed to determine clinicopathological features of thyroid cancer in
patients ≥65 years old.
Methods: Data of 933 patients diagnosed with thyroid cancer histopathologically between January
2009-December 2014 in our clinic were retrospectively reviewed. Malignant nodules in patients ≥65
and <65 years old were taken as Group 1 and Group 2, respectively. Thyroid functions,
ultrasonography(US) features and cytological and histopathological findings were compared.
Results: There were 109 (11.7%) patients ≥65 and 824 (88.3%) <65 years old. Thyroid functions,
thyroid autoantibody positivity and thyroidectomy indications were similar. There were 153 (11.4%)
and 1185 (88.6%) malignant foci in Group 1 and 2, respectively. Among nodules with available
preoperative US features, mean nodule diameter was significantly higher in Group 1 (p=0.008).
Echogenity, texture, micro and macrocalcifications, margin irregularity and vascularization pattern
were similar in two groups. Hypoechoic halo was observed in 16.4% and 28.6% of nodules in Group
1 and 2, respectively (p=0.034). Cytological results were distributed similarly in two groups
(p=0.433). Histopathologically, tumor diameter, rates of microcarcinomas and incidentality were
similar (p=0.605, p=0.759 and p=0.605, respectively). Of all cancer types, 88.8% in Group 1 and
93.9% in Group 2 were papillary thyroid cancer (p=0.028). Hurthle cell cancer constituted 3.9% of
Group 1 and 1.1% of Group 2 carcinomas (p=0.015). 2.0% and 0.2% of tumors in Group 1 and 2 were
anaplastic, respectively (p=0.012). There was not any significant difference in capsular and vascular
invasion and extracapsular extension between groups.
Conclusion: Rates of Hurthle cell cancer which is known to have worser prognosis among other
DTCs and anaplastic cancer are increased in geriatric ages. Cytological evaluation of thyroid nodules
should strongly be considered due to increased tendency for agressive tumor types in these patients.
Objectives: Previous studies have reported that patients with differentiated thyroid cancer (DTC) are most frequently females whereas incidences of aggressive type thyroid cancer, anaplastic thyroid cancer (ATC), and medullary thyroid cancer (MTC) are not different in both sexes. In this study, we aimed to evaluate the distribution of gender in patients with thyroid cancer, and also to compare the histopathologic features and tumor stages of patients according to gender.
Methods: In this retrospective study, we evaluated 1009 thyroid cancer patients who were followed-up in our clinic. The demographics, postoperative histopathologic features, and tumor stages (TNM) were reviewed.
Results: There were 224 (22.2%) male and 785 (53.5%) female patients. Mean ages of male and female patients were 51.18±12.88 and 8.96±12.51 years, respectively (p=0.020). Among the 1425 carcinoma foci, 304 (21.3%) were detected in males and 1121 (78.6%) were in females (F/M=3.7). The rate of incidental carcinoma was similar in two sexes (p=0.730). The most frequent cancer type was papillary thyroid carcinoma (PTC) (n=1331, 93.4%), followed by the follicular thyroid carcinoma (FTC) (n=31, 2.2%), thyroid tumor of uncertain malignant potential (TT-UMP) (n=24, 1.7%), hurthle cell cancer (HCC) (n=21, 1.5%), ATC (n=5, 0.4%), and MTC (n=13, 0.9%). PTC was seen more frequently in females (p=0.010), while the rate of FTC, TT-UMP, HCC, and MTC were similar in two groups (p>0.05, all parameters). ATC was more prevalent in males (1.0% vs 0.2%, p=0.034). The incidence of PTC variants was similar in both sexes (p=0.424). There was no difference in both groups according to TNM stages (p=0.392).
Conclusions: In our study, we found that ATC was more frequent in males. However, there was no difference between the two groups according to other aggressive type cancers and PTC variants with probable aggressive course. Furthermore, male and female patients had similar TNM stages.
Table 1. Comparison of histopathologic features and TNM stages of groups according to gender
Tall cell variant
Diffuse sclerosing variant
Encapsulated follicular variant
PTC: papillary thyroid cancer, FTC: follicular thyroid cancer, TT-UMP: thyroid tumors of uncertain malignant potential, HHC: hurthle cell cancer, MTC: medullary thyroid cancer, ATC: anaplastic thyroid cancer
Objectives: Thyroid Imaging Reporting and Data System (TIRADS) is a simple and reliable reporting
system which uses the number of suspicious ultrasound (US) features and US risk scores in estimation of
malignancy risk. In this study, we aimed to determine the role of TIRADS in prediction of malignancy in
nodules with atypia of undetermined significance (AUS) and follicular lesion of undetermined
Methods: 318 nodules with AUS and 121 with FLUS cytology were included. US features and
postoperative histopathology (benign/malignant) results were documented. Thyroid nodules without any
suspicious US features were classified as TIRADS category 3. Nodules representing one, two, three or
four, or five suspicious US features were determined as category 4a, 4b, 4c, and 5, respectively. Every
suspicious US feature was scored according to presence or not as 1 and 0, respectively.
Results: In AUS group, TIRADS categories of histopathologically benign nodules were significantly
different compared to malignant nodules (p = 0.028). Malignant group had more frequent TIRADS 4c
category nodules than benign ones (p = 0.027). The rates of microcalcification and hypoechogenicity
were higher in malignant group (p = 0.015 and p = 0.007) and there was no difference in solid nodule
texture and marginal irregularity between groups (p > 0.05). Malignant group had higher nodule
anteroposterior diameter/transverse diameter ratio (p = 0.009). In FLUS group, there was no difference
between malignant and benign groups with respect to TIRADS categories and US features (p > 0.05, all).
In AUS nodules, the cut-off value of US score at maximum sensitivity and specificity were calculated as
≥3 (AUC: 0.596).
Conclusion: Preoperative prediction of malignancy is very important for appropriate treatment and
prevention of unnecessary surgeries in patients with AUS/FLUS cytologies. Combinations of suspicious
US features seems to be helpful in prediction of malignancy in these nodules.
Objectives: We aimed to evaluate malignancy risk and compare tumoral features in different clinical
thyroid diseases classified according to functional and nodular status.
Methods: Patients who underwent thyroidectomy between June 2007 and June 2014 were classified as
euthyroid nodular goiter (ENG), euthyroid multinodular goiter (EMNG), hypothyroidism with single
nodule, hypothyroidism with multiple nodules, toxic nodular goiter (TNG), toxic multinodular goiter
(TMNG), Graves’, Graves’ with solitary nodule and Graves’ with multiple nodules according to
preoperative functional status, etiology of hyperthyroidism and presence of solitary/multiple nodules.
Postoperative malignancy rates and tumoral characteristics were compared.
Results: There were 2203 (76.8%) female and 667 (23.2%) male patients. 1719 (59.9%) were euthyroid,
962 (33.5%) were hyperthyroid and 189 (6.6%) were hypothyroid. Overall malignancy was detected in
980 (34.1%) patients and 47.9% was incidental. Malignancy rates were 42.1%, 42.9% and 18.3%% in
euthyroid, hypothyroid and hyperthyroid patients, respectively (p < 0.001). 41.4% of ENG and 46.3% of
EMNG patients had malignant histopathology (p = 0.169). Mean tumor size, capsular invasion and
vascular invasion were lower in EMNG than ENG (p < 0.001, p = 0.003 and p = 0.015, respectively).
Among hypothyroid patients, 45.7% of patients with solitary and 42.2% of patients with multiple nodules
were malignant (p = 0.705). Sex distribution, mean age and tumoral characteristics were similar.
Malignancy rates were similar in all subgroups of hyperthyroidism, exceptionally Graves’ had lower
malignancy rate compared to others (p ≤ 0.01 for each). When TMNG and TNG were analysed together,
malignancy rate was 24.7% (104/421), and when Graves’ with nodule/nodules were considered, it was
Conclusion: In hypothyroid or euthyroid patients who underwent thyroidectomy for various reasons,
malignancy rate was higher than 40%. Although prevalence of malignancy was lower in hyperthyroid
patients, it does not confer protection against thyroid cancer. Patients with multiple nodules carry a
similar risk of malignancy as patients with solitary nodule independent of the functional status.
Background: Differentiated thyroid cancer is a slowly progressive malignancy and have a low metastatic potential. The most common sites of distant metastases are lungs and bones. Sternum, ribs and spine are being the most frequent sites of osseous metastases. Here, we presented a female patient with uncommon metastasis to pelvis during 3 years associated with papillary thyroid carcinoma.
Case: A 52-year-old female patient was examined in our department 3 years after she had undergone total thyroidectomy of papillary thyroid carcinoma (PTC). She presented with severe pain in her left buttock radiating to her lower leg. After total thyroidectomy, radioactive iodine whole-body scan revealed iodine uptake in left sacroiliac region. A positron emission tomography scan revealed hypermetabolic mass in left iliac fossa (SUV max: 10,7). Magnetic resonance imaging scan of the patient revealed a 12x11 cm lesion in the posterior region of left sacroiliac joint. Fine-needle aspiration cytology showed follicular variant of PTC. Patient was referred to the oncology center for palliative radiotherapy and completed 13 cycles. Patient received a total dose of 750 mCi radioiodine-131. Post-therapy scani demonstrated no change of uptake in mass and high serum thyroglobulin titer was sustained. The sciatic nerve could not be identified throughout its trajectory due to the close proximity of the mass to the sciatic nerve. In addition this hypervascular mass had particular challenge for the surgeon and it represented a significant danger of massive blood loss during surgery. The patient had undergone preoperative transcatheter arterial embolization. After reduction of vascularity, mass excision was performed safely in 3rd day of embolization. The patient's postoperative course was symptom free.
Conclusion: Bone metastases may cause severe complications that need multidisciplinary approach.
Preoperative transcather arterial embolization for hypervascular bone metastasis is widely accepted as
a safe procedure for reducing intraoperative blood loss and surgical morbidity.
Introduction: There are studies suggested that TSH can stimulate the development of thyroid
malignancy, and that elevated serum TSH levels are also associated with a higher incidence of thyroid
cancer and advanced tumor stage. In contrast, some have suggested that clinical hyperthyroidism
might be associated with aggressiveness of tumors, because thyroid hormone can act as a tumor
growth factor mediated by integrin αvβ3 in solid tumors, including thyroid cancer. There is scarce data
in the literature searching whether the incidence of PTC variants differ between patients with normal
or suppressed TSH.
Methods: Between January 2007 and December 2004, 2910 thyroid surgeries were performed at our
institution. Of these, 960 patients with histologically confirmed PTC were involved in the study.
Patients were divided in two groups as “euthyroid” or “toxic” according to their thyroid function tests
performed preoperatively at the time of first admission to the endocrinology clinics. Euthyroid status
was defined as normal levels of serum TSH, free T4, and T3, and thyrotoxicosis was defined as a
decrease in serum TSH level below the reference range, with normal or elevated serum free T4 and T3
concentrations. Those two groups were compared according to the frequency of different variants of
Result: There were no statistical differences between the 2 groups with respect to age, gender,
primary tumor size and lymph node metastasis at the time of initial diagnosis. Follicular variant PTC
was significantly more prevalent in patients with thyrotoxicosis (15.9% vs 4.8%, p<0.001).
Conclusion: In our study, patients with subclinical hyperthyroidism had greater proportion of FVPTC
compared with patients with the euthyroid state. If we consider that FVPTC is more akin to minimally
invasive follicular thyroid cancer, a lesion that is known to be of low risk than to classical PTC, we
can conclude that thyrotoxicosis is not associated with worse prognostic subtypes of PTC.
Introduction: Differentiated thyroid carcinoma is the most common endocrine malignancy. It usually
has an excellent prognosis with low rates of recurrence and metastasis. Risk scoring and initial
treatment plan depends on the histopathology of the tumor. This study aimed to investigate the
adequacy of the pathology reports of patients operated in our institution and diagnosed with
differentiated thyroid carcinoma (DTC).
Method: This is a cross sectional study of DTC patients operated between January 2007 and
December 2014.We performed the retrospective analysis of the pathology reports. Data collected from
the pathology reports of patients with DTC were: (1) histological type and subtype, (2) maximum
diameter of the tumor, (3) whether the tumor was uni-or multifocal, (4) information regarding
lymphovascular invasion, (5) extrathyroid extension of the tumor, (6) completeness of excision, and
(7) site ,size and number of lymph nodes involved, if they were excised. In the case of FTCs, data
regarding invasiveness [minimal invasion (either capsular and/or vascular) or wide invasion] were also
Result: 960 pathology reports of DTC patients were analyzed. Size of the tumor was reported in 100%
of the patients. Extrathyroidal invasion, vascular invasion, completeness of the surgery were missing
in 2% of the patients. Variant of PTC was reported in 85% of the patients and the missing cases were
mostly microcarcinomas. The most missing items were the information about the capsule invasion of
the involved lymph node, the size of the metastasis within the lymph node and number of invaded
vessels in follicular cancers.
Conclusion: The pathology reports of DTC specimens frequently miss some of the information
considered necessary to provide a comprehensive patient care.
Introduction: Recently, it has been suggested that thyrotropin (TSH) concentration can be used as a
marker for prediction of thyroid malignancy. However, the association between the cytology results and
TSH levels is not clear. In this study, we aimed to investigate the relationship between TSH levels and
Bethesda categories and determine the role of TSH levels in prediction of malignancy in patients with
different Bethesda categories.
Methods: The data of 1433 euthyroid patients with 3206 thyroid nodules who underwent thyroidectomy
were screened retrospectively. The preoperative cytology results, thyroid function tests, thyroid
autoantibodies and presence of histopathological Hashimoto’s thyroiditis (HT) were recorded.
Results: Of the 1433 patients, 585 (40.8%) had malignant and 848 (59.2%) had benign histopathology.
Malignant group had smaller nodule size, elevated TSH levels, a higher rate of presence of HT compared
to benign group (p<0.001, all). Cytology results of 3206 nodules were as follows; 832 nondiagnostic
(ND), 1666 benign, 392 atypia of undetermined significance/follicular lesion of undetermined
significance (AUS/FLUS), 68 follicular neoplasm/suspicious for follicular neoplasm (FN/SFN), 133
suspicious for malignancy (SM), and 115 malignant. Both SM and malignant cytology groups had
significantly higher TSH levels than other 4 Bethesda categories (p<0.05, all). Benign cytology group had
significantly lower TSH levels compared to other cytology groups (p<0.05, all). TSH was significantly
lower in ND cytology group compared to AUS/FLUS, SM, and malignant cytology groups (p<0.001, all).
Patients with malignant final histopathology in ND and AUS/FLUS cytology groups had significantly
higher TSH levels compared to patients with benign final histopathology (p<0.05, all). As Bethesda
category proceeded towards cytologies with higher estimated risk of malignancy, TSH levels tended to
Conclusion: In addition to cytology, TSH levels can be used as a supplementary marker in prediction of
malignancy in certain Bethesda categories.
Introduction: Hyalinizing trabecular tumor is a very rare neoplasm of thyroid and can be
misinterpreted as papillary or medullary cancer in fine needle aspiration biopsy (FNAB).
Case report: Multinodular goiter was detected in a 65 years old woman using metformin and L-
thyroxine for impaired blood glucose and Hashimoto thyroiditis, respectively. FNAB was performed
in two nodules and reported as suspicious for malignancy and benign. She underwent total
thyroidectomy and a lesion with fragmented thin fibrous capsule was detected. The lesion was not
including colloid and was characterized by eosinophilic, polygonal and elongated cells with wide
cytoplasm and oval, elongated and irregular nucleus. There was also straight nuclear notchs and
pseudoinclusions. Narrow hyalinized stroma including thin vascular structure was present between
trabecules. There was no capsular or vascular invasion. Cytokeratin 19, HBME-1 and calcitonin were
negative and TTF-1 was highly positive with immunocytochemical staining. Ki 67 proliferation index
was 1-2%. No staining with BRAF VE-1 antibody was observed. The lesion was diagnosed as
hyalinizing trabecular tumor depending on morphological and immunocytochemical findings.
Conclusion: It is difficult to differentiate hyalinizing trabecular tumor of thyroid and papillary thyroid
cancer due to similarities in morphology and origin of two tumors, and FNAB may be misinterpreted
as papillary thyroid cancer. Diagnosing hyalinizing trabecular tumor of thyroid which is benign or has
low malignant potential and which can be treated by lobectomy will certainly prevent patient from
Background: Differential diagnosis of a thyroid nodule is difficult if it is a follicular lesion. Follicular
lesions include follicular adenoma (FA) or a malign neoplasm (follicular cancer (FC) or follicular
variant of papillary thyroid carcinoma (FVPTC)). Cytology can’t separate benign from malignant
condition in follicular lesions. Differential diagnosis is important because patients often undergo less
than ideal interventions, such as a total thyroidectomy for a benign lesion or require completion
thyroidectomy after a lobectomy for a malignant nodule. Herein we aimed to search whether there is a
clinical or ultrasonographic marker discriminating malign lesions from benign ones.
Method: Eighty consecutive patients with an operated follicular thyroid neoplasm at a tertiary hospital
from 2007 to 2014 were reviewed. Age, gender, symptoms, history, physical findings, nodule size,
sonographic, cytologic, and final pathologic results were recorded. Malignant and benign groups were
compared according to preoperative clinical and imaging features
Results: 34 of 102 nodules were malignant where as 68 were benign. Gender distribution, baseline
thyroid function tests and thyroid autoantibody positivity were similar between the benign and
malignant groups. Family history of differentiated thyroid cancer (DTC) was significantly higher in
the malignant group (p=0.002). Regarding to ultrasonographic parameters, nodule volume and
vascularity were significantly greater in the malignant nodules (p=0.04 and 0.008, respectively)
Presence of microcalcification/irregular macrocalcification was also higher in the malignant group
compared to benign group (p=0.017). When we subdivided malignant nodules as FVPTC (18 lesions)
and FC (16 lesions), microcalfication was significantly more common in FVPTC (p=0.022).
Conclusion: Family history and certain ultrasonographic parameters might be helpful in preoperative
differentiation of benign and malignant follicular neoplasms. A combination ofthose with both FNA
and molecular results may help us to decide management of patients with follicular thyroid lesion.
Introduction: In this study, we aimed to evaluate the usefulness of ratio of primary tumor diameter to
total tumor diameter as a new parameter for the differentiation of agressive and favorable papillary
thyroid microcarcinomas (PTMC).
Methods: The diameter of the largest tumor focus was taken as the primary tumour diameter (PTD).
For multifocal tumors, total tumor diameter (TTD) was calculated as the sum of the maximal diameter
of each lesion. A ratio was obtained by dividing PTD to TTD and defined as tumor diameter ratio
(TDR) (PTD/TTD=TDR). Positive (PPV) and negative predictive values (NPV) and sensitivity and
specifity of TDR to predict capsular invasion, extrathyroidal extension (ETE) and lymph node
metastasis (LNM) were determined.
Results: Mean TDR significantly decreased as number of tumor foci increased. In multifocal PTMCs,
the sensitivities of TDR for the detection of LNM, ETE and capsular invasion were 100%, 100% and
94.2%, respectively, the specifities were 86.2%, 88% and 94.7%, respectively. TDR had a PPV of
99.3% and NPV of 100% for LNM; PPV of 58.5% and NPV of 100% for ETE; and PPV of 89.1% and
NPV of 97.3% for capsular invasion. In patients with multifocal PTC>10 mm, mean TDR was
signficantly lower in patients with LNM compared to ones without LNM (0.76±0.12 vs 0.44±0.10;
Conclusion: Decreased TDR was associated with capsular invasion, ETE and LNM in patients with
multifocal PTMC. It was also predictive for LNM even in patients without capsular invasion or ETE.
This new parameter might be particularly helpful for the detection of aggressive behavior in multifocal
Introduction: The increased rate of thyroid malignancy as well as incidental and subcentimeter
thyroid nodules have been attributed to increasing use of high-resolution US which can detect the non-
palpabl or subcentimeter (maximum diameter 1 cm) thyroid nodules. We aimed to evaluate the
sonographic features of the tyroid nodules between 1 cm and > 1cm according the histopathology
results and to determine the ultrasonographical predictive factors for malignancy and an
ultrasonographic score according the sonographic features to avoid unnecessary fine-needle aspiration
Methods: We retrospectively evaluated 2233 nodules of 1118 patients who underwent thyroidectomy.
Predictive factors for distinguishing between malignant and benign histopathologic results according
the ultrasonographic features were evaluated by multivariate logistic regression analysis. Multiple
binary logistic regression with the forward logistic regression method was used to develop the formula
for recommending sonographically guided biopsy.
Results: Among the 2233 nodules 337 nodules were in the 1 cm (group 1), 1896 were in the >1cm
(group 2). According the histopathological results, in group 1; 173 nodules were in the benign, 164
nodule were in the malignant group. Whereas in group 2; 1423 nodules were in the benign, 473
nodules were in the malignant group. In group 1, AP/T 1, the presence of microcalcification,
macrocalcification and hypoechoic pattern were significantly higher in the malignant group and in
group 2, the presence of microcalcification, macrocalcification, hypoechoic and iso-hypoechoic
pattern, solid texture, peripheral and intranodular vascularization pattern were significantly higher in
the malignant group. In group 1, the best ultrasonographic index score was found >2, whereas in group
2 the it was found >4.
Conclusion: Our US scoring may lead to clinicians and surgeons to diagnose thyroid malignancy
more accurately and to select the nodules for FNAB especially in subcentimeter nodules.
Introduction: In this study, we aimed to evaluate impact of multifocality, tumor number and total
tumor diameter on clinicopathological features of PTC.
Methods: Medical records of 912 patients who underwent thyroidectomy and diagnosed with PTC
were reviewed retrospectively. Patients were grouped into 4 according to number of tumoral foci; N1
(1 focus), N2 (2 foci), N3 (3 foci) and N4 (≥ 4 foci). The diameter of the largest tumor was considered
as the primary tumor diameter (PTD) and total tumor diameter (TTD) was calculated as the sum of the
maximal diameter of each lesion in multicentric tumors.
Results: Capsular invasion, extrathyroidal extension and lymph node metastasis were significantly
higher in patients with multifocal tumors compared to patients with unifocal PTC. As the number of
tumor increased, extrathyroidal extension and lymph node metastasis also increased (p=0.034 and
p=0.004, respectively). The risk of lymph node metastasis was 2.287 (OR=2.287, p=0.036) times
higher in N3 and 3.449 (OR=3.449, p=0.001) times higher in N4 compared to N1. Capsular invasion,
extrathyroidal extension and lymph node metastasis were significantly higher in multifocal patients
with PTD ≤ 10 mm and TTD 10 mm than unifocal patients with tumor diameter ≤ 10 mm (p<0.001,
p<0.001 and p=0.001, respectively). There was no significant difference in terms of these parameters
in multifocal patients with PTD ≤ 10 mm and TTD 10mm and unifocal patients with tumor diameter
> 10 mm.
Conclusion: In this study, increased tumor number was associated with higher rate of capsular
invasion, extrathyroidal extension and lymph node metastasis. In a patient with multifocal papillary
microcarcinoma, TTD 10 mm confers a similar risk of aggressive histopathological behavior with
unifocal PTC greater than 10 mm
Background: The characteristics of multifocal PTC remain controversial. Surgical approach to
multifocal tumor changes between centers. In cases that the initial procedure was lobectomy, most
clinicians would suggest for completion thyroidectomy since the risk of PTC in the contralateral lobe
is significant. This study aimed to evaluate the incidence of bilateral involvement, predictive factors
for bilaterality and whether or not bilaterality was related with more aggressive histopathologic
features in patients with multifocal PTC.
Method: Medical records and pathologic data of 914 patients who underwent total thyroidectomy and
diagnosed with PTC were retrospectively reviewed. The patients with multifocal disease were detected
and subdivided into two subgroups as unilateral-multifocal PTCs and bilateral multifocal PTCs. These
two groups were compared to each other regarding demographic, clinical and histopathological
Result: Multifocal disease was detected in 294 patients (32.7 %).Of all, 102 patients (36.7%) had
unilateral whereas 192 cases (65.3%) had bilateral involvement. As a result of univariate analysis,
bilaterality was significantly associated with the number of tumor foci (p<0.001), tumor size
(p=0.008), TSH (p=0.002) and capsule invasion (p=0.018). Multivariate analysis demonstrated that the
number of tumor foci and TSH level were independent risk factors for bilaterality in multifocal PTC
(p<0.001 and p=0.006, respectively).
Conclusion: Incidence of bilateral tumors is high and increases with the number of tumor foci in
multifocal PTC. Bilateral involvement in multifocal PTC is not associated with worse
histopathological futures.TSH can be taken as a preoperative indicator able to predict multifocal
cancers and guide clinical decision making and surgical management.
Introduction: In recent years, due to the improvements in ultrasonography (US), it has become
possible to gain more information about the papillary throid carcinoma (PTC) and papillary tyroid
microcarcinoma (PTMC). However, whether PTC and PTMC exhibit the same ultrasonographic
features and behave same features is controversial. We aimed to evaluate the patients diagnosed with
PTC and PTMC in terms of clinical, ultrasonographical (US) and histopathological features and their
relationships with tumor size.
Methods: We retrospectively evaluated 881 patients who underwent thyroid surgery between 2007
and 2014 in our clinic and diagnosed with PTC histopathologically were enrolled the study.
Demographic characteristics, US findings and histopathological features were evaluated.
Results: In total, 1264 nodules were identified in the 881 patients. The incidentality rates were higher
in the PTMC group and also in the 5 mm group. In total multifocality rate was 32.9%, and it was
significantly higher in PTMC group than the PTC group. PTC and 5 mm PTMC groups compared to
PTMC and 5 mm groups respectively, were more aggresive histopathological features
Conclusion: Since the incidentality rates were found significantly more common in our patients with
PTMC and those with 5 mm, ultrasonographic features of the nodules should be evaluated carefully
and for cases which are suspicious with US, US-guided fine needle aspiration biopsy (FNAB) should
be considered in order to make the correct treatment strategy. Also our study revealed that PTC and 5
mm PTMC groups compared to PTMC and 5 mm groups respectively, have more aggresive
Introduction: Thyroid tumors of uncertain malignant potential (TT-UMP) has been accepted as a
subgroup of follicular-patterned thyroid tumors for which benignancy or malignancy cannot be assessed
exactly. We aimed to evaluate demographic characteristics, ultrasound (US) findings, and cytological
results of patients with TT-UMP and compare these findings with the classical variant of papillary thyroid
carcinoma (CV-PTC) and non-encapsulated follicular variant of PTC (NEFV-PTC) patients, and also to
evaluate the immunohistochemical characteristics of patients with TT-UMP.
Methods: Twenty-four patients with TT-UMP, 672 with CV-PTC, and 132 with NEFV-PTC were
included to the study.
Results: Mean longitudinal nodule size and median nodule volume were higher in TT-UMP group
compared to CV-PTC and NEFV-PTC groups (p<0.001 and p<0.001 for CV-PTC; p<0.001 and p=0.008
for NEFV-PTC). Presence of halo and peripheral vascularization were observed more frequently in TT-
UMP group compared to CV-PTC group (p=0.002 and p=0.024). Nodule localization, texture,
echogenicity, presence of microcalcification, and presence of macrocalcification were similar in TT-UMP
and CV-PTC groups. US findings and cytological results were similar in TT-UMP and NEFV-PTC
groups (all, p>0.05). Benign and follicular neoplasm/suspicious for follicular neoplasm cytological results
were higher in TT-UMP group compared to CV-PTC group (p=0.030 and p=0.001). Median tumor size
was higher in TT-UMP group than CV-PTC and NEFV-PTC groups (25 mm vs 6 mm, p<0.001 and 25
mm vs 14.4 mm, p=0.006, respectively). In TT-UMP group, positive expression of HBME-1, CK-19 and
Gal-3 was found as 50%, 33.3% , and 25%, respectively.
Conclusion: This study demonstrated that patients with TT- UMP had higher nodule and tumor size
compared to CV-PTC and NEFV-PTC patients. Moreover, we found that US features and cytological
results were similar in NEFV-PTC and TT-UMP patients.
Introduction: Atypia of undetermined significance/follicular lesion of undetermined significance
(AUS/FLUS) termed as Bethesda Category III constitute 15-30% of thyroid cytology. However, the
risk of malignancy in this heterogenous category is estimated as 5-15%. The recent studies has been
reported the malignancy rate in the wide range of 6-48%. This causes surgical approach variability
between different centers. We aimed to evaluate the initial malignancy rate, indication of
complementary thyroidectomy, and malignancy rate in contralateral thyroid lobe in patients with
AUS/FLUS thyroid nodules who underwent hemithyroidectomy .
Methods: We reviewed the medical records of 47 (7 male, 40 female; mean aged 40.3±13.3) patients
with cytologically 48 AUS/FLUS nodules who underwent hemithyroidectomy operation at our
institution. The patients with tumor size <10 mm (microcarcinoma), papillary carcinoma with
follicular, oncocytic, clear cell variants were accepted as low risk group. Patients with tumor size ≥ 10
mm, papillary carcinoma with columnar, tall cell, insular, solid, diffuse sclerosing variants, follicular
carcinoma with widely invasive variant were accepted as high risk group.
Results: The preoperative cytology was evaluated as AUS in 32 (66.7%) nodules and FLUS in 16
(33.3%) nodules. Histopathology was reported as benign in 34 (72.3%) patients and as malignant in
13 (27.7%) patients. However, 9 (19.2%) patients was in high risk group, 4 (8.5%) patients was in
low risk group. Of 13 patients, complementary thyroidectomy was performed in 11 (23.4%) patients.
Of 11 patients who underwent contralateral lobectomy, 9 (81.8%) patients had benign histopathology
and 2 (18.2%) patients had malignant histopathology.
Discussion: Malignancy rate in patients with AUS/FLUS nodules who underwent hemithyroidectomy
was found as 27.7%. Moreover, malignancy rate in contralateral lobe was demonstrated as 18.2%. It
seems that lobectomy is a reasonable initial surgical approach for these patients. Further studies with
larger sample size are needed.
Introduction:We aimed to determine demographical, hormonal, ultrasonography(US) and cytological
features of cases with neck lesions that are located outside the thyroid region and have similar
echogenity with thyroid tissue.
Method:Neck US reports of patients who underwent fine needle aspiration(FNAB) under US
guidance in our clinic in a period of one year were reviewed retrospectively. Lesions having similar
echogenity with thyroid tissue and defined as ectopic or outside the thyroid bed were enrolled.
Demographical, hormonal, US and cytological features were obtained from medical records.
Results:There were 76 patients(69 female, 7 male) with a mean age of 51.07±12.81. 64(84.2%) of
patients had a history of thyroid surgery and 12(15.8%) were not operated before. 85.5%of lesions
were located at the level of hyoid bone, 9.2% inferior to thyroid lower pole and 5.3% in other sites.
Localization of lesions did not differ between patients with and without previous
thyroidectomy(p=0.083). Median lesion volume was 0.57 ml(0.06-24.13). Ultrasonographically,
93.4% of lesions were isoechoic and 6.6% were hypoechoic. 89.5%of lesions were solid and 10.5%
had mixed texture. Marginal irregularity was observed in 13.2%of lesions. US features were similar in
patients with and without thyroidectomy. 62(81.6%) lesions were positive with Tc99m pertechnetate
scintigraphy and avidity rate was significantly higher in operated patients(p=0.001). Cytological
diagnosis was benign in73,7%, atypia of undetermined significance/follicular lesion of undetermined
significance in 2.6%, nondiagnostic in22.4% and acute supurative infection in1.3%. There were no
differences in cytopathological results between patients with and without thyroidectomy(p=0.649).
Conclusion:In patients with a history of thyroid surgery, US examination should be extended to
outside the thyroid bed to detect possible ectopic tissue. We showed that such lesions might also occur
in patients without surgery and US features and cytopathological findings were similar in
thyroidectomized and nonthyroidectomized patients.
Purpose: The predictors of malignancy are important for decision of appropriate management in
nodules with atypia of undetermined significance/follicular lesion of undetermined significance
(AUS/FLUS). Our aim was to determine the ultrasonographical, clinical and biochemical predictors of
malignancy in these patients.
Methods: A total of 427 patients with Bethesda Category III (AUS/FLUS) thyroid nodules were
included in this retrospective study. We divided the nodules into two subgroups according to the
histopathology as benign and malignant, and compared the preoperative ultrasonographical, clinical
and biochemical findings.
Results: In overall, 427 patients with 449 AUS/FLUS nodules that went on surgery, the rate of
malignancy was 23.4% (105/449). When evaluated seperately, the rate of malignancy was 25.8% in
nodules with AUS (82/318) and 17.6% in nodules with FLUS (23/131) (p=0.061). The vast majority
of malignant specimens in histopathology consisted of papillary thyroid carcinoma (PTC) (n=91,
86.7%). Preoperative ultrasonographic features of 105 malignant nodules in histopathology were
compared with the 344 benign nodules. AP/T ratio was significantly higher in malignant group
compared to benign group (p=0.013). In multiple logistic analyses, we found that AP/T ratio, and
microcalcification were independently correlated with malignancy (p<0.05). Although, in univariate
analysis, presence of thyroid autoantibodies and Hashimoto’s thyroiditis in histopathology were higher
in malignant group significantly, we did not find any correlation between malignancy and
Hashimoto’s thyroiditis in histopathology in multivariate analysis (p>0.05).
Conclusion: In Bethesda Category III nodules with higher AP/T ratio and microcalcification, surgery
might be considered as the first theurapeutic option instead of repeat FNAB or observation.
Introduction: Association between high thyrotrophin receptor antibodies (TRAb) and relapse of thyroid
cancer in Graves’ patients was reported previously. In this study, we aimed to investigate possible relation
between TRAb and thyroid malignancies in patients with toxic multinodular (TMNG) and toxic nodular
Methods: Thyroidectomized patients with a preoperative diagnosis of TMNG, TNG and euthyroid
multinodular or nodular goiter (MNG/NG) were retrospectively recruited for the study. Preoperative
TRAb measurements were available in 221 patients with TMNG/TNG and 43 patients with euthyroid
MNG/NG. Results were compared in these two groups.
Results: Histopathology was malignant in 71 (32.1 %) and benign in 150 (67.9 %) of TMNG/TNG
patients. In euthyroid group, malignancy was observed in 18 (41.9 %) and benign histopathology was
observed in 25 (58.1 %) patients. In TMNG/TNG group, TRAb was positive in 7 (9.9%) patients with
malignant and 17 (11.3%) patients with benign histopathology (p=0.742). In euthyroid group, TRAb was
positive in 1 (5.6%) patient with malignant and 2 (8.0%) patients with benign histopathology (p=0.756).
TRAb positivity did not change between TMNG/TNG and euthyroid patients with malignant and benign
histopathology (p=0.569 and p=0.620, respectively).
Conclusion: TRAb positivity seems to have no effect on malignant histopathology in patients with
TMNG and TNG. Limited number of cases and lack of TRAb measurement in all TMNG/TNG patients
undergoing thyroidectomy might contribute to this finding.
Introduction: Tolosa Hunt syndrome (THS) is described as unilateral orbital pain associated with paresis
of one or more of the third, fourth and/or sixth cranial nerves caused by a granulomatous inflammation in
the cavernous sinus, superior orbital fissure or orbit. Pituitary gland is rarely involved in this syndrome.
Herein we represented a case with hypophysitis with Tolosa Hunt who was operated with the suspicion of
Case: A 63-year- old female patient with diabetes history admitted to our clinics with the complaints of
weight gain and headache. In the physical examination, BMI was 40 kg/m 2 and there was buffalo hump,
central obesity and acanthosis nigricans. With the suspicion of Cushing syndrome, biochemical screening
was performed with low dose dexamethasone suppression test and free cortisol in 24-hour- urine
collection. Serum cortisol after 1 mg dexamethasone suppression was 2.2 whereas free urinary cortisol
was normal. For exclusion of pseudocushing, we performed 2 days 2 mg dexamethasone suppression with
CRH and the result was equivocal (cortisol after CRH: 1.5). Her ACTH value was 20, and high dose
dexamethasone test result was consistent with Cushing’s disease. In the CRH test there was %300
increase in ACTH and %100 increase in cortisol after the administration of CRH. In the pituitary MRI, a
lesion 1.8 cm in size was reported. While the evaluation was going on, the severity of headache was
increased and ophtalmoplegia developed. The patient underwent endoscopic transsphenoidal surgery. The
histopathology of the lesion was consistent with granulamatous reaction with caseous necrosis.
Tuberculosis and sarcoidosis was excluded by PPD, thorax CT, lumbar puncture and analysis of the
cerebrospinal fluid, mycobacterium tuberculosis PCR and the culture of the pathology specimen. The
final diagnosis was Tolosa Hunt.
Conclusion:Tolosa Hunt is a very rare cause of hypophysitis and panhypopituitarism. It should be
considered in the differential diagnosis of a sellar mass.
Introduction: Tolosa Hunt syndrome (THS) is described as unilateral orbital pain associated with paresis
of one or more of the third, fourth and/or sixth cranial nerves caused by a granulomatous inflammation in
the cavernous sinus, superior orbital fissure or orbit. Pituitary gland is rarely involved in this syndrome.
Herein we represented a case with hypophysitis with Tolosa Hunt who was operated with the suspicion of
Case: A 63-year- old female patient with diabetes history admitted to our clinics with the complaints of
weight gain and headache. In the physical examination, BMI was 40 kg/m 2 and there was buffalo hump,
central obesity and acanthosis nigricans. With the suspicion of Cushing syndrome, biochemical screening
was performed with low dose dexamethasone suppression test and free cortisol in 24-hour- urine
collection. Serum cortisol after 1 mg dexamethasone suppression was 2.2 whereas free urinary cortisol
was normal. For exclusion of pseudocushing, we performed 2 days 2 mg dexamethasone suppression with
CRH and the result was equivocal (cortisol after CRH: 1.5). Her ACTH value was 20, and high dose
dexamethasone test result was consistent with Cushing’s disease. In the CRH test there was %300
increase in ACTH and %100 increase in cortisol after the administration of CRH. In the pituitary MRI, a
lesion 1.8 cm in size was reported. While the evaluation was going on, the severity of headache was
increased and ophtalmoplegia developed. The patient underwent endoscopic transsphenoidal surgery. The
histopathology of the lesion was consistent with granulamatous reaction with caseous necrosis.
Tuberculosis and sarcoidosis was excluded by PPD, thorax CT, lumbar puncture and analysis of the
cerebrospinal fluid, mycobacterium tuberculosis PCR and the culture of the pathology specimen. The
final diagnosis was Tolosa Hunt.
Conclusion:Tolosa Hunt is a very rare cause of hypophysitis and panhypopituitarism. It should be
considered in the differential diagnosis of a sellar mass.
Introduction: Parathyroid lipoadenoma(PLA) is a rarely seen, benign variant of parathyroid
adenoma(PA). However, PA usually consists of uniform, polygonal chief cells with a few nests of
oxyphil cells, PLA consists of similar histologic features, but with an abundance of fat cells.
Additionally, PLA may be functional with the secretion of parathyroid hormone (PTH) or non-
functional. Here, we present a case of atypical PLA presented with severe hypercalcemia and skeletal
Case: A 41-year old male referred to emergency department due to the cranial trauma following the
syncope episode. In his cranial magnetic resonance imaging no pathology was found. He had no
chronic disease except hypertension. His laboratory evaluation revealed elevated creatinine and
calcium (Ca) levels (1.7 and 14.3 mg/dl, respectively). PTH level was found 735 pg/ml , urinary
calcium excretion was found 348 mg/24 hour. Neck ultrasound (US) revealed an isoechoic mass with
18.5X29.5X38.7 mm in size in the left inferior part of the thyroid gland which was consistent with
parathyroid scintigraphy. Grade I hypertensive retinopathy was detected in ophtalmological
examination. Bone mineral densitometry revealed severe osteoporosis , especially in lumbal
vertebraes. Pathologic fracture was not determined in vertebral graphics. He had severe scoliosis and
pectus excavatum. Ca levels were regressed to 12 mg/dl with intravenous hydration and diuretic
treatment. He had underwent left hemithyroidectomy and parathyroidectomy and pathology was
revealed atypical PLA and benign thyroid disease. Also the surgical specimen was revealed a large
size mass with a 5 cm in diameter and neoplastic cells were seen in one area in the capsule.
Conclusion: Although PLAs are benign lesions, our case had atypical features. He had severe
osteoporosis and skeletal anomalies in addition to severe hypercalcemia. However, there has been no
known malignant PLA, the cases which show atypical features should be followed closely.
Introduction: Ectopic and atypically localized parathyroid adenomas such as in the anterior
mediastinum, paraesophageal or retrotracheal position, although rare, can be seen in clinical practice.
Ultrasound (US) which is a frequently used and one of the best conventional imaging modality
sometimes fails to identify the lesion especially in atypically localized adenomas. Endoscopic US
(EUS) is a new technique that can be used for localization of parathyroid lesions. We reported a case
with paraeosophageal parathyroid adenoma which was localized accurately with EUS.
Case: A 55-years old woman with papillary thyroid microcarcinoma (PTMC) (0.8 cm in size) was
operated 5 years ago. After the thyroid surgery her Ca levels (10.5-11 mg/dl) were found as elevated.
She had been evaluated for hypercalcemia and PTH level was also found elevated. In her neck
ultrasound (US) and parathyroid scintigraphy no pathology was found. Since she had no operation
indication for asymptomatic hyperparathyroidism she had been followed for 5 years. Bone mineral
densitometry revealed osteoporosis in lumbal vertebraes. Neck US found no pathology. Recent
parathyroid scintigraphy revealed parathyroid adenoma in the posterior of the trachea in the inferior
thyroid region. Neck and upper mediastinal computerised tomography showed heterogenous solid
nodular lesion in the superior right paraeosophageal region 11 mm in size. In order to determine the
exact localization of the parathyroid adenoma EUS was performed and detected a hypoechoic lesion
close to esophagus on the right parathyroid localization. The patient underwent parathyroidectomy
with minimally invasive procedure, parathyroid adenoma was detected and excised.
Conclusion: Preoperative localization of parathyroid pathology is important in appropriate cases of
minimal invasive surgery. EUS can be accepted as a tool for detection of parathyroid adenoma. When
the other imaging methods are negative or conflicting, EUS can be considered in these patients
Introduction: Congenital adrenal hyperplasia (CAH) is a group of autosomal recessive diseases
characterized by enzyme deficiencies in cortisol secretion. The most common form is 21-alpha
hydroxylase deficiency. Here, we report a patient with undertreated CAH and bilateral large adrenal
Case report: 34 years old male patient diagnosed with CAH and testicular anorchia at the age of 7
admitted to our clinic for general weakness. Hydrocortisone treatment was started at the diagnosis but
he never used it regularly and was not taking glucocorticoid replacement for 10 years. In physical
examination, blood pressure was 100/70 mmHg, there was diffuse hyperpigmentation, and no
testicular tissue could be palpated. In laboratory examination, fasting blood glucose was 97 mg/dL,
sodium 143 mmol/L, K 4.5 mmol/L and renal, liver and thyroid functions were normal. His serum
cortisol, adrenocorticotrophin hormone (ACTH) and 17-OH progesteron levels were 4.8 mcg/dL, 366
pg/mL and 217 ng/mL, respectively. Serum aldosteron was low and and renin was high. In abdominal
MRI, there were hypertrophied adrenal glands with solid nodular lesions of 47x44 mm in right and
22x24 mm in left glands. Pheochromocytoma was excluded by normal 24 hour urinary
catecholamines. 17-OH progesteron decreased to 40.8 ng/mL after 2 months of 0.5 mg/day
Conclusion: Although, adrenal enlargement is an expected finding in untreated CAH due to excessive
ACTH secretion, adrenal lesions are rarely observed. CAH should be included in the differential
diagnosis of large bilateral adrenal lesions to avoid unnecessary adrenalectomies.
Introduction: Klinefelter syndrome is known as the set of symptoms that result from two or more X
chromosomes in males. There is no known association of this syndrome with GH hypersecretion. The
most remarkable symptom is gigantism and it can also be observed in androgen deficient states as such as
the Klinefelter syndrome and some more genetic syndromes such as the Sotos syndrome, the Marfan
syndrome, the homocystinuria, and the fragile X-syndrome. Herein we presented a case with both
Kleinfelter and acromegaly.
Case: A 40-year- old male with previously known hypergonadotropic hypogonadism due to Kleinfelter
syndrome (47, XXY) was referred to our clinics with the symptoms of increased ring size, arthralgia,
excessive sweating and headache. Physical examination revealed multiple skin tags, mild coarsening of
the facial features, soft fleshy hands and interdental separation. He was 186 cm in height and 82 kg in
weight. In the hormone panel, basal gonadotropins were elevated with low plasma testosterone, spot
growth hormone (GH) was 4.22 μg/ L serum and insulin like growth factor-1 (IGF1) level was 611 μg/ L
which was above the age matched reference range (105-280 μg/L). We performed OGTT with 75 mg
oral glucose and the nadir GH was 1.0 μg/L.MRI scan of the pituitary revealed an adenoma 12 mm in
size. Adenoma was resected with endoscopy guided transsphenoidal approach and the histopathology was
consistent with adenoma stained positive with GH. His IGF-1 was normalized and spot GH was < 1 μg/ L
three months after the operation.
Conclusion: Acromegaloidism was reported in Kleinfelter syndrome which was recognized as a
condition which resembles acromegaly by its clinical manifestations without excess secretion of GH and
somatomedins. Ours was the first Kleinfelter case in the literature diagnosed with acromegaly that means
clinical tests are indicated in the presence of suspicious findings.
Introduction: Rathkes cleft cyst is one of the pituitary non-adenomatous tumors that found in about
20% of pituitary glands at autopsy. Symptomatic Rathke’s cleft cysts are rarely, but these cysts can
cause serious medical problems associated with compression of the pituitary gland, pituitary stalk,
optic nerve or hypothalamus. Here, we report a rare case of 73 years old man with sudden onset
headache due to Rathke’s cleft cyst present with symptoms and radiological features like apoplexy of
Case: A 73-year- old man admitted to our hospital with weight loss and sudden onset headache. His
body mass index were 31.8 kg/m 2 , blood pressure: 120/84 mmHg and 68/min with a regular rhythm.
Neurologic examination was normal. Laboratory findings were as follows: CBC was normal, Serum
sodium: 138 mmol/L, potassium: 4.8 mmol/L, urea nitrogen: 35 mg/dL, creatinine: 1.1 mg/dL, fasting
plasma glucose: 102 mg/dL, hemoglobin A1c: 7.3%. Anterior pituitary function tests were as follows:
morning serum cortisol 0.99 μg/dL, Adrenocorticotrophic hormone (ACTH) 14.2 pg/mL, free T3 1.82
μg/dL, free T4 1.32 μg/dL, thyroid stimulating hormone (TSH) 2.36 mIU/mL, luteinizing hormone
(LH) 1.18 mIU/mL, follicle stimulating hormone (FSH) 2.47 mIU/mL, serum testosterone 0.0025
ng/dL and serum prolactin of 12 ng/mL. His laboratory tests revealed panhypopituitarism. Brain
magnetic resonance imaging (MRI) showed a 20x15 cm sized sellar cystic lesion, which consisted of a
Rathke’s cleft cyst. On the basis of these results, supplementation with thyroid hormone and
glucocorticoid was started. After 1 month of supplementation treatment control MRI showed a 8.7x4.3
cm Rathke’s cleft cyst which was regressed compared to initial imaging.
Conclusion: The neurologic symptoms of endocrinopathies can be associated with Rathke’s cleft cyst
and hemorrhagic pituitary adenoma. The radiological evaluation can be spurious in these patients.
Longer follow-up must be needed in order to confirm the exact diagnosis.
Introduction: Acromegaly patients are known to have an increased risk of malignancies. This may be
as a result of the effect of insulin-like growth factor I (IGF-I) on cellular proliferation and apoptosis
inhibition. Although there are various reports related with hematological malignancies in children who
treated with growth hormone (GH), few data are available about hematological malignancies in
acromegaly patients. Here, we report a patient with acromegaly who has been developed chronic
lypmhocytic leukemia (CLL) in the follow-up period.
Case: A 30 years old woman who was at 25 th weeks gestation were consulted for gestational diabetes
mellitus 9 years ago. Physical examination, random GH, IGF-I levels and glucose suppression test
results were consistent with acromegaly. She reached full term without treatment, and had a caesarian
section and delivered a 4200-gr- baby boy with Apgar score of 9. After 1 year delivery transsphenoidal
surgery was performed and 3 months after the operation long-acting somatostatin analog treatment
was begun. Since she had residual adenoma and biochemical remission was not achieved with medical
treatment, she had underwent second operation after 1 year later the first surgery. Since the remission
was not achieved despite the medical treatment, after 1 year later the second operation gamma-knife
therapy has been performed. After 5 years later the radiotherapy, GH and IGF-I levels were decreased
gradually, somatostatin therapy was lowered and finally discontinued. However, the patient had
progressive leukocytosis with 90% lymphocytes. Flowcytometric analysis of the peripheral blood was
consisted with CD5+, CD19+, CD20+, CD22+, CD79b+, CD43+, CD200+ lymphocytes with surface
anti-kappa monoclonality. Fluorescent in situ hybridization analysis of bone marrow aspiration
revealed 20% deletion 17p13.1(TP53). Her findings were consistent with CLL-stage II.
Conclusion: Occurrence of CLL in the course of acromegaly may have been caused by excessive
endogenous GH or may be a coincidental situation.
Introduction: Primary hyperparathyroidism (PHP) is a highly prevalent disease, which is treated most
effectively by surgery. Postoperative hypocalcemia, a morbidity of surgical treatment of
parathyroidism, can prolong the hospital stay. The aim of this study was to identify the factors
predictive of hypocalcemia and hungry bone syndrome (HBS) in patients who undergo
parathyroidectomy due to PHP.
Materials and methods: Preoperatively and on days 1 and 4, and month 6 postoperatively, the
patients’ laboratory data including parathyroid hormone (PTH), calcium, phosphorus, 25-hydroxy D 3
(25-OHD), albumin, magnesium, alkaline phosphatase (ALP), blood urea nitrogen (BUN), and thyroid
stimulating hormone (TSH, free T3 and free T4 levels; and neck ultrasonography (US) and bone
densitometry findings were recorded.
Results: Hypocalcemia was observed in 63 (38.4%) of 164 patients on day 1 following
parathyroidectomy. On the postoperative 6 th month, permanent hypocalcemia was present in 10 (6.1%)
patients. HBS was observed in 22 (13.4%) of the patients who underwent parathyroidectomy due to
PHP. Among the PHP-related parathyroidectomy patients, postoperative hypocalcemia was observed
more frequently among patients with parathyroid hyperplasia and those with osteoporosis. On the
other hand, PTH, ALP and BUN values were higher among patients who developed HBS.
Additionally, HBS was observed more frequently among osteoporosis and parathyroid hyperplasia
patients and those who had thyroidectomy simultaneously with parathyroidectomy.
Conclusion: As a result, a more thorough preoperative follow-up is recommended for patients with
risk factors for hypocalcemia and HBS development.
Objective: Reoperative surgery for thyroid disease is rare. It is sometimes indicated for nodular
recurrence after partial surgery for initially benign thyroid disease or for a completion total
thyroidectomy when a final diagnosis of thyroid cancer is confirmed on a permanent section of a
partially removed thyroid gland. We aimed to investigate the demographic features and reoperation
indications in patients with reoperative thyroidectomy.
Material and Method: Thirty-six patients reoperated between 2008-2011 were included into the
study. Demographic features, indications of reoperation and histopathological results of patients were
Results: After reoperative thyroidectomy, the results of histopathological evaluation of 24 patients
were malignant (19 papillary thyroid carcinomas, 3 follicular thyroid carcinomas, 1 Hurthle cell
neoplasm and 1 neoplasm with undetermined malignant potential) while 12 patients were benign. Of
36 patients, 11 (30.5%) went to reoperation due to giant thyroid nodule (>4 cm), 5 (13.9%) due to ≥ 2
nondiagnostic fine needle aspiration biopsy (FNAB), 3 (8.3%) due to toxic multinodular goitre, 5
(13.9%) due to malignant cytology, 2 (5.6%) due to suspected malignancy, 2 (5.6%) due to suspicion
for a follicular neoplasm, 3 (8.3%) due to follicular lesion of undetermined significance, 1 (2.8%) due
to atypia of undetermined significance, 1 (2.8%) due to suspected Hurthle cell neoplasm and 3 (8.3%)
due to cytology of cellular adenomatoid nodule and ultrasonography suggesting malignancy.
Conclusion: Thyroid surgery may lead to regional scars and some degree of fibrotic process. This
may result in problems in collecting thyroid FNAB samples and assessing cellular abnormalities. Our
study findings demonstrated that histopathological evaluation of 14 patients whose cytological results
showed no malignancy, was consistent with malignancy. We consider that decision for reoperative
thyroidectomy should not be made with cytological findings, but patients’ symptoms and ultrasound
findings should also be taken into account.
Introduction: High values of fine needle aspiration washout thyroglobulin (FNA-Tg) are diagnostic
for metastatic lesions of thyroid cancer. However, there is not a consensus on cut-off for high Tg level.
The most important confounding factor for FNA-Tg is inability to calculate Tg per unit volume
because residual aspiration material in the needle cannot be known exactly. Another problem is
possible contamination of whole blood during lymph node aspiration. In this study, we aimed to
determine a more accurate and standardised parameter for FNA-Tg.
Methods: Ultrasonographically suspicious 155 lymph nodes in 120 patients with histopathologically
confirmed differentiated thyroid cancer and suspicious for malignancy/malignant thyroid nodule FNA
result in cytology were evaluated. Tg was measured in samples obtained by aspiration (FNA) and non-
aspiration (FNNA) biopsy. The highest value obtained by these methods from the same lymph node
was defined as FNB-Tg. Simultaneous venous blood sample was taken. Tg was measured from whole
blood and serum washouts which were obtained by using syringes and needles identical to ones used
for lymph node biopsy.
Results: Data of 16 lesions in 14 patients who underwent lymp node dissection were analysed.
FNNA-Tg, FNB-Tg/whole blood washout-Tg, FNB-Tg/serum washout-Tg, FNB-Tg/serum Tg were
significantly higher in malignant lymph nodes compared to benign ones. Areas under the ROC curve
for FNNA-Tg, FNNATg/whole blood washout-Tg, FNNA-Tg/serum washout-Tg were statistically
significant for the discrimination of benign and malignant lymph nodes. Best cutoff values for FNNA-
Tg and FNB-Tg were 15.86 and 31.8 ng/ml. respectively. Among ratios, best cut off values to
discriminate benign and malignant lymph nodes were 5.44 for FNB-Tg/whole blood washout-Tg and
3.95 for FNBTg/serum washout-Tg.
Conclusion: Determining ratio of FNB-Tg to whole blood washout-Tg and/or serum washoutTg
might be a promising method for increasing accuracy and providing standardization of lymph node
aspiration to detect malignant lymph nodes.
Introduction: Neoplasms of the thyroid gland are classified according to the cell that it originates and
commonly they originate from follicular or parafollicular C cells. The most common differentiated
thyroid cancers (DTC) are papillary and follicular carcinomas. Coexistence of two different
histological types of primary follicular thyroid neoplasm is a rare condition. There are previous reports
of concomitant medullary and papillary thyroid cancers .However there is scarce data about the
simultaneous two different histological types of primary follicular thyroid tumors and this is the first
study on that subject.
Method: From January 2007 to September 2014 , our instutional database was reviewed for patients
who underwent thyroid surgery for various indications. Medical records and cytopathology reports of
those patients were examined retrospectively. Simultaneous neoplasms of follicular origin were noted.
Results: A total of 3700 patients were operated. Histopathological examination result was benign in
2686 (73%) patients while it was malignant in 1014 (27%) patients. Among the patients with the
diagnosis of DTC only 20 (1.9%) had accompanying second neoplasia within the same thyroid gland.
PTC had thyroid capsule invasion in seven patients (35%) while capsule was intact in thirteen (65%).
In seventeen (85%) patients there wasn’t vascular invasion whereas in three patients (15%) vascular
invasion was detected in PTC. Second neoplasm was follicular carcinoma in 10 patients, Hurthle cell
carcinoma in 2 patients, Hurthle cell adenoma in 5 patients and follicular adenoma in 3 patients.
Conclusion: Such simultaneous tumors may be part of a familial tumor syndrome or an unidentified
novel gene mutation playing role in the pathogenesis of more than one type of tumor. Based on the
current evidence the synchronous occurrence of those neoplasms in a given patient is likely
coincidental in the literature. Further study is required using a larger patient population with
standardized genetic characterization.
INTRODUCTION: Endocrinological and metabolic changes can occur in critically ill patients, which
may affect the prognosis and outcome. The hypothalamic-anterior pituitary axis (HPA) plays a crucial
role in the endocrine regulation of metabolic and immunological homeostasis. In this prospective
study, we evaluated the pituitary-adrenal-gonadal-thyroid axis in the adult ıntensive care unit (ICU)
patients ,their outcome, the association between these hormonal changes and “The Acute Physiology
and Chronic Health Evaluation II score (APACHE II)”, Sequential Organ Failure Assessment (SOFA),
length of hospitalization and mortality.
METHODS: Patients hospitalized in adult ICU (not for trauma or operation) between January 2014
and January 2015 were enrolled in this study. Severity of illness was assessed by APACHE II and
SOFA on admission to the ICU and 15 days later. Blood samples were collected within the first 4
hours of ICU admission and 15 days later for measurement of anterior pituitary and end organ
RESULTS: Total patient number was 157. Eighty five patients were in survival (S), 72 patients were
in the non-survival (NS) group. In the NS group, patients’ mean age, APACHE II and SOFA scores at
the admission were significantly higher. In the NS group median GH, E2, cortisol levels were
significantly higher whereas median FSH, LH, fT3, fT4 were lower. Fifteen days after admission,
there was significant increase in median IGF-I and ACTH levels and decrease in median cortisol and
SOFA scores compared to baseline values. Strongest predictors for mortality were found to be
hospitalization length, SOFA score, deltaTSH and age. None of the other endocrine parameters had an
effect on mortality.
CONCLUSION: In critical illness, activation of the HPA and the cortisol response are essential for
survival. Combinations of endocrine parameters may provide better indices than measurement of a
single hormone or an APACHE II-based score.
Introduction: Increasing evidence is available for the role of prolactin in the development of various
cancers. The purpose of this study is to evaluate the frequency of thyroid cancer in patients with
prolactinoma followed up at a single site.
Materials and methods: Medical records of 182 patients, diagnosed with prolactinoma, were
reviewed retrospectively. Out of these patients, 114 patients (103 female patients,11 male patients,
mean age 35 ±10.4), who had undergone thyroid ultrasonography (US), were included in the study.
Serum prolactin, anti-thyroglobulin (antiTg), anti-thyroid peroxidase antibody (anti TPO),thyroid
stimulating hormone (TSH), free T4 (fT4), free T3 (fT3) values, and pituitary gland magnetic
resonance imaging (MRI) and US reports were evaluated.
Results: It was found that 45(39.5%) patients had thyroid nodule (13 solitary, 32 multiple). 10 patients
were administered thyroidectomy, and differentiated thyroid cancer (DTC) was detected in 6 of these
patients (5.3%).1 patient had lung metastasis. Control group consisted of 113 individuals (101
females, 12 males, mean age 32.1±9.1).In US, 28 of these individuals (24.8%) had thyroid nodule (5
solitary, 23 multiple). 1 individual (0.8%) had DTC.
Conclusion: When compared to control group, thyroid volume and thyroid nodularity were
significantly higher in patients with prolactinoma (respectively, p<0.001, p=0.018), however, no
statistically significant difference was available for the incidence of thyroid cancer (p=0.196).
Introduction: Prolactin is a multifunctional pituitary hormone. The effect of prolactin on platelet
activation is not well understood. Prolactinomas are the most common type of pituitary adenomas, and
they are medically responsive to dopamine agonists. Mean platelet volume (MPV) is a marker of
platelet function and activation. The aim of this study was to evaluate MPV values before and 6
months of cabergoline treatment when normoprolactinemia was achieved.
Methods: A total of 101 newly diagnosed prolactinoma patients and 102 healthy control subjects were
included in the study. Patients with hematological disorders that affect MPV and those on medications
were excluded. Prolactin, platelet count and MPV levels were recorded before and 6 months after the
initiation of cabergoline treatment (0.5 to 1 mg, two times a week).
Results: There was no significant difference in platelet count and MPV before and after 6 months of
treatment with cabergoline in patients with prolactinoma compared with the control group (p>0.05).
Conclusion: Our results showed that MPV, a marker of platelet function, was unchanged in patients
Introduction: Pheochromocytomas (PHEO) are catecholamine producing tumors that are mostly
adrenal in origin. PHEO is diagnosed with classic findings and symptoms but biochemical
confirmation must be made and followed by anatomical localization. PHEO can also be associated
with adrenal incidentalomas (AI). All of the patients with AI must be evaluated for PHEO
biochemically. Either urinary or plasma chatecholamines and metanephrines can be used for
biochemical evaluation. Normal values rule out the diagnosis, whereas four fold increase above the
upper limit of normal confirm the diagnosis. But value of borderline or less than 4 fold elevations in
the diagnosis is not clear. We aimed to determine the urinary fractionated metaneprine and
catecholamine levels in patients with PHEO.
Material and Methods: Thirteen patients who underwent adrenalectomy and finally diagnosed as
PHEO and 10 age- and sex- matched AI patients who underwent to adrenalectomy based on size
criteria, preoperative hormonal test results and finally diagnosed as benign neoplasm between January
1, 2008, and January 1, 2015 were evaluated retrospectively.
Results: Of the 13 patients with a pheochromocytoma on final pathologic diagnosis, VMA levels
were as follows: 3 (23.1%) patients had borderline elevations, 1 patient (7.7 %) had 2 fold elevations,
1 patient had 3 fold (7.7%), 1 (7.7%) had 4 fold , and 3 (23.1%) patients had 6 fold elevations above
the upper limit of normal. However, 4 (30.8%) patients had normal VMA values. For non-PHEO
group 4 (40%) patients had borderline elevations, and 6 (60%) patients had normal values. There was
no statistically significant difference between PHEO and non-PHEO groups (p=0.42). For PHEO-
group urinary HVA values were as follows: 2 (16.7%) had borderline elevations, 10 (83.3%) had
normal values. In 1 patient it was not evaluated. For non-PHEO group, 1 (10%) had 2 fold, 1 (10%)
had 6 fold elevations, and 8 (80%) had normal values. There was no significant difference for HVA
(p=0.70). Urinary metaneprines were as follows: 3 (25%) had borderline elevations, 9 (75%) had
normal values in PHEO-group, however 1 (10%) had borderline elevation, 1 (10%) had 6 fold
elevations, 8 (80%) had normal values. The difference was evaluated as statistically insignificant
(p=0.19). Normetanephrine values were as follows: borderline elevation in 5 (41.7%), 2 fold elevation
in 1 (8.3%), 6 fold elevation in 1 (8.3%) and normal values in 5 (41.7%) patients in PHEO-group;
borderline elevations in 2 (20%) , 2 fold elevation in 1 (10%), normal values in 7 (70%) patients in
non-PHEO group. This was also statistically insignificant (p=0.39). There were also no statistically
significant differences in urinary adrenalin and noradrenalin levels between groups.
Conclusion: Patients with borderline -elevated urinary metanephrine levels can also have PHEO. In
patients with AI who are candidate for surgery and have borderline elevated metaneprines should be
evaluated carefully. In this group of patients, we advocate either routine preoperative preparation as
patients possessing PHEO or further diagnostic tests in order to prevent the serious complications.
Introduction:Primary Hyperparatyhyroidism (PHPT) is usually caused by single or multiple
adenomas and cancer is rare accounting for less than 1 % of all presentations. The presence of certain
cytological, and architectural features such as adherence to adjacent organs, a solid growth pattern,
broad bands of fibrosis, cytological atypia, and an irregular growth contour do not indicate malignancy
but are recognized as atypical features encountered more commonly in malignant than benign tumors.
Tumors that demonstrate these atypical features and do not fulfill criteria for carcinoma can be
classified as atypical adenomas. Herein we aimed to evaluate the clinical and biochemical features of
the patients histopathologically diagnosed with an atypical parathyroid adenoma.
Method:Our endocrine database was searched retrospectively for the patients with operated PHPT and
diagnosed with atypical adenoma. Demographic, clinical and biochemical data of the patients were
recorded. A control group was formed from the patients who were also operated with the diagnosis of
PHPT and classical parathyroid adenoma was detected histopathologically.
Results:There were sixteen patients in the atypical adenoma group and thirty patients in the control
group. Age and gender distribution of the patients were similar in between groups with female
predominance. Serum Ca and P levels were also similar where as preoperative serum PTH, ALP and
urinary Ca excretion were significantly higher in patients with atypical adenoma (p<0.001, p<0.001
and p=0.021, respectively). Adenoma size was significantly higher in the atypical adenoma group
compared to controls (p=0.006) and cystic degeneration and isoechoic appearance on USG were more
prevalent among the atypical adenomas (p=0.016).
Conclusion:Preoperatively high PTH, ALP and urinary Ca levels may be predictive for atypical
adenoma or carcinoma within a patient being evaluated for PHPT. The surgeon might prefer enbloc
parathyroidectomy instead of minimal invasive surgery in such cases with more strict postoperative
Introduction: Primary hyperparathyroidism (pHPT) is a common endocrine disease mainly caused
by single or multiple hyperfunctioning parathyroid lesions. In 2% to 7% of cases, surgery is not
curative at first operation and reoperation is required. Ultrasonography and sestamibi scan are the most
widely used methods for identification of the the culprit parathyroid gland with the disadvantage of
high false positives caused by other cervical pathologies. Herein we aimed to search the diagnostic
value of measurement of parathyroid hormone (PTH) concentration in the needle washout of
suspicious lesions suggestive for parathyroid adenoma with negative or unequivocal MIBI results.
Methods: Our endocrine database was searched retrospectively for the patients with PHPT who
underwent PTH washout. There were 100 lesions of 70 patients. Among them, 21 lesions in 16
patients were operated and data of these lesions were analyzed. All patients had at least one suspicious
parathyroid lesion detected by ultrasonography and all patients were evaluated by 99mTc-MIBI.
Result: The mean age of the patients was 53.3±10.6 years with the majority of them being female
(87.5%). The mean preoperative serum calcium level was 11.04±0.33 mg/dl. The median serum PTH
level was 140 pg/ml (ranging from 55 to 371) and the median serum PTH washout level was 3316
pg/ml ranging from (13 to 5000 ). Preoperatively 99mTc-MIBI scan was negative or unequivocal in
15 of 21 operated lesions while it was positive in 6. For the lesions that the MIBI failed to localize, the
sensitivity of PTH washout was 91% and the specifity was 66%.
Conclusion: PTH washouts can contribute significantly in establishing the parathyroid nature of
cervical lesions that has conflicting preoperative sestamibi results and also might help the surgeon to
perform a more succesful operation.
Introduction: Mitochondrial diseases usually occur by mutations of mitochondrial or nuclear DNA.
Mitochondrial cytopathy is a disease affecting many systems including endocrine system. We present
a case diagnosed as mitochondrial myopathy previously accompanying multiple endocrinological
Case : Fifty-two years old female patient admitted in another center with a complaint of drooping of
upper eyelids 25 years ago. Acetylcholine receptor antibodies were negative and her EMG was
compatible with progressive external ophthalmoplegia. She was diagnosed as mitochondrial myopathy
by left biceps muscle biopsy. Coenzym Q 10 and L-carnitine treatments were started. She admitted to
our center with numbness and spasm in her hands. Serum calcium was 6.1 mg/dl, phoshorus was 6.9
mg/dl, magnesium was 1.5 mg/dl and parathyroid hormone level was 8.9 pg/ml. There were common
symmetric calcifications at basal ganglions, bilateral cerebellar hemispheres, thalamus and
periventricular white matter in cranial CT. EEG was normal. Creatine kinase was 507 U/l, LDH was
435 U/l and plasma lactate level was 2.4 mmol/l. Calcium carbonate and calcitriol were administered
to the patient with diagnosis of hypoparathyroidism. Thyroid autoantibodies were positive. Thyroid
hormone levels were normal. Thyroid ultrasound was compatible with chronic thyroiditis. In eye
examination bilateral ptosis and cataract were detected. Retina examination was normal. Her
audiometry was normal. She was diagnosed as type 2 DM.
Conclusion: Mitochondrial myopathies can be together with various endocrinological problems. Our
patient had adult onset pure mitochondrial cytopathy and primary hypoparathyroidism, chronic
autoimmune thyroiditis and type 2 DM were accompying endocrinological pathologies. Associations
with hypoparathyroidism, autoimmune thyroiditis, DM and GH deficiency have been reported in
patients with Kearns Sayre syndrome in the literature. Also mitochondrial myopathy, encephalopathy,
lactic acidosis, stroke (MELAS) and adrenal insufficiency’s association was reported. Because of
probability of affecting multisystem, cases with mitochondrial myopathies should be evaluated for
various endocrinological pathologies.
Objective: Polycystic ovary syndrome (PCOS) is a complex endocrinopathy affecting 5-10% of
women in reproductive period. Our goal is to determine which symptoms and findings are the most
common in Turkish adolescents with PCOS.
Material and method: Ninety three adolescents (15-19 years old) who admitted to our outpatient
clinic with at least one of the complaints (acne, obesity, menstrual irregularities and hirsutism) were
enrolled in the study. All patients were evaluated due to both Rotterdam and NIH criteria.
Results: Due to Rotterdam and NIH criteria 40 (43.01%) and 32 (34.40%) of patients were diagnosed
as PCOS respectively. Due to Rotterdam menstrual irregularities were 90%, hirsutism was 45%,
obesity was 25% and acne was 32.5% in patients diagnosed as PCOS. Due to NIH these ratios were
96.9, 50, 25 and 31.3% respectively. Patients were divided into 12 subgroups due to combinations of
complaints. Due to Rotterdam, PCOS diagnosis were 100% for menstrual irregularities and hirsutism
together, 75% for menstrual irregularities and acne together, 66.7% for menstrual irregularities and
obesity together, 66.7% for only hirsutism, 50% for hirsutism and acne together, 40% for only
menstrual irregularities, 3.7% for only acne and 0% for only obesity. Due to NIH, PCOS diagnosis
were 100% for menstrual irregularities and hirsutism together, 66.7% for menstrual irregularities and
acne together, 44.4% for menstrual irregularities and obesity together, 33.3% for only hirsutism,
26.7% for only menstrual irregularities, 0% for only acne or only obesity. Eight patients were
diagnosed as PCOS only due to Rotterdam.
Conclusion: The most common complaints in Turkish adolescents with PCOS were menstrual
irregularities, hirsutism, acne and obesity in our study. According to guidelines PCOS in adolescents is
based on clinical and/or laboratory hyperandrogenism together with persistent oligomenorrhoea.
Polycystic ovarian morphology can be a part of reproductive changes in adolesce
Introduction: 47,XYY syndrome is characterized by an extra copy of the Y chromosome in each cells
of a male. It occurs in about 1/1,000 of newborn boys and most males with this syndrome have normal
sexual development and fertility. They tend to have tall stature and mild motor and language
developmental problems. Testosterone levels are normal. Increased rate of criminal activity in XYY
males was related to a lack of judgement and lower socioeconomic status due to a lower mean IQ
Case report: A 21 year-old- man applied to our clinic with complaints of small testis and penis and,
lack of beard and ejaculation. He had normal libido and erection. There was no family history of
infertility. He hadn’t commited any crime. In physical examination, he had eunuchoid habitus, his
height was 178 cm, weight was 66.6 kg, and BMI was 21 kg/m 2 . His testes were palpable in the
scrotum. Axillary and pubic hair development was consistent with Tanner stage 4. Penis length was
6.5 cm. His neurocognitive development and functions were normal. Hormonal tests revealed
hypogonadotropic hypogonadism. Other hypophyseal hormons were normal. Bone age was
compatible with 14 years and epiphyseal plates were open. In testicular ultrasonography, volumes
were 8 ml on the right and 7.5 ml on the left. Hypophyseal MRI showed partially empty sella. In
chromosomal analysis, 47,XYY karyotype was detected. After administration of human chorionic
gonadotropin treatment, androgen levels increased and ejaculation started although in small amounts
Conclusion: Men with 47,XYY syndrome have a diverse spectrum of clinical presentation and
because of the heterogeneous phenotype and lack of spesific symptoms, its diagnosis may be difficult.
As presented in our case, hypogonadotropic hypogonadism might be a presenting feature in patients
with 47,XYY genotype.
1. Kim IW, Khadilkar AC, Ko EY, Sabanegh ES Jr. 47,XYY Syndrome and Male Infertility. Rev
Urol. 2013;15(4):188-96. Review.
2. El-Dahtory F, Elsheikha HM. Male infertility related to an aberrant karyotype, 47,XYY: four
case reports. Cases J. 2009 Jan 8;2(1):28. doi: 10.1186/1757-1626- 2-28.
3. Visootsak J, Graham JM Jr. Social function in multiple X and Y chromosome disorders:
XXY, XYY, XXYY, XXXY. Dev Disabil Res Rev. 2009;15(4):328-32. doi: 10.1002/ddrr.76.
4. Ceylan GG, Ozbey U, Yüce H, Elyas H. 47,XYY Sendromlu Bir Olgu. Fırat Tıp Dergisi
Introduction:Normal or elevated TSH level in the presence of elevated T4 is defined as
“inappropriate TSH syndrome”.Two main clinical conditions that can lead that syndrome are TSH
secreting adenoma (TSHoma) and resistance to thyroid hormone (RTH). Making the correct diagnosis
is crucial in order to decide the most appropriate treatment option. Herein we presented clinical and
laboratory data of seven patients who were hospitalized for the differential diagnosis of the two
Method:Our database was reviewed for the patients diagnosed with inappropriate TSH syndrome at
our hospital between 2010-2014. After exclusion of the other rare causes of inappropriate TSH
syndrome, seven patients who were hospitalized for the differential diagnosis of TSHoma and RTH
were included in this report
Result:Age of the patients was changing between 20 and 52 years. Clinically two patients were
asymptomatic, three had tachycardia and weight loss and one had goiter. Final diagnosis was RTH in
four patients, TSHoma in two and unequivocal in one. Two patients diagnosed with TSHoma were
operated and had positive staining with TSH. Both of the TSHoma cases had macroadenoma on
pitiutaryMRI and visual field defect while two of four patients with RTH had microadenoma. Alpha-
subunit/TSH molar ratio was above 1 in all patients diagnosed with TSHoma while it exceeded 1 in
two patients with the final diagnosis of RTH. TRH stimulation test revealed a blunted response in all
patients with TSHoma and a positive response (increase >100%) was observed in all with THR. TSH
was suppressed after T3 supression test in all patients with the final diagnosis of RTH.
Conclusion:Differential diagnosis of RTH and TSHoma can be a clinical challenge and requires
complex hormonal tests and imaging methods. Since incidental pituitary tumors are not rare, presence
of an adenoma should not rule out diagnosis of RTH.
Introduction: Xantoma disseminatum (XD) is a rare non-Langerhans cell histiocytosis (NLCH)
which is often resistant to treatment.In this report, we presented a case with extensive cutaneous,
hypothalamohypophysial, cerebral and gastrointestinal system involvement, which responded well to
Case: A sixteen-year- old female patient admitted to our hospital with the complaints of amenorrhea,
weight gain, polidipsia, poliuria, yellow-brownish papular lesions on the cervical, periorbital, axillary
and genital regions. Lesions first appeared 18 months ago and increased in amount and size in time.
Hormonal evaluation was done including dynamic tests and secondary hypothyroidism,
hypogonodothropic hypogonadism, growth hormone deficiency and central diabetes insipidus were
detected.Pituitary MRI demonstrated a mass 15x8 mm in diameter at hypothalamohypophysial tract
together with multiple cerebral lesions. Her visual and neurologic examination was normal. A biopsy
was performed on skin and duodenal lesions and the result of pathologic analysis was coherent with
NLCH. In the light of those findings, she was diagnosed with XD. Hormonal replacement therapies for
hypothyroidism, hypogonadism and DI were initiated. For hypothalamic mass and skin lesions 60
mg/day methyl prednisolone was started and its dosage was gradually reduced to maintenance dose of
4 mg/d. MRI screening performed at 6th month of therapy didn’t show any regression in mass sizes.
Hence, medical therapy was changed with cyclophosphamide 100 mg/d. No complete remission was
achieved but significant regression in cutaneous, hypothalamohypophysial, cerebral and
gastrointestinal lesions was obtained in 24 months. No side-effects were noticed related with
cyclophosphamide. The skin lesions did not relapse after discontinuation of cyclophosphamide.
Conclusion: The coexistence of XD with hypopituitarism is a rare condition. There are various
systemic treatments such as radiotherapy, cryotherapy, corticosteroids, and antiblastic chemotherapy
but no single treatment is universally successful.In rare cases complete remission was obtained with
low-dose oral cyclophosphamide in adults as it occurred in our case.
Introduction: Acromegaly is a chronic disease caused by excessive secretion of growth hormone
(GH), and as a result, of insulin-like growth factor -1 (IGF-1). Although controversial, frequency of
both benign and malignant neoplasm formation is thought to be increased in acromegalic patients.
Pleomorphic adenoma is the most common arising tumor from the parotid salivary gland. Here we
report the case of a 33-year- old woman with acromegaly and also who presented with a swelling on
the left neck and diagnosed as pleomorphic adenoma arising from parotid gland after excision of the
Case report: Thirty three-year- old woman admitted to the hospital complaining of a two-weeks
history of visual loss and headache. She also determined weight gain, menstrual irregularity, libido
loss, galactorrhea, and a slowly growing swelling on the left neck during the last year. Hypophyseal
MRI revealed a mass of 20x32 mm occupying the sellae and invasing right cavernous sisternae and
extending to the optic chiasm. Hormonal evaluation demonstrated that the patient had acromegaly and
secondary hypothyroidism. Parotid ultrasound (US) revealed a 42x28x45 mm heterogenous,
hypoechoic intraglandular lobulated solid mass occupying left parotid gland superficial lobe and
extending to the deep lobe. Hypohpyseal adenoma was excised by transsphenoidal route and
immunohistochemical analysis showed extensive GH positivity. She had residual tumor after the
operation and somatostatin analogous therapy was started in the follow-up period. After eight months
from the hypophyseal operation the parotid tumor was excised and pathology showed that it was a
Conclusion: It seems that this is the first case of a coincidence between an acromegaly and
pleomorphic adenoma of parotid gland in the English literature. We don’t have still enough knowledge
about an association between salivary gland tumors and acromegaly. If present or not this association
must be evaluated with the further studies.
Aim: Ocular changes and ocular symptoms may be encountered in patients with hypothyroidism and
hyperthyroidism. However, the data concerning the effects of thyroid disorders on intraocular pressure
(IOP), central corneal thickness (CCT) and retinal thickness (RT) are very rare. Here, we aimed to
evaluate the alterations in IOP, CCT and RT in patients with euthyroid autoimmune thyroiditis (AIT).
Material- Methods: Twenty-five subjects with euthyroid AIT were included into the study. The
patients were compared with age and sex-matched 40 healthy subjects. A detailed ophthalmologic
examination including the IOP, CCT and RT was performed in both groups.
Results: There was no statistically significant difference in mean right RT, left RT, right CCT and
left CCT between two groups (p>0.05 for all parameters). Also, no significant difference was found
between groups concerning right and left IOP (p>0.05 for all parameters). In patients groups, left RT
was significantly higher in patient with TSH>2.5 µIU/mL than those of TSH< 2.5 µIU/mL
(294.85±23.58 vs 261.50 ±21.70, p=0.003). A positive correlation was observed between left RT and
thyrotropin levels (r=0.269, p=0.033). No significant correlation was found between free
triiodothyronine levels, and right CCT, right RT, right IOP, left CCT, left RT and left IOP levels
(p>0.05 for all parameters). Also, free tetraiodothyronine levels were not significantly correlated with
right CCT, right RT, right IOP, left CCT, left RT and left IOP levels (p>0.05 for all parameters).
Conclusion: An increase in IOP in Graves ophthalmopathy (GO) is a well-known entity. In literature,
hypothyroidism seems to cause a reversible increase in CCT and IOP. In this study, we observed no
significant difference between groups concerning IOP, CCT and RT. So, further studies with larger
sample size are needed to evaluate IOP, CCT and RT in patients with euthyroid AIT.
Aim: Exophytic nodule refers to a nodule that sticks out of the normal thyroid boundary/outline. Other
definition is a nodule with an acute angle between the lesion and adjacent thyroid capsule. Exophytic
configuration is not known risk factor for thyroid cancer. We aimed to compare ultrasonographical
features and cytopathologic results of exophytic and non-exophytic thyroid nodules.
Material and method: Fourty-four exophytic and 34 non-exophytic thyroid nodules in which fine
needle aspiration biopsy was indicated throughout 3 months were evaluated prospectively. Mean
nodule size was similar in two groups (18.83±8.71 mm and 15.28±7,57 mm, p=0.173). The ratio of
presence of peripheral hypoechoic halo and marginal irregularity was also similar in both group
(p=0.512 and p=0.153, respectively). Microcalcification was present in 21.4% and 29.4% of exophytic
and non-exophytic nodules, respectively (p=0.424). Macrocalcification was detected in 4.5% of
exophytic and 11.8% of non-exophytic nodules (p=0.111). 47.6% of exophytic nodules was
hypoechoic and 52.4% was isoechoic. 47.1% of non-exophytic nodules was hypoechoic and 52.9%
was isoechoic. Color flow doppler pattern was defined as non-vascular, peripheral, central, or of
mixed type and was similar in both groups (p=0.138). Cytopathologic results of exophytic nodules
were 75% benign, 4.3% follicular lesion or atypia with undetermined significance, 2.3% suspicious for
malignancy, 2.3% malign, and 15.9% non-diagnostic. In non-exophytic group, 79.4% was benign and
20.6% was non-diagnostic (p=0.497).
Conclusion: Exophytic configuration of thyroid nodules was rarely investigated as a possible
predictive feature for malignancy in the literature. In the literature, only one study evaluated exophytic
feature of thyroid nodules in neck CT (1). They reported malign thyroid nodules had more frequently
exophytic configuration than benign ones without statistical significance. In our study, we did not find
any difference in terms of ultrasonographical features and cytological results between exophytic and
non-exophytic thyroid nodules. However, more comprehensive studies with larger sample sizes are
needed to clarify any possible relation between exophytic configuration and malignancy.
1.Kim DW, Jung SJ, Baek HJ. Computed tomography features of benign and malignant
solid thyroid nodules. Acta Radiol. 2014 Oct 7. pii: 0284185114552216. [Epub ahead of print]
Background: Functional expression of sodium iodide symporter (NIS), a membranetransporter of iodine is essential for postoperative radioiodine treatment in papillary thyroid cancer (PTC). It is reported that BRAFV600E mutation was correlated with worse clinicopathologic features due to impaired NIS expression. In this study we evaluated the relationship of the BRAF mutation and functional NIS expression in patients with classical variant (CV) PTC.
Design: BRAF mutation was analyzed by RT-PCR in 106 consecutive cases withCV-PTC and immunohistochemical staining of NIS protein was evaluated in 96 cases. Localisation (intracellular or membraneous), intensity were characterized semiquantitatively. The density of cytoplasmic staining was also noted. Clinicopathologic features such as extrathyroidal invasion, lymph node metastesis were correlated with BRAF mutation and functional NIS expression. 88 patients who completed at least 24 months follow up were used for the outcome.
Results: Mean age was 46,2±13,7. Gender F/M: 79/17. 75/96 (78.1%) cases had BRAFmutation. Functional (membranous) NIS was higher in BRAF mutation positive group (78.7%) than in BRAF negative group (57.1%) (p=0.047). Nonfunctional (cytoplasmic) NIS was lower in BRAF mutation positive group (21.3%) than in BRAF negative group (42.9%) (p=0.047). Those with moderate and intense cytoplasmic staining had 6.43 times higher BRAF mutation (90%) than those with weak staining (58.3%) (95% CI=2.20-18.80,p=0.001). There was no association between NIS expresion patterns and lymph node positivity, extrathyroidal extension ans surgical margin positivity. Extrathroidal extension was present in 54.7% of cases with BRAF mutation and 33.3% without (p=0.084). Surgical margin positivity was present in 85.7% of cases with BRAF mutation and 14.3% without (p=0.084). There was no association for lymph node involvement (p=0,625). 7/88 patients without remission had BRAF mutation; 5 had functional NIS expression.
Conclusions: Functional NIS expression is higher among CV-PTC with BRAFmutation. But the clinical features were not found to be associated with NIS expression. There may be different mechanisms determining the outcome of therapy.
Background: Hypogonadism is related to additional endocrine abnormalities. Thyroid abnormalities may be common in hypogonadism patients, although this association is not clear.
Objective: In this study, we examined the incidence of thyroid disorders in hypogonadisms.
Methods: A case-control study of 68 hypogonadal patients and 74 age-matched healthy controls from the general population was conducted. Thyroid function, thyroid volume measurements, and presence of thyroid autoantibodies were examined.
Results: The mean BMI and age of the patient and control groups were similar (P=0.43 and P=0.407 respectively). The thyroid status differed signiﬁcantly between the patient and control groups (P=0.002). In the patient group, 55 (80%) patients were euthyroid, 10 (14%) patients were hypothyroid, and 3 (6%) patients were hyperthyroid. In the control group, 71 (95%) subjects were euthyroid, and 1 (5%) was hypothyroid. Serum TSH levels were signiﬁcantly higher in hypogonadal patients than in controls (P=0.018); however, serum free T4 and free T levels did not differ signiﬁcantly between the two groups (P=0.29 and P=0.63 respectively). The presence of thyroid autoantibodies (anti-TPO and anti-TG) did not differ signiﬁcantly between the patient and control groups (P=0.49 and P=0.89 respectively). There were no differences observed by ultrasonography between the patient and control groups. The thyroid volumes of the right and left lobes were measured. There were no signiﬁcant differences in thyroid volumes of the patient and control groups (59.67±30.34 and 68.02±43.45 ml respectively;P=0.22).
Conclusion: A high incidence of hyperthyroidism and a high incidence of hypothyroidism were observed in hypogonadal patients.
INTRODUCTION: Fine-needle aspiration (FNA) is a simple, minimalinvasive,cost-effective and widelyused diagnostic tool for evaluating thyroid nodules. Recent times a technique called fine-needle sampling non-aspiration (FNNA) or fine-needle capillary thyroid biopsies (FNC) has been more preferred. This technique prevents the use of suction so there is no aspiration crush and therefore nondiagnostic outcomes are reduced.The aim of this prospective study was to compare the FNA and FNNA with reference to diagnostic adequacy and diagnosisaccording to Bethesda System.
MATERİALS AND METHODS: Ultrasonography-guided FNA and FNNA biopsy were performed successively on 100 nodules. Both techniques were performedonthe same nodule and assessed by the same pathologist, beginning with the first (FNA) on half of the patients (randomly selected) and vice versa. The pathologist was unaware of the sampling method employed (FNA/FNNA) for any particular set of slides to avoid individual bias. The final cytopathologic finding was reported by using the Bethesda criteria, in which a sample is considered adequate if it contains a minimum of 6 groups of well observed follicular cells, with at least 10 cells per group.
RESULTS: During this study interval, FNA and FNNA were performed on 100 thyroid nodules of99 patients (78 patients were female,21 were male). The patients’ age range was 19-75 yearsold. The sizes of the thyroid nodules which biopsy samples were taken, areranged from 6 to 59 mm in mean diameter. A significant difference between FNA and FNNA examination was found ininadequate results (42% vs 22%, p=0.02).
There was no significant differences innodule features including;echogenicity, calcification and nodul size between the two techniques.
Table1: The cytopathologic results of FNA and FNNA sampling
Cytologic atypia or follicular lesion with undetermined significance
CONCLUSION: FNNA is an easier technique to perform with better patient compliance. We think our study will lead a further suggestion to prefer FNNA toreduce nondiagnostic results.
INTRODUCTION: Pregnant women with known hypothyroidism must have monthly follow up with thyroid function tests. Appropriate L-thyroxin replacement dose can be given due to trimester specific thyroid stimulating hormone (TSH) levels. We will discuss about a hyperthyroid pregnant woman who was taking L-thyroxin replacement before and during the first trimester of pregnancy for hypothyroidism.
CASE: A 24 year old woman admittedto our out-patient clinic for fatigue and weight gain. She had a family history of Hashimoto thyroiditis. Her TSH was 10.13 uIU/mL (0.27-4.2), free T4 was 1.27 ng/dL (0.9-1.7), free T3 2.98 pg/mL (1.8-4.6), anti thyroid peroxidase antibody (TPO Ab) was 11.8 IU/mL (0-34) and anti thyroglobulin was 17.27 IU/mL (0-115). Her thyroid ultrasonography was compatible with chronic thyroiditis. L-thyroxin replacement was started after Hashimoto disease diagnosis. After euthyroidisim achieved she became pregnant. With monthly follow up L-thyroxine dose adjusted. On the 20th week of pregnancy thyroid function tests revealed thyrotoxicosis. Despite cessation of L-thyroxin treatment thyrotoxicosis persists and when we take the titer of thyrotropin receptor stimulating antibody (TSHR Ab) it was 405 u/L (0-14). There was no ophtalmopathy on physical examination. Propylthiouracil treatment was started. And she had a healthy boy baby with no obvious thyroid dysfunction.
Table. Thyroid hormone levels of patients
11 th week
(while taking L-thyroxin)
20 th week
(L -thyroxin stopped)
26 th week
CONCLUSION: TSHR Ab is responsible for two distinct clinical syndromes. Stimulating antibodies (TSAb) cause thyrotoxicosis when blocking antibodies(TBAb) cause hypothyroidism. Antibody switch can occur during some periods one of which is pregnancy. The etiology of this process remains unknown but hemodilution of TBAb titer can be one of the possible mechanisms. This is at least one of the important issues that close follow up is mandatory during pregnancy.
INTRODUCTION: Ectopic thyroid tissue is the result of abnormal gland migration from the foramen caecum to its normal pretracheal position. An ectopic thyroid can be lingual (at the base of the tongue), sublingual (below the tongue), prelaryngeal (in front of the larynx), or can be found at other rare sites. The most frequent noncervical location for ectopic thyroid tissue is the thoracic cavity. Here we discuss about a rare case of mediastinal ectopic thyroid tissue presenting with a superior mediastinal mass compressing the brachiocephalic truncus without any symptom in a patient with breast cancer.
CASE: An 61-year-old nonsmoker female patient with an incidental finding of a mediastinal mass on Thorax computerized tomography (CT)scan for following up of breast cancer had consultated us from medical oncology department. Her previous medical history included chronic obstructive pulmonary disease, hypertension, type 2 diabetes mellitus. She had two operation for breast cancer and multinodular goiter before.Thyroid stimulating hormone (TSH), free thyroxine (fT4) and the titers of serum thyroid auto-antibodies were within the normal range.She had history of chest radiation and chemotherapy because of breast cancer.
Her thyroid was not palpable, and there was no evidence of cervical lymphadenopathy.An ultrasound of the remnant thyroid identified only two solid nodules. A CT scan of the thorax revealed a 4.7x3.0cm heterogeneously enhanced mass in the superior mediasten. The mass was located at the intersection of the caudal margin of the left brachiocephalic vein and assendan aorta, and it compressed the brachiocephalic truncus. However, there were no symptoms related to the compression. Tc-99m pertechnetate thyroid and mediastinal scintigraphy revealed a mass which was 4 cm and increased uptake in superior mediasten (Ectopic thyroid or metastatic lesion?). As it can the mediastinal metastasis of the breast cancer that can uptake technesium, total body scanning with I-131 revealed which showed increase uptake of iodide in the superior mediastinal mass with 4.5x4.0x5.5 cm dimensions. The mass was resected totally. Histopathological examination revealed nodular colloidal goiter.
Picture. Radioiodine anterior and posterior whole body images
CONCLUSION: Ectopic thyroid is a rare condition, and its location in the mediastinum is even rarer. Although entirely intrathoracic ectopic thyroids are rare, they must be considered in the differential diagnosis of all mediastinal masses. Thoracotomy or sternotomy is required for resection of the mass and prognosis is excellent following a successful excision.
CASE: A 63-years-old acromegalic woman admitted to our hospital for lassitude and dizziness. She has been diagnosed acromegaly ten years ago and had two transsphenoidal operations. Since remission has not achieved she started to use Lanreotide (somatostatin analogue) and for seven years she has been treated with it. Laboratory examinationrevealed that, basal plasma growth hormone (GH) level 1.21 ng/mL (normal range:0-5); nadir GH level after glucose tolerance test1.2 ng/mL (normal range: less than 1); Insulin-like growth factor-1 (IGF-1), 129.1 ng/mL (normal range: for age: 75-212); thyroid stimulating hormone (TSH), 0.824 uIU /mL (normal range: 0.27-4.2); free thyroxine (fT4), 1.26 ng/dL (normal range: 0.9-1.7); and prolactin, 6.66 ng/mL (normal rangein women: 0-20). Magnetic resonance imagining (MRI) of pituitary glandwith gadolinium contrast revealed a pituitary microadenoma. Since routine resting electrocardiograms of patient showed bradycardia (46 bpm) and supraventicular extrasystoles, lanreotide treatment stopped. After then patient’s symptoms relieved and heart rate increased (64 bpm).
Picture 1.ECG of patient using lanreotide Picture 2. ECG of patient after lanreotide
CONCLUSION: Somatostatin is a peptide hormone with a short half-life (2-3 min), which is synthesized in multiple tissues, including the hypothalamus, to inhibit GH secretion. Somatostatin analogues (Octreotide and Lanreotide) are indicated principally for the treatment of acromegaly that remains active after transsphenoidal surgery, whether or not the patient has also undergone radiotherapy. Octreotide-induced bradycardia has previously been reported as an unusual finding in different clinical situations (nonacromegalic patients) and a male patient with acromegaly.A rat study shows bilateral microinjection into the rostral ventrolateral medulla of either somatostatin or the receptor-selective agonist lanreotide evoked dramatic, dose-dependent sympathoinhibition, hypotension, and bradycardia. Our case is the first reported patient with acromegaly who had bradycardia and supraventricular extrasystoles associated with use of Lanreotide.
BACKGROUND: Prolactin secreting pituitary adenomas (prolactinomas) arethe most common pituitary adenomas. The magnitude of prolactin(PRL)secretion in prolactinomas is usually proportionate to the tumor’s size. Invasive giant prolactinoma is a large prolactinoma(>4 cm in dimension) presenting with serum prolactin levels of >1000 ng/mL and mass related clinical symptoms. Giant prolactinoma is rare and usually presents in men.
CASE: A52-year-old man was admitted to our hospital with headache, decreased libido, blurred vision and diplopia existing for 6 months. Magnetic resonance imaging (MRI)showed a giant pituitary adenoma (47x35x33 mm) with extension to sylvian, suprasellar cisterns, invading to right cavernous sinus and extension from right of third ventricle to the superior, wrapping the right internal carotid and middle cerebral arteries. The hormon levels at admission showed follicle stimulating hormone (FSH), 4.48 mIU/mL (normal range;1.5-12.4); luteinizing hormone (LH), 3.75 mIU/mL (normal range;1.7-8.6); testosterone 0.736 ng/mL (normal range; 2.84-8), thyroid stimulating hormone (TSH),0.959 uIU/mL (normal range;0.27-4.2); free thyroxin index 1.28 ng/dL (normal range;0.9-1.7) and prolactin, 470 ng/mL (normal range;0-15 ). Because of apoplexy, patient was promptly operated. Postoperative prolactin level was 470 ng/mL as before. Then prolactin assay was repeated in 1 in 100 dilution of the serum, which was reported as 2060 ng/mL.
CONCLUSION: The intensity of an antigen-antibody interaction depends primarily on the relative proportion of the antigen and the antibody. A relative excess of either will impair adequate immune complex formation. This is called the ‘high dose hook effect’. The high dose hook effect often interferes with the assay result. To overcome the hook effect, the serum sample is diluted and then prolactin assayed. In our patient, a 1:100 dilution gets accurate values. We suggest that in order to accurately estimate PRL in patients with large pituitary tumors, PRL should be assayed in 1:100 or even higher dilutions of serum in order to gate an accurate estimate of serum PRL.
Picture 1. Pituitary MRI of the patient in coronal plane
Macroprolactinemia is reportedly 10-25% in patients with hyperprolactinemia (1). This condition corresponds to the predominance of higher molecular mass prolactin (PRL) forms (big-big PRL, MW > 150 kDa), that have been postulated to represent PRL monomer complexed with anti-PRL immunoglobulins or autoantibodies (2). PRL plays a major role in breast development. Factors which lead to the elevation of serum PRL such as pregnancy and administration of dopamine antagonists also lead to breast growth (3). Macromastia, gigantomastia, breast hypertrophy are used interchangeably. Patients present with typical physical, social and psychological problems associated with macromastia. They present with symptoms related to muscular discomfort such as shoulder, back, neck and breast pain as well as postural problem mainly kyphoscoliosis because of the weight of the breasts. Hygienic problem in the submammary crease leading to irritation and rashes and sometimes ulceration can be presenting symptoms (4). Its treatment include surgery, hormonal treatment or both. Most authors conclude that gigantomastia cannot be treated medically and only resolves with surgical manoeuvres (5). We report a case with gigantomastia diagnosed with macroprolactinemia and treated with cabergolin.
Case: A 44-year-old woman admitted to our clinic with 6 months history of breast enlargement, nipple discharge, mastalgia, and back pain. She requested surgical reduction. She had three children and her menstrual cycles were regular. There were no history of excessive weight gain, chronic disease or use of any drug. No known family history of mammary hypertrophy. Her body mass index was 31,2 kg/m2 . The breasts are firm to palpation and diffusely tender. The superficial veins are prominent and dilated. She had no fever, erythema, ulceration of the breast skin. Breast circumference was 116 cm. Galactorrhea was present. Hormonal assay revealed hyperprolactinemia (PRL:87 ng/mL) and macroprolactinemia. Other anterior pituitary hormons levels were in normal range. Hook effect was not detected in the diluted serum sample. MRI showed 6 mm pituitary adenoma. Breast ultrasound and mammography were normal. Cabergoline 0.5 mg per week was started. Macroprolactinemia and hyperprolactinemia were normalized within one month. Breast circumferences were 110, 108 and 106 cm in first, second and third mounths, respectively, although galactorrhea continued. Cabergoline dose was increased to 1 mg per week. Patient was satisfied with postmedical recovery and gave up operation demand.
Conclusion: The clinical significance of macroprolactinemia has been a matter of debate for many years. Some reports have associated it hyperprolactinemic symptoms whereas others have suggested that it causes no symptoms. This controversy could be explained by heterogeneity of macroprolactin structure. In the majority of cases, the high molecular form consists of complexes of PRL and anti-PRL autoantibodies predominantly of IgG , rarely IgA and IgM class (7). Macroprolactin synthesis is generally thought to be an extrapituitary postsecretory phenomenon. On the other hand, pituitary adenomas are revealed in 20% with macroprolactinemia. Additionally, galactorrhea is present in 20% and oligo/amenorrhea in 45% (6). Two explanations are possible in our case: coexistence of pituitary adenoma and macroprolactinemia or macroprolactin production by pituitary tumor itself. Literature data have provided evidence in favor of both possibilities. Leslie et al. have shown the monomeric PRL isoform in tissue samples from pituitary adenomas in patients with macroprolactinemia, This result may support the hypothesis of peripheral mechanism of macroprolactin synthesis (8). In contrast, two studies have demonstrated significantly higher concentrations of macroprolactin in extracts from prolactinoma tissue compared to those in samples from normal adenohypophysis (9, 10). Coexistence of pituitary nonfunctioning adenoma and macroprolactinemia could be suggested in patients with oligosymptomatic clinical presentation. One case report has been published in support of the thesis for the tumoral origin of macroprolactinemia. Lakatos et al. presented the history of a 80-year-old man with an intra and parasellar pituitary tumor and marked hyperprolactinemia mainly due to macroprolactinemia (11). Consequently, cabergolin treatment seems to be safe and effective in controlling gigantomastia and macroprolactinemia without surgical intervention. Although macroprolactinemia is considered to be a benign condition, pituitary imaging, dopamine agonist treatment, and prolonged follow-up should be recommended in some cases (7).
1. Shimatsu A, Hattori N. Macroprolactinemia: Diagnostic, Clinical, and Pathogenic Significance. Clin Dev Immunol. 2012:167132. doi: 10.1155/2012/167132. Epub 2012 Dec 4.
3. Stringer BM, Rowson J, Williams ED. Effect of raised serum prolactin on breast development. J Anat. 1989; 162: 249-261.
4. Rahman GA, Adigun IA, Yusuf IF. Macromastia: a review of presentation and management. Niger Postgrad Med J. 2010;17(1):45-49.
5. Dancey A, Khan M, Dawson J, Peart F. Gigantomastia--a classification and review of the literature. J Plast Reconstr Aesthet Surg. 2008;61(5):493-502.
6. Melmed S, Casanueva FF, Hoffman AR, Kleinberg DL, Montori VM, Schlechte JA, Wass JA; Endocrine Society. Diagnosis and treatment of hyperprolactinemia: an Endocrine Society clinical practice guideline. JCEM. 2011;96(2):273-288.
7. Elenkova A, Abadzhieva Z, Genov N, Vasilev V, Kirilov G, Zacharieva S. Macroprolactinemia in a patient with invasive macroprolactinoma: A case report and minireview. Case Rep Endocrinol. 2013;2013:634349. doi: 10.1155/2013/634349. Epub 2013 Jan 15.
8. Leslie H, Courtney CH, Bell PM. Laboratory and clinical experience in 55 patients with macroprolactinemia identified by a simple polyethylene glycol precipitation method JCEM. 2001;86(6): 2743-2746.
9. Mounier C, Trouillas J, Claustrat B, Duthel R, Estour B. Macroprolactinaemia associated with prolactin adenoma. Hum Reproduction. 2003;18(4):853-857.
10. Ohnami S,Eto S, Ohnami S. Characterization of ‘bigbig prolactin’ in serum and tumor extract in patients with PRL-secreting tumor. Endocrinol Jap 1987;34(3):325-334.
BACKGROUND: Polycystic ovary syndrome (PCOS) is one of the most common disorders affecting at least 5 to 10% of women of reproductive age. Increased prevalance of autoimmune thyroiditis and goiter were reported in PCOS patients. This study investigated the prevalance of hypothyroidism, thyroid autoimmunity, ultrasonographic features and presence of nodules in PCOS patients and compare them with the control group. We also aimed to detect correlation of thyroid volume (TV) with serum ınsulin-like growth factor-1 (IGF-1) and the other hormon levels in patients with PCOS.
MATERIALS AND METHODS: Seventy PCOS patients and 84 age matched controls were enrolled in this study. Patient group and the control group were compared with each other according to hormonal parameters, anthropometric measures, thyroid volume, echogenicity on ultrasonography (USG) and autoimmunity. We also investigated the correlation between TV and IGF-1 levels in the PCOS group.
RESULTS: Body mass index (BMI), Ferriman Gallwey score (FGS), fasting insulin level, dehydroepiandrosterone-sulfate (DHEA-S), total and free testosterone, luteinizing hormone (LH), thyroid volume and insulin like growth factor binding protein-3 (IGFBP-3) levels were significantly higher in PCOS patients compared to the control group. Thyroid volume was similar in patients with or without insulin resistance diagnosed with HOMA-IR. There was no differences according to prevalence of hypothyroidism or ultrasonographic features, in between the groups. We have detected a positive and significant correlation between TV and BMI.
CONCLUSION: As a conclusion, we found that thyroid autoimmunity and nodularity were similar between PCOSand control subjects whereas TV was more in the PCOS group. Two parameters that were foundto be positively associated with TV were BMI and serum LH level. Oral cantraceptives which are the mainstay of PCOS treatment can reduce LH and decrease TV and the number of patientswith goiter. There is need for further studies measuring pre and post therapy thyroid volume andits association with serum LH measurements in PCOS patients receving oral contraceptives inorder to prove aforementioned hypothesis
Table 1. Correlation of different hormonal and antropometric parameters with thyroid volume
Table 2.Comparison of the groups according to ultrasonographic findings
BACKGROUND: Hypoglycemia is common in people with diabetes who aim to achieve strict blood glucose control. The neurologic manifestations of hypoglycemia are mostly reversible and includes behavioral changes, difficulty in concentration, confusion, loss of fine motor functions and seizures. Herein we have presented a case who was pregnant and experienced severe hypoglycemia which led to permanent ataxia.
CASE: 26 years old female patient was brought to our emergency room by her husband because of being found unconscious. She was 10 weeks of pregnant and had history of type 1 diabetes mellitus (T1DM) for 13 years. At the time of admission her plasma glucose level was 23 mg/dl. Intravenous glucose infusion and glucagon were applied rapidly. In the initial physical examination she was lethargic, blood pressure was low with tachycardia while body temprature was normal.In the obstetric ultrasonography (USG), the fetus was alive. She had nonproliferative retinopathy in the eye examination and sensory neuropathy. In the labaratory examination, she had microalbuminuria and normal kidney and liver function tests, electrolytes, thyroid function tests and vit B12 levels. After her blood glucose returned to normal, complete neurologic examination was made. Her pupils were reactive, tendon reflexes were normal but she was dysarthric. On the second day, dysarthria continued. We realized she had gait disturbace and on cordination tests she had severe dysmetria in all 4 limbs (finger to nose and heel to shin). Cranial magnetic resonance imaging (MRI) and electroencephalography (EEG) didn’t reveal any pathology. With short acting anologue and NPH insulin, her blood glucose levels were within the target range but her dysartria and ataxia persisted upon discharge on the 12 th day. One month after discharge, she still had moderate gait disturbance and slow speech in the pregnancy and the newborn control visit.She had an uneventful labor on the 39 th week of was healthy.
CONCLUSION: The neurologic manifestations of hypoglycemia include behavioralchange, confusion, loss of consciousness, and seizures.Rarely, neuroglycopenia can present as ataxia, and prolongedand potentially irreversible deficits may occur with repeatedepisodes of hypoglycemia. Cerebellar dysfunction is a rare complication of hypoglycemia and may occur in patients with altered cerebellar glucose kinetics.In summary, glucose uptake and utilization in the cerebellumappear to be protective with regard to hypoglycemia.Hence, cerebellar dysfunction is a rare complication ofhypoglycemia, this disorder may occur in patients with alteredcerebellar glucose kinetics. It appears that the neuronal damage in our patient was severe enough to causeprolonged ataxia.Differential diagnosis involves hematoma, cerebellitis, drug or alcohol ingestion, Wernicke encephalopathy, vit B12 deficency and ataxia telengiectasia. Reconsideration of therapy and glycemic targets and supportive therapy is warrented.
Table 1. Labaratory data of the patient
BACKGROUND: Diabetic nephropathy (DN) is one of the important complications and is detected in almost 30-40% of the patients with type 1 diabetes mellitus (T1DM). Besides the well known risk factors, endothelial dysfunction also plays a role in the pathogenesis of DN and diabetic retinopathy. Our aim was to determine flow medaited dilation (FMD) measurements and serum soluable endothelin-1 (ET-1), intercellular adhesion molecule-1 (ICAM-1) and vascular cell adhesion molecule-1 (VCAM-1) levels in type 1 diabetic patients with or without inceased albumin excretion and compare them with the control group.
MATERIALS AND METHODS: We enrolled 73 patients with T1DM. Diabetic patients were divided into two subgroups according to microalbumin measurements in 24 hour urine collections. Patients with microalbuminuria formed Group 1 and without microalbuminuria were defined as Group 2. We have also enrolled 40 subjets with similar sex and age distrubution as control group (Group 3). Serum ET-1, ICAM-1 and VCAM -1 levels were determined and FMD measurements were done in all individuals.
RESULTS: Mean age, sex distrubition, presence of hypertension, serum low density lipoprotein (LDL) and triglyceride levels were similar in all groups. Diabetic groups were similar in regard to glycemic control and disease duration. Mean FMD measurement was lower in diabetic groups compared to the control group. FMD was negatively correlated with age. We didn’t detect any difference between groups according to serum ET-1 levels. Median serum ICAM-1 level was higher in diabetic groups compared to the control group. Median serum VCAM-1 level was higher in the group of patients with microalbuimuria compared to the normoalbuinuric and control groups. Serum VCAM-1 level was found to be posively correlated with degree of urinary albumin excretion (p>0.001).
CONCLUSION: ICAM-1 and VCAM-1 are proinflammatory molecules that play an important role in pathogenesis of endothelial dysfunction. Medical agents that reduce the serum levels of those two molecules would take place in prevention of microvascular complications. Moreover, VCAM1 may be used as a predictive marker for risk stratification of nephropathy development and progression in T1DM.
Table 1. Comparision of groups according to ICAM-1,VCAM-1 and endothelin-1 levels
Table 2. FMD measurements of the groups
BACKGROUND: Diabetic retinopathy (DR) is the leading cause of blindness in the world. Retinopathy and nephropathy can still progress in diabetics despite optimal metabolic control. This suggests that factors other than hyperglycemia, such as abnormal hemostatic parameters, may play a role in the disease pathogenesis. Based on this hypothesis, several markers of hypercoagulation including fibrinogen, plasma activator inhibitor (PAI), and alpha-2-anti plasmin have been identified. The aim of the present study was to determine whether different degrees of DR (proliferative or non-proliferative) were associated with abnormally modulated hemostatic parameters in patients with type 1 diabetes mellitus (DM).
MATERIALS AND METHODS: 52 type 1 diabetic patients and 40 healthy controls were enrolled in the study. Patients were then subdivided into three categories. Group I was defined as those without retinopathy, group II with non-proliferative retinopathy (NPRP), and group III with proliferative retinopathy (PRP). We have compared these subgroups with each other and the control group (group IV) according to the serum fibrinogen, plasminogen, α2-anti-plasmin, and PAI.
RESULTS: We detected that PAI-1 levels were higher in the diabetic groups than control, but this was not statistically significant whereas serum fibrinogen (p=0.224) and plasminogen (p=0.224) were similar between the diabetic and control groups. Alpha-2-anti-plasmin in groups I, II, and III was higher compared to the control group (p<0.01, p<0.05, and p<0.001, respectively) and the positive correlation identified between serum α2-anti-plasmin and HbA1c levels (r=0.268, p=0.031).
Table. Biochemical and hemostatic measurements ofdiabetic patients and healthy controls
a:Difference between Grup I and Grup IV is significant (p<0,01), b: Difference between Grup II and Grup IV is significant (p<0,05), c: Difference between Grup II and Grup IV is significant (p<0,001).
Figure. Expression of α2-antiplasmin in the diabetic and control groups
CONCLUSION: To our knowledge there are only a small number of studies measuring α2- antiplasmin levels in type 1 diabetes. A positive correlation between α2 anti-plasmin with HbA1c suggests that fibrinolytic markers may improve with disease regulation, and better glycemic control. High α2-anti-plasmin level might be a novel risk factor for development of DR. Confirmation of these data would allow a better understanding of the pathogenesis of DR.
Background: Diabetes is very common disorder. Many studies have shown that patients with diabetes mellitus have incresing trombotic complications both arterial and venous trombosis. Bad control diabetes increases risk of trombosis. Recent reports have shown that shortened APTTs and increased fibrinogen indicate procoagulan situations. In this study, we aimed to evaluate whether chronic hyperglisemia or bad control diabetes causes trombosis which is reflected by shortened APTTs and increased fibrinogen.
Materials and methods: Our study included 349 patients with type 2 diabetes mellitus. They all underwent blood sampling APTT, PT, ﬁbrinogen, fasting plasma glucose (FPG), postprandial plasma glucose (PPG), complete blood count(CBC), serum lipids and HBA1C measurements. Among 349 patients whose APTT<22 sec and PT<10.5 sec were determined. Patients were divided into two groups based on HBA1C levels as follows: regulated diabetic group (HBA1C<7.0%) and disregulated diabetic group (HBA1>7.0%).
Results: But there was no signiﬁcant difference in terms of APTT<22 sec, PT<10.5 sec and ﬁbrinogen levels between two groups.
Conclusion: APTT, PT and ﬁbrinogen measurements are relatively inexpensive and are available. But they are not enough alone for evaluating hypercoaguable states in diabetes patients.
BACKGROUND: Type 1 diabetes mellitus(T1DM)is one of the most common metabolic diseases in childhood: Epidemiological data, collected by worldwide population-based registries, shows an increasing incidence of diabetes over the past 20 years, turning the illness into the most frequent chronic disorder. It is hypothesized that genetic and environmental factors (either of toxic or viral origin) may contribute to diabetes susceptibility.The adaptive immune response genes (HLA) still provide the major contribution to the onset of Type 1 diabetes, but understanding how viral or bacterial infections, vaccines or dietary components or simply stress determine an autoimmune reaction in certain individuals is still a matter of interest. The occurrence and significance of autoimmune manifestations after the administration of viral vaccines remain controversial. Herein we have represented a case who developed type 1 diabetes one month after vaccination for measles in military.
CASE: 25-years-old male patient admitted to our clinic with the complaints of polyuria, poydipsia and weight loss. When we questioned his personal history, we have learnt that he had measles vaccination in the army, one month ago. In the initial labaratory examinations, plasma glucose was 400 mg/dl, dipstick urine test was ++++ ketone and there was metabolic acidosis with anion gap. After treatment of diabetic ketoacidosis, we skipped to intensive insulin treatment with short and long acting anologue insulins. Since he had very low c peptide level together with positive anti glutamic acid decarboxylase (Anti GAD) and Anti-islet antibodies, he was diagnosed to have T1DM. His anti thyroid peroxidase antibody (Anti TPO) was positive and had thyroiditis on thyroid ultrasonography. We have screened other components of autoimmune syndrome and found that celiac markers and Antiparietal antibodies were negative. He had adequate cortisol response to short cosyntrophin test. He was discharged after regulation of blood glucose levels.
CONCLUSION: Very few patients may develop some autoimmune diseases following viral vaccination (in particular; arthropathy, vasculitis, neurological dysfunction and thrombocytopenia). To date, there are controversial results concerning the implication of viruses in human β-cell autoimmunity. Further investigations based upon the temporal relationship between viral diseases and onset of Type 1 diabetes might help to design more accurate national and international prevention strategies. For the majority of people, vaccines are safe and no evidence linking viral vaccines with type 1 diabetes, multiple sclerosis (MS) or inflammatory bowel disease can be found. However there are rare cases in the literature reporting new onset autoimmune diabetes after vaccination. Therefore, it might be reasonable to screen patients who are prone to diabetes for the signs and symptoms of diabetes after vaccination.
Table. Labaratory data of the patient
BACKGROUND: When follicular thyroid carcinoma(FTC) is diagnosed, extrathyroidal invasion, lymphatic and distant metastasis have been determined in 25%, 5-10% and 10-20% of the patientsrespectively.The most common site of distant metastases of FTC is the lung, followed by the bone. The incidence of skull metastasis of FTC is about 2.5 to 5.8%. Skull metastasis of FTC islocated in the skull base and occipital area.
CASE: 60-years-old man was operated for total thyroidectomy in1998and histopathology of the surgical specimen was reported as follicular carcinoma of thyroid with features of vascular invasion. 150 mCi of radioactive iodine (RAI) treatmentwas givenafter the surgery. Post RAI I-131whole-body scanning(I-131-WBS) was normal.When the patient admitted to our centerin 2006, I-131-WBS was performedand revealed occipital bone and lung metastasis.
The patient was operated and occipital bone removed. Histopathology of the surgical specimen was reported as FTC metastasis. After then 200 mCi additional radioiodine dose was given. In 2008, 250 mCi additional radioiodine dose was given for recurrence.I-131-WBS revealed occipital bone and multiple defined mass, which were metastasis in both lungs in September 2012.Alsocranial magnetic resonance imaging (MRI)revealed 24x24x22 mm mass in occipital zone. He underwent F-18-FDG PET/CT scan for investigating distant metastasis. On PET scan, an increased of F-18-FDG (SUVmax: 24.1) uptake was seen in 23 mm mass which had destructed occipital bone. Also, increased FDG uptake (SUVmax: 10.8) in 26 mm masson the upper lobe ofthe right lung and in 34 mm mass on the middle lobe medial ofthe right lung(SUVmax: 2.4) was determined. There were multiple parenchymal lesions, which were in different diameters and in different metabolic activities in both lungs. The patient was given 275 mCi additional radioiodinetherapy
Picture 1.Torax CT of the patient
Picture 2.Brain CT of the patient
CONCLUSION: This is a rare case of follicular thyroid carcinoma metastasis tooccipital bone. The treatment choice of FTC is total thyroidectomy with radioiodine administration, and surgical procedure for metastatic lesionsand TSH suppressive therapy
INTRODUCTION: Anaplastic thyroid carcinomas (ATCs) are sometimes accompanied by well-differentiated carcinomas (WDCs), and have been speculated to be dedifferentiated from the preexisting or coexisting WDCs. We will present two cases determined with both ATC and papillary thyroid carcinoma (PTC).
CASE-1: A 82-year-old woman was investigated due to a painful neck mass. The case reported no complaints of dysphagia or dysphonia. Thyroid function tests were within normal ranges. Thyroid ultrasonography revealed isohypoechoic nodules in sizes of 19x21.2x45 mm and 6.2x11.4x13.5 mm in right lobe and a isoechoic nodule in size of 7.8x8x11.3 mm in left lobe. Fine needle aspiration biopsy was performed, and PTC was detected in both nodules on the right.Bilateral total thyroidectomy was performed, and during the operation it was observed that a tumor was invaded trachea and eusophagus. In pathological investigation, the nodule of 45 mm in the right lobe was seen to be an ATC including regions of classical variant PTC (Figure 1). Anaplastic carcinoma regions were largely with epithelioid appearance and also included squamous differentiation regions. Marked pleomorphism and frequent mitosis were determined in the tumor including widespread necrotic regions. Immunohistochemical examination revealed that pancytokeratin was positive, HBME 1 was focal positive, but TTF-1 was negative. Proliferation index of Ki-67 was 70%. Additionally, the pathology of the nodule of 13.5 mm in the right lobe was consistent with classical variant PTC (Figure 2). ATC and PTC were present in the case in the form of two different foci. PET/CT revealed the involvements of increased 18 FDG consistent with metastasis, and due to the metastatic condition in the case, radiotherapy was performed.
CASE-2: A 62-year-old male presented to our clinic complaining of a neck lump, hoarseness, and dysphagia. Physical examination revealed a 4-cm mass and cervical lymph nodes on the left side of the neck. Thyroid function tests were within normal ranges. Thyroid ultrasonography revealed hypoechoic nodules in sizes of 41 mm nodule in the left lobe. Two preoperative fine-needle aspiration biopsies were reported as non-diagnostic. He underwent a bilateral total thyroidectomy and left extended lymph node dissection. The final postoperative pathology report was a 3-cm ATC in the left lobe and a 5-mm PTC in the right lobe (Figure 3). He was given external beam radiation therapy postoperatively.
Figure 1. Microscopic photograph of anaplastic thyroid carcinoma, HE x200(Case 1)
Figure 2. Microscopic photograph of papillary thyroid carcinoma, HE x200 (Case 1)
Figure 3. A: Anaplastic thyroid carcinoma, B: Papillary thyroid carcinoma, HE x200 (Case 2)
CONCLUSION: PTC followed by poorly differentiated and follicular carcinoma are most frequently cited to coexist or as precursors of ATC. The early diagnosis of thyroid carcinoma results in decrease of the incidence of ATC.
BACKGROUND: Differentiated thyroid cancer is the most frequent thyroid tumor. Combinations of follicular and papillary carcinoma can be seen. Functional pituitary adenoma coexisting with differentiated thyroid carcinoma was reported previously in literature. We report a 47-year-old women with three different synchronous endocrine tumors; papillary thyroid cancer, follicular thyroid cancer and prolactinoma.
CASE: 47-years-old female patient was admitted to out-patient clinic with oligomenorrhea and galactorrhea. Except patient’s prolactin (PRL) rise, hormonal levels were in normal ranges (PRL: 186 ng/ml). Macroprolactin was negative. Pituitary magnetic resonance imaging (MRI) demonstrated a mass with 9x11 mm size (Image). Cabergolin 0.5 mg/ twice a week was started. She was euthyroid and thyroid autoantibodies were in normal ranges. In thyroid ultrasonography (US), 17x10 mm nodule in left lobule, 21x19 mm nodule in right lobule and 8x7mm nodule in isthmus were detected. Fine needle aspiration biopsy suggested suspicious for follicular neoplasm for nodule in right lobule, benign for the left one. She underwent total thyroidectomy. The histopathological examination revealed presence of a follicular cancer within right lobule (2 cm) and multifocal papillary cancer (0.5 cm, 0.8 cm, 1.2 cm) within left lobule. Radioactive iodine was given to patient after surgery.
Image: Pituitary MRI of patient
Picture 1. Papillary thyroid carcinoma Picture 2. Follicular thyroid carcinoma
CONCLUSION: Underlying pathological cause of most pituitary adenomas remains unclear despite the recent identification of a number of potential molecular genetic abnormalities. Pituitary tumor transforming gene (PTTG) initially isolated from pituitary tumor cells. PTTG protein is expressed at higher than normal levels in several tumors, including those of the pituitary, thyroid, colon, ovary, testis, breast and hematopoietic neoplasms. Co-existence of three endocrine tumors in our case may be caused from different causes. It may be releated with the potential molecular genetic abnormalities like PTTG. Or, incidental occurrence of them may be a reason, because each tumor occurs with a high prevalence in general population.
INTRODUCTION: Tuberculosis is the most commonly encountered cause of Addison's disease. The exact status of adrenal reserve in tuberculosis still remains controversial, and recovery of adrenal function is unpredictable. There are few reports in the literature suggesting that adrenal insufficiency may improve with anti-tuberculosis therapy during the active phase of the disease. Herein,we presented a case of reversible adrenal failure in a patientwith activetuberculosis.
CASE REPORT: A 50-year-old female patient was admitted to our clinic with the complaints of weakness and darkening of the skin. In her history, she had receivedanti-tuberculosis treatment for the last 8 months. On her physical examination, she had hypotension and hyperpigmentation. Other systemic examinations were in normal ranges. Laboratory findings were presented in Table 1. Thyroid function tests were within normal range, and cortisol and adrenocorticotrophic hormone (ACTH)were 8 µg/dLand 802 pg/mL, respectively.There was no cortisol response to cosyntropin stimulation test, (30th minute cortisol was 10 µg/dL,and 60th minute was 11 µg/dL).Then, we started glucocorticoid therapy.In magnetic resonance imaging, thickness of both adrenal glands were increased.Anti-21 hydroxylase antibody was negative. Anti-tuberculosis treatment were stopped at the 9th month. We repeated the cosyntropin test one month after the therapy was stopped. We detected there was a positive cortisol response to ACTH (cortisol was 25 µg/dL at30th minute and 29 µg/dL at 60th minute). We stopped the glucocorticoid since we thought adrenal failure improved.
Table 1. Laboratory findings of the case
Aspartate aminotransferase (U/L)
Alanine aminotransferase (U/L)
CONCLUCIONS: Adrenal tuberculosis is witnessed in up to 6% of patients with active tuberculosis and is usually bilateral. Adrenal destruction via tuberculosis may cause overt or subclinical adrenal insufficiency. Adrenal cortex has a considerable capacity to regenerate with marked hyperplasia and hypertrophy of cortical cells, noted during the period of active infection. Reversal of adrenal function following anti-tubercular therapy is a controversial issue (1,2). Barnes et al. (2) reassessed adrenal function following the therapy and showed that short synacthin test returned to normal in all patients except one, suggesting adrenal dysfunction to be uncommon and antitubercular drugs that have a favorable effect on adrenal function. While some of the studies showed normalization of adrenal function following therapy in a large number of cases, others indicated a contradicted result. In their study, Prasad et al. (3) evaluated adrenocortical reserve and morphology in tuberculosis and reported that the compromised adrenal reserve and enlargement seemed to reverse with therapy. In a recent study byLaway et al. (4), adrenal cortical function and morphology before and after treatment of pulmonary tuberculosis were investigated, and it was reported that basal and stimulated cortisol is less in patients with pulmonary tuberculosis as compared with healthy controls and increases after antitubercular treatment. We suggest that patients who are diagnosed to have adrenal failure due to tuberculosis should be reevaluated after completion of anti-tuberculosis treatment with dynamic tests.
1) Penrice J, Nussey SS. Recovery of adrenocortical function following treatment of tuberculous addison’s disease. Postgard Med J 1992;68: 204-5.
2) Barnes DJ, Naraqi S,Temu P, Turtle JR. Adrenal functions in patient with active tuberculosis. Thorax 1989;44:422-4.
3) Prasad GA, Sharma SK, Mohan A, Gupta N, Bajaj S, Saha PK, Misra NK, Kochupillai NP, Pande JN. Adrenocortical reserve and morphology in tuberculosis. Indian J Chest Dis Allied Sci. 2000;42(2):83-93.
4) Laway BA, Khan I, Shah BA, Choh NA, Bhat MA, Shah ZA. Pattern of adrenal morphology and function in pulmonary tuberculosis: response to treatment with antitubercular therapy. Clin Endocrinol (Oxf) 2013;79(3):321-5.
BACKGROUND: Adrenocortical carcinoma (ACC) is a very rare but typically aggressive malignancy. About one quarter to three quarters of ACC is functioning with excess hormonal production.
CASE: A 44 years-old female patient was admitted to out-patient clinic with obesity, oligomenorrhea and abdominal pain. She had central obesity, buffalo hump, and palpable flank mass. Hypertension, transient ischemic attack and epilepsy history was present. Serum cortisol, dehydroepiandrosterone sulfate (DHEAS) and testosterone levels were elevated. Cushing’s syndrome was diagnosed by elevated urine free cortisol and a non-suppressible dexamethasone test. Serum aldosterone and renin activity, 24 hr urinary catecholamines were normal. Abdominal computerized tomography (CT) detected a 16x11 cm hypodense solid mass lesion at the right adrenal gland. It showed inhomogeneous appearance, irregular margin, neovascularization, liver invasion and inferior vena cava (IVC) thrombus extension (2.3x2.2 cm). It was adherent to the liver, kidney, and IVC (Image 1). Because of the unresectable adrenal mass, CT-guided abdominal mass biopsy was performed, and the diagnosis of ACC was made on the basis of pathology and immunohistochemistry. According to the AJCC staging system, the tumor was classified as T4NXM1, stage IV.Mitotane 4.5 gr/day and glucocorticoid was started. Also, warfarin was started due to presence of thrombus .The mean level of total testosterone and DHEAS tended to decrease during the follow-up. After 5 month, radiotherapy and chemotherapy (Cisplatin and Etoposide/3 cycle) were given to patient. Tumor regressed to 10x7.6 cm and IVC thrombus extension also regressed to 2.2x1.4 cm (Image 2). The patient showing partial remission underwent operation, but because of invasion to adjacent tissues, the tumor could not be resected.
CONCLUSION: Adrenal tumors in association with venous thrombosis are rare pathological conditions. No effective adjuvant treatment is currently available. We report a case of stage IV adrenocortical cancer with IVC thrombus extension and partial clinic response to the chemoradiotheraphy.
Image 1:Before treatment Image 2: After treatment
Table. Laboratuary parameters of patient after Mitotane, radiotherapy and chemotherapy.
After 12 weeks Mitotane therapy
After Chemotherapy and Radiotherapy
fT4 (0.9-1.7 ng/dl)
fT3 (2-4.4 pg/ml)
Cortisol (6.2-19.4 ug/dl)
Totaltestosterone (0.006-0.82 ng/ml)
Free testosterone (0.29-3.18 pg/ml)
DHEAS (0-340 ng/ml)
BACKGROUND: Major factor that modulates the parathyroid hormone (PTH) secretion is serum calcium (Ca) level. Paratyhyroid gland also receives direct autonomic innervation. To date, measurement of several hormones such as cortisol, prolactin, renin and aldosteron were found to be affected by changing the posture from recumbent to the upright position. In the present study, we aimed to investigate postural change of PTH in normal individuals and patients with primary hyperparathyroidism (PHPT).
MATERIALS AND METHODS: 23 patients with PHPT and 9 age healthy controls were enrolled in our study. Blood samples were taken from all indivuduals after 12 hours of fasting. Following replacement of an intravenous catheter, the patients were requested to rest in bed in recumbent position but not sleeping for an hour and blood samples were obtained for PTH and Ca measurements at the 45 th and 60 th minutes of resting.Afterwards, the patients changed the posture to the upright position and stood up for an hour and again blood samples were obtained at the 45 th and 60 th minutes of standing. Pulses and blood pressures of all individuals were recorded in both postures.
RESULTS: In the group of patients with PHPT, mean serum PTH was measured as 75.36 pg/ml which is higher during upright position compared to recumbent position and the difference was statistically significant. In the control group mean serum PTH was measured only 3.09 pg/ml higher during the upright postion compared to recumbent position and the difference didn’t reach statistical significance. In both groups, Ca was higher when the patient was in the upright postion compared to the recumbent position.
CONCLUSION: It was reported that total calcium measurement increases in upright posture which should normally decrease the measured PTH level. However PTH secretion is autonomic in PHPT and increased in upright position regardless of serum Ca level.
Table 1. Comparisions of 45 th and 60 th minutes measurements of Ca and PTH within the control ant the patient groups
45 th min
60 th min
Table 2. Other clinical parameters of the control and the patient groups
1.7 (-4.4 - 14,6)
47.7 (5.9 - 289,3)
3.5 (-9.6 - 31.6)
33.3 (6.8 - 93.7)
Ca change (%)
5.4 (3.1 - 6.7)
5.7 (1.4 - 18.9)
CASE: A 30-years-old man with hypoparathyroidism who has been treated with calcitriol and calcium for two years, admitted to our hospital with persisting diarrhea. An endoscopic procedureis plannedfor his complaint.But he was waiting for this examination as outpatient condition, he had a convulsion and had been taken in hospital by parents. Initial laboratory analyses revealed that he was hypocalcemic (total calcium of 6 mg/dL), and Parathormone (PTH)level was;8 pg/mL(normal range; 15-65) , phosphorus level 5,7 mg/dL(normal range; 2.5-4.5) and magnesium level was 2 mg/dL(normal range;1,5-2.5). He was treated with intravenous calcium gluconate urgently. Then treated with oral calcium carbonateand calcitriol with a stepwise increase in the dosage. An upper gastrointestinal system endoscopy has applied to the patient. Diagnosis of gluten-sensitive or celiac disease was suggested at endoscopy, due to flat mucosa and confirmed by histological findings in duodenal biopsy including absent villi, crypt hyperplasia and lymphocytic infiltration in the epithelium. Serologic examination confirmed the diagnosis. After then he was placed on gluten-free diet, which rapidly lead to the normalization of his bowel habits and improved his metabolic parameters. The needed drug dosage is decreased.
CONCLUSION: Hypoparathyroidism is an uncommon endocrine-deficiency disease characterized by low serum calcium levels, elevated serum phosphorus levels, and absent or inappropriately low levels of PTH in the circulation. Afterpostoperative hypoparathyroidism, autoimmune hypoparathyroidism is the next most common form of hypoparathyroidism in adults. Patients with hypoparathyroidism most often present with paresthesia, cramps, or tetany, but the disorder also may manifest with acute seizures, bronchospasm, laryngospasm, or cardiac rhythm disturbances. Autoimmune hypoparathyroidism may be isolated or part of an autoimmune polyglandular syndrome. Celiac disease and autoimmune hypoparathyroidism togetherness is a very rare condition but the possibility of celiac disease should be considered in patients with hypoparathyroidism that seems unduly difficult to treat.
BACKGROUND: Primary hyperparathyroidism (PHPT) is usually caused by single adenoma. Functional parathyroid cysts are a rare cause of PHPT. Parathyroid cysts can be subdivided into nonfunctional, without biochemical derangement, or functional, with elevated serum calcium accompanying clinical evidence of hyperparathyroidism. Parathyroid cysts are found in the neck and anterior mediastinum. Functional parathyroid cysts are not only secretary, larger cysts can lead to compression symptoms, including dysphagia, dyspnea, cough, stridorand hoarseness. Mediastinalparathyroid cysts are usually presented as asymptomatic and identified accidentally by a routine chest X-ray or computed tomography (CT). We present a case of a patient with a functional parathyroid cyst.
CASE: A 66-year-old male patient referred to our department because of hypercalcemia and anterior mediastinal mass determined on thorax CT which is performeddue topulmoner suspicion of pulmonary embolism.He had no symptom of hypercalcemia except history of nephrolithiasis. Biochemical test revealed hypercalcemia (12.24 mg/dl; normal range:8.8-10.2), and hyperparathyroidism (parathyroid hormonelevel 140.6 pg/ml; normal range:15-65), also phosphorus level was 2.98 mg/dl(normal range:2.5-4.5), creatine 0.84 mg/dl(0,71,2), vitamin D level was 11.4 mg/Land 24-hour urinary calcium excretion was 504 mg/day. Renal ultrasonography determined 7 mm renal stone in the left kidney. Bone mineral dansitometry revealed osteopenia. Thorax CT scan revealed a 4.7x3.3 cm sized solid mass, located onanterior mediastinum. After initiating of adequate hidration and furosemide treatment for hypercalcemia, the patient referred to chest and chest surgery department because of the anterior mediastinal mass and pulmonary embolism detected on thorax CT.
The surgery decision was made because of the CT mass appearance. After removal of the mass calcium and parathyroid levels were reduced to normal levels. Pathologic examination revealed the diagnosis of a parathyroid cystic.
CONCLUSION: Mediastinal parathyroid cyst is an uncommon cause for hypercalcemia. Also it is difficult to establish a preoperative definitive diagnosis.
Picture 1. Torax CT of the patient
Picture 2. Pathology specimen of the patient
Aim: Vitamin D deficiency is reported as a risk factor for the development of diabetes in several epidemiologic studies. In this study, we investigated the frequency of 25-OH vitamin D defciency in type 2 diabetes and the relationship between 25-OH vitamin D defciency and microvascular complications.
Materials and methods: Retrospectively, medical records of 557 type 2 diabetic patients admitted to the Endocrinology Outpatient Clinic in JanuaryÐMarch period and 112 healthy
controls who were randomly selected among individuals admitted to the hospital for a check-up and had a laboratory result of 25-OH vitamin D level were screened. The level of 25-OH vitamin D in type 2 diabetes and the relationship between 25-OH vitamin D deÞciency and microvascular complications are investigated.
Results: There was not statistically signifcant difference in terms of 25-OH vitamin D levels between diabetic and control group. No correlation between HbA1c and vitamin D levels was found. 25-OH vitamin D level was lower in diabetic patients with nephropathy. Also patients not using any medication and followed by only dietary suggestion, had nephropathy in higher frequency.
Conclusion: Vitamin D deficiency is more common in diabetic patients with nephropathy. Upon evaluation of the total microvascular complications, vitamin D level was also lower. Vitamin D defciency is associated with microvascular complications of diabetic patients.
BACKGROUND: Pregnancy or lactation related osteoporosis(PLO) is very rare. It usually occurs in the third trimester or in the early post partum period and manifestations are severe back pain and loss of height due to vertebral fractures.Its etiology is not well understood.Classical treatment is cessation of lactation, calcium and Vit-D supplementation and biphosphanates in chosen cases.All osteoporosis drugs are approved mainly for post-menouposal osteoporosis and reports of teriparatide treatment in this group of patients is off label worldwide.Here we represented a case with severe pregnancy related osteoporosis to whom we started teriparatide treatment.
CASE: 23-years-old female patient admitted at the post partum 2nd week with complaints of severe back pain.She denoted that pain started in the last month of her pregnancy and persisted after labour despite calcium and vit-D supplementation. Her body mass index (BMI)was 24 kg/m2, she had regular menstrual cycles, and she didn’t have any risk factors for osteoporosis such as smoking, corticosteroid usage or family history.Thyroid functions, parathormone level, celiac markers, kidney and liver function tests, serum calcium (Ca), phosphorous (P)and vitamineD levels were in normal ranges. We detected multiple vertebral fractures at T5,T7,T10,T11,T12 and her total vertebrate Z score was -4.2 where as femur neck Z score was -1on bone mineral densitometry (BMD). We have initiated teriparatide therapy 20 µg/day along with 1000 mg calcium and 800 IU cholecalciferol per day.Thorocal orthosis was also prescribed. At the second month of therapy her pain was totally relieved.At the 6 th month of therapy BMD was increased15%at the lumbar spine and we continued the therapy.
CONCLUSION: Effective treatment of PLO is controversial.There are some concerns about biphosphanates in premenouposal age group because of possible adverse effects on fetus.They accumulate in bone and can cross placenta despite withdrawal.In previous reports teriparatide caused increased BMD up to36% .It can also prevent futher vertebral fractures.Therefore it can be a reasonable choice for treatment.
Table. Labaratory data of the patient
ALT / AST
10/ 13 U/L
Figure. Loss of height in the thorocal vertebrates of the patient
Background: Osteoporosis is a common problem in postmenoausal women. There is limited data about the physiological importance of endogenous testosterone on bone mineral density (BMD) in older women is poorly understood.
Aim: The aim of this study was to evaluate association of endogeneous testosterone with BMD and BMI.
Materials-methods: This cross-sectional study included 64 patients (45-85 year) postmenopausal women; their demographic features, BMD and serum total testosteron levels and relationship between testosterone and BMD were evaluated. When the patients divided into three cathegories according to BMD; Group 1A: normal; Group 1B: osteopenic; Group 1C:osteoporotic.
Results: Serum total testosterone levels were found not to be correlated with BMD. We didn’t find any differences in serum testosterone levels between three BMD groups.
Conclusion: This study suggests that endogenous androgens are influential on bone density in postmenopausal women. However, we didn’t find any relationship. Effects of endogenous testosterone level on BMD is controversial.
BACKGROUND: Ectopic ACTH secretion by pheochromocytoma causing Cushing’s syndrome has been reported rarely. Here, we present a patient with ectopic ACTH-dependent Cushing's syndrome, caused by a pheochromocytoma with normal fractionated 24-h urinary catecholamines and metanephrines.
CASE: 48- year old female patient admitted to our clinics with the complaints of severe hypertension despite receiving anti hypertensive therapy. Severe headache, malaise, nausea , vomiting, proximal muscle weakness, weight loss and palpitation episodes were the accompanying symptoms. In her physical examination, she was anxious and depressive. Her pulse was 140/minute, blood pressure was 200/100 mmHg. She didn’t have any typical sign of Cushing syndrome except proximal myopathy. Labaratory tests were significant for severe hypokalemia (2.5 mmol/L), hypoalbuminemia (2.6 g/dl). Her serum cortisol concentration was 63.4 μg/dL and it wasn’t supressed after 1 mg and 2 days 2 mg dexamethasone suppression tests (DST). 24-h urinary free cortisol was extremely high (18980 μgr/day) whereas urinary fractionated catecholamines and metanephrines were normal. Her serum ACTH was measured with IRMA and was found as 289.3 pg/ml. Our initial endocrinologic diagnosis was ACTH-dependent ectopic cushing syndrome since there wasn’t any supression with high dose DST, treatment resistant hypokalemia, negative pitiutary imaging and dramatic and rapidly progressing clinics. Abdominal computed tomography (CT) scan revealed a 43x37 mm tumoral mass in the left adrenal gland and PET-CT showed a 5-cm sized lesion in the left adrenal gland with high SUVmax (18.7) and hyperplasia in the other adrenal. She was underwent right adrenalectomy with Addison and pheochromocytoma protocol. After operation pathological examination was compatible with pheochromocytoma, and immunostained with ACTH extensively
Picture 1. Abdominal CT of the patient
Picture 2. PET-CT of the patient
CONCLUSION: Ectopic ACTH-secreting pheochromocytoma is a diagnostic challenge for the clinicians. Serum or urinary metanephrines and catecholamines are very sensitive and specific tests for the diagnosis of pheochromocytoma but negative results may occur and lead to confusion in the diagnosis.
INTRODUCTION: Primary hyperparathyroidism (PHPT) is characterized by hypercalcemia and concomitant inappropriate secretion of parathyroid hormone (PTH) and isthe most common cause of hypercalcemia in the outpatient setting .PHPT is caused by adenomas (80-85%), four-gland hyperplasia (10-15%), and rarely due to carcinoma (0.8-2%).Conventional non-invasive imaging modalities are ultrasonography (US) and 99mTechnetium methoxyisobutylisonitrile (99mTc-MIBI) scintigraphyfor enlarged parathyroid lesions.99mTechnetium MIBI single-photon emission computed tomography (CT) and/or magnetic resonance imaging (MRI) can be used in cases of failure to detect small or ectopic tumors with those modalities. Endosonography (EUS) images lesions using a high frequency ultrasound probe, providing detailed visualization of the esophagus, stomach, and duodenum. Lesions in the mediastinum or near the esophagus can be detected with EUS, and a US-guided biopsy can be performed.A few small studies have evaluated the effectiveness of EUS for localizing parathyroid lesions before surgery. The purpose of the present study was to determine the diagnostic accuracy of EUS in terms of localizing parathyroid adenomas compared with those of US and 99mTc-MIBI scintigraphy findings. When compared to the previous reports in the literature, our study was conducted with the highest number of patients. Another outstanding and important feature of our study is inclusion of solely parathyroid adenomas.
METHODS: Forty-seven patients with a PHPT diagnosis and who were recommended for surgery were enrolled in this study. An endoscopist who was blinded to the previous US and 99mTc-MIBI scintigraphy results performed the EUS in each patient.
RESULTS: Thirty-nine female and eight male patients with PHPT were evaluated. The presence of adenoma was confirmed by subsequent postsurgical pathology results. One case was excluded because the histopathological evaluation was compatible with a lymph node, although the lesion was detected using three different imaging modalities preoperatively. Demographic data, distribution of adenomas according to location and the true positive rates of the imaging modalities are listed in Table 1. The locations of the parathyroid adenomas were correctly documented by US in 39 patients (84.7%) by 99mTc-MIBI scintigraphy in 35 (76.0%), and by EUS in 44 (95.6%) of 46 patients. EUS located all 31 adenomas detected previously with US and 99mTc-MIBI scintigraphy. EUS also successfully located three adenomas that could not be identified by US and 99mTc-MIBI scintigraphy. The positive predictive value and diagnostic accuracy of EUS, US, and 99mTc-MIBI were 97.7, 97.7, and 95.6%; 88.6, 97.5, and 86.9%; and 77.7, 97.2, 76.0%, respectively(Table 2). The location of the parathyroid adenoma was correctly documented by US in 39 (84.7%) Image of the parathyroid adenoma taken during EUS examination is shown in Figure 1.
CONCLUSION: Preoperative localization of parathyroid pathology is important in appropriate cases of MIP. When the efficacy, comfort, cost, and low complication and morbidity rates of MIP are considered, EUS facilitated identification of lesions in patients in whom MIBI and US failed but did not need bilateral neck surgery and so were candidates for MIP. Therefore, EUS was a safe and effective imaging tool for parathyroid adenomas that could not be localized by US and parathyroid scintigraphy.
Table 1. Baseline demographical, clinical, and laboratory findings in patients with PHPT
51.48 ± 14.49
Male / Female (%)
Serum calcium (8.6-10.2 mg/dL)
11.59 ± 1.30
Serum phosphours (3.5- 4.5 mg/dL)
2.48 ± 0.54
Serum parathyroid hormone (11-67 pg/mL)
285.98 ± 127.96
25-OH vitamin D (20- 120 µg/L)
13.79 ± 8.50
2.05 ± 2.41*
True positive rates of imaging methods (%)
Location of adenomas after operation
Lower left (%)
Upper left (%)
Lower right (%)
Upper right (%)
Table 2. Sensitivity, positive predictive value and diagnostic accuracy rates of the imaging methods
Positive predictive value (%)
Diagnostic accuracy (%)
Fig 1. Endoscopic ultrasonography image of the parathyroid adenoma, showing a well-defined hypoechoic, solid lesion
AIM: Datas in literature about coincidence of toxic nodular goiter and thyroid cancer,clinical features and prognosis is debating. In this study we aimed to evaluate rate of thyroid cancer,clinical findings and tumor fetaures in patients who underwent total thyroidectomy with the diagnosis of toxic nodular goiter.
MATERIALS AND METHODS: Patients who have been applied to Endocrinology and Metabolism outpatient clinic in Ankara Ataturk Education and Research Hospital between March 2006-January 2012 with the diagnosis of toxic adenom and underwent total thyroidectomy were included to the study and they have evaluated in a multidisciplinary council consisted of endocrinologist, general surgeon, pathologist and nuclear medicine experts.
RESULTS: According to pathological findings, totally 77 nodules obtained from 77 patients were divided into two groups as benign (n=63, %81.8) and malignant (n= 14,%18.2) respectively. In malignant group, 10 (%71.4) patient’s malignant foci were inside of the adenoma and malign foci of 4 (%28.6) patients were in the parenchyma . 9 papillary microcarcinomas,3 papillary carcinomas and 2 microinvasive follicular carcinomas were identified in malign nodules. Mean tumor diameter was 8 mm in the carcinomas that located inside of adenomas. Any case of relapse , distant metastases or death did not occur among malign patients during follow up. In our study patients with toxic nodular goitre,diagnostic sensitivity of fine needle aspiration biopsy was %16.7 and specifity was %96.3 ; but it’s observed that in differantial diagnosis,fine needle aspiration biopsy doesn’t have significant determination. None of the morphological findings which established by USG, is determinating in the differantial diagnosis.
CONCLUSION: RAI and surgery may be the choices for the definitive treatment of toxic nodular goitre. It’s important to exclude malignancy while choosing appropriate treatment due to probability of incidentally discovered thyroid cancer rate. In conclusion we think that while planing definitive treatment of toxic nodular goitre ,especially surgery should be preferred.
Table 1. Histopathologic findings
Microinvasive follicular carcinoma
Malignancy in nodule
INTRODUCTION: It has been suggested that deviations of prolactin (PRL) levels from the normal range can result in significant alterations in the immune system. We attempted to establish whether there is a relationship between hyperprolactinemia and primary thyroid disorders with the focus on patients with autoimmune features.
METHODS: The medical records of 100 patients with hyperprolactinemia (HPRL) admitted to our endocrine unit from 2005 to 2013 were retrospectively examined. Records of thyroid ultrasonography (USG), basal serum levels of thyroid stimulating hormone, circulating free thyroxine, free triiodothyronine, antithyroglobulin (anti-Tg) and antithyroperoxidase (anti-TPO) antibodies were analyzed. In 100 control subjects, matched by age and gender with HPRL patients, thyroid USG, thyroid function tests (TFTs) and autoantibody panel were obtained.
RESULTS: The median PRL in patients was 93 ng/ml(range: 37-470). Twenty-five patients (25%) and 22 controls (22%) had positive anti-Tg and/or anti-TPO titre (P=0.739). The median serum PRL was 98 (37-470) ng/ml in patients with positive thyroid autoantibodies and 92 (40-470) ng/ml in patients who tested negative for thyroid autoantibodies (P=0.975). Among the individuals with autoantibody positivity TFTs abnormalities were more frequent in HPRL patients (60%, 14 subclinical hypothyroidism and one hyperthyroidism out of 25) than in controls (9.1%, 2 subclinical hyperthyroidism out of 22) (P<0.001)Twenty-seven patients with HPRL and 31 controls had goiter (27 vs 31%, P=0.437). Forty-six patients (46%) and 50 (50%) control subjects had one or more of the features of thyroid disorder which are goiter, positive thyroid autoantibody and thyroid function abnormality (P=0.888).
CONCLUSION: HPRL may be associated with more severe thyroid dysfunction in patients with thyroid autoimmunity.
Table 1. Thyroid function tests and autoantibody panel of the patients with hyperprolactinemia (HPRL) and control subjects.
Subclinical Hypothyroidism (%)
Subclinical Hyperthyroidism (%)
Anti-Tg Positivity (%)
Anti-TPO Positivity (%)
Antibody Positivity (%)a
TSH, thyroid stimulating hormone; fT3, free triiodothyronine; fT4, free thyroxine; anti-Tg, antithyroglobulin antibody; anti-TPO, antithyroperoxidase antibody; TFTs, thyroid function tests; USG, ultrasonography. Parametric values was expressed as mean±S.D. Statistical significance was set a P value of 5%.
Normal values: fT3: 1.8-4.6 pg/ml , fT4: 0.9-1.7 ng/dl , TSH: 0.27-4.2 uIU/ml. a Positivity of anti-Tg and/or anti-TPO.
INTRODUCTION: Endogenous Cushing’s syndrome (CS) is a nonphysiological hypercortisolism state which causes a reversible state of immunosuppression. Autoimmune diseases have improved during the active phase of CS whereas there is a risk of worsening of the same conditions upon remission. CS may alter the performance of the hypothalamic-hypophyseal-thyroid axis in several ways as well . In this study we attempted to establish whether there is a relationship between hypercortisolism and primary thyroid disorders with the focus on patients with autoimmune features.
METHODS: The medical records of 40 patients with Cushing’s syndrome (CS) admitted to our endocrine unit from 2006 to 2013 were retrospectively examined. Pre-surgical records of thyroid ultrasonography (USG), basal serum levels of thyroid stimulating hormone, circulating free thyroxine, free triiodothyronine, antithyroglobulin (anti-Tg) and antithyroperoxidase (anti-TPO) antibodies were analyzed. When available, data on thyroid function tests (TFTs) and autoantibody panel 6 months after surgery were also evaluated. Diagnosis of hypercortisolism had been established by an overnight low dose dexamethasone suppression test and urinary free cortisol (UFC) measured in 24-h samples. Etiological diagnosis was made by 8 mg dexamethasone suppression test, measurement of ACTH levels and imaging techniques. After treatment, all patients were cured which was established by the finding of subnormal serum cortisol concentrations and/or subnormal 24-h UFC levels. In 40 control subjects, matched by age and gender with CS patients, thyroid USG, TFTs and autoantibody panel were obtained.
RESULTS: Six patients (15%) and 7 controls (17.5%) had positive anti-Tg and/or anti-TPO titre at study entry, while 2 out of 25 patients (8%) developed positive anti-Tg and/or anti-TPO titre after disease cure (P>0.05). Sixteen patients with CS and 8 controls had nodular goiter (40 vs 20%, P<0.05). Regarding TFTs, one patient (2.5%) had subclinical hyperthyroidism and one (2.5%) had subclinical hypothyroidism whereas one control (2.5%) had hyperthyroidism. Twenty-one patients (52.5%) and 8 controls (20%) had one or more of the features of thyroid disorder which are goiter, positive thyroid autoantibody and thyroid function abnormality and the difference was significant (P=0.026).
CONCLUSION: There is a remarkably high prevalence of primary thyroid disorders in patients with CS but thyroid autoimmunity is not more frequent even during the resolution period of hypercortisolism.
1A vs. 2
1B vs. 2
1A vs. 1B
Anti-TPO Positivity (%)
Antibody Positivity (%)
Group 1A: Pretreatment Cushing Syndrome patients
Group 1B: Posttreatment Cushing Syndrome patients
Group 2: Control patients
Objectives: We aimed to compare early total thyroidectomy with the anti-thyroid treatment regimens, in patients with moderate to severely active Graves' orbitopathy (GO) prospectively.
Methods: The inclusion criteria: Hyperthyroidism and GO developed in the last six months, thyroid volume ≥15 mL, no previous treatment except local interventions for GO. GO activity has been defined as clinical activity score (CAS) ≥3 and carrying at least one of the following criteria; Proptosis ≥21 mm in one eye, ≥2 mm difference between two eyes, presence of diplopia, lid aperture ≥9 mm. Initially, all the patients were made cuthyroid (TSH 0.4-1 mlU/L). Pulse methylprednisolone of total 4.5 gr were given intravenously to all patients before randomization. In the first group, patients were sent to total thyroidectomy and in the second group, patients were followed with antithyroid drugs. TSH was kept between 0.4-1 mlU/L
Results: 18 patients were randomized to total thyroidectomy (UT) group and 23 patients were randomized to medical antihyroid treatment (AT) group. There were no difference between the two groups with respect to age, gender, smoking habit, duration of hyperthyroidism and GO, thyroid volume, TSH, free T4, and TSH receptor antibody (TRAb) levels initially. The follow up period was 6-48 months. When the TT group was compared with AT group, TRAb were significantly decreased in TT group while there was no significant difference with respect to proptosis, lid aperture, CAS and diplopia between groups However in TT group additional pulse methylprednisolone treatment was given to 3 (21%) patients and urgent orbital decompression was applied to 2 (14%) of those patients. Hyperthyroidism reocurred in 3 patients in AT group after 18-24 months of antithyroid treatment.
Conclusion: Although the significant decrease of thyroid autoantibodies were achieved in TT group, this was not reflected as an beneficial effect on the course of GO.
INTRODUCTION: Papillary thyroid microcarcinoma (PTMC) is the most frequent form of papillary thyroid carcinoma (PTC). İncidence rate of papillary thyroid microcarsinoma (PTMC) has almost doubled during the recent years but treatment and follow up is still a matter of debate. In this study we aimed to analyze clinical and histopathological risk factors at the time of diagnosis and to observe their implications for treatment, follow up and prognosis.
PATIENTS AND METHODS: Two hundred forty-eight patients were included in this study between january 2007 and november 2012. They were all evaluated in the outpatient clinic of Ankara Ataturk Education and Research Hospital Endocrinology Department with the diagnosis of nodular goiter. The age, sex, the method of diagnosis (incidental or with a clinical suspicion), cervical lymph node metastases and relapse and/or distant metastases during follow up were retrospectively recorded.
RESULTS: Two hundred one were female and 47 were male. Total thyroidectomy was performed in all patients. All of the patients had postsurgical radio-iodine ablation treatment. When compared according to tumor size (≤5 mm vs >5 mm), bilateral involvement, vascular invasion, capsular invasion, extrathyroidal extension and lymph node metastases were significantly more frequent in the patients with tumor size > 5 mm (p values p<0.046, p<0.021, p<0.001, p<0.003, p<0.000 respectively). Diagnosis after a clinical suspicion and thyroglobulin (TG) value were found to be associated with lymph node metastases at the end of the multiple logistic regression analysis.(Table2). The relevant TG value was 7.98 ng/ml with a sensitiviy of 57.14 % and specificity of 83.17 % [Positive predictive value (PPV): %19, negative predictive value (NPV): %96.6]. Relapse was associated with TG value and lymph node metastases at the time of diagnosis. Tumor size which predicts relapse was 6 mm with a sensitiviy of 50 % and specificity of 76.37 % [PPV: 8.2 %, NPV: 97.3 %].
Table 1. Clinical and pathological factors for worse prognosis by sizeand ratio
Bilateralite n, (%)
Vasculer invasion n, (%)
Capsüle invasion n, (%)
Extratiroidal extension n, (%)
lymph node metastases n, (%)
Table 2. Multivariate regression analysis of factors that may affect the evaluation of lymph node metastasis
CONCLUSION: Local relapse and lymph node metastases are more frequent in patients with a tumor size of more than 6 mm or stimulated serum Thyroglobuline (TG) levels in post thyroidectomy period of more than 7.98 ng/ml. Local relapse is significantly associated with lymph node metastases at the time of diagnosis. Regarding the treatment of PTMC our approach is to perform total/near total thyroidectomy and than RAI treatment. We think that the low relapse in this study is related with our therapeutic approach. On the other hand, PTMC should not be regarded as a relatively benign disease when our patients with lymph node metastases, local relapse and distant metastases were taken into consideration.
INTRODUCTION: Our objective for the current review was to investigate the thyroid cancer frequency rate within the patients who have had total thyroidectomy procedure for definitive Graves’ disease treatment and to evaluate the contribution of the presence of nodules to malignancy rates.
MATERIAL AND METHODS: The present study was conducted retrospectively.by scanning the data of 214 patients who were applied total thyroidectomy for permanent Graves disease treatment. The participants were separatedinto 3 subgroups;benign nodule group, malignant nodule group and nodulenegativegroup. The groups were also compared in regards to demographic characteristics and laboratory data.
RESULTS: 14 of the 214 cases were diagnosed with thyroid cancer. The malignancyprevalence was determined as 6.5%. The sex distributions were found to be statistically similar between the malignant and benign nodule groups (p=0.776). The mean age of the malignant nodule group was significantly higher than the benign nodule group (p=0.042). No significant differences was found between the benign and the malignant nodule group in regards to median Thyroid Stimulating Hormone (TSH)receptor antibody levels (p=0.134). The cases were divided into two groups regarding to nodüle presence.Pre-operational USG revealed nodules in 19 cases. Five of these patients had malignancy .The malignancy frequency was significantly higher in the nodule positive group than the nodule negative group (26.3% vs. 4.6% respectively, p=0.004). There was also no statistically significant TSH receptor antibody, Anti-thyroid peroxidase (Anti-TPO)antibody titres and thyroid functioning differencesbetween these groups (p> 0.05).
CONCLUSION: We have determined the incidental thyroid cancer frequency in Graves’ disease patients population as 6.5%.Malignancy rate was found higher when co-morbid nodules were present (26.3%). We recommend that when total thyroidectomyis performed for the treatment of Graves’ disease, especially if nodules are present, malignancyrisk must be takeinto consideration
Table 1.Comparison of benign and malignant groups according to nodule and TRAB positivity
Introduction: Nodule diameter was considered to be related with thyroid cancer. Whether under ultrasound (US) guidance or not, FNAB has some limitations particularly in big nodules. In this study, we aimed to evaluate diagnostic value of US-FNAB in nodules bigger than 3 cm or more. We also compared ultrasonographical features of benign and malignant nodules.
Material and methods: Data of 267 patients operated for nodulary goiter were screened retrospectively. The study group consisted nodules with a diameter of 3 cm or more. Nodules with a diameter of less than 3 cm were considered as control group. Cytological results were classified as malignant, suspicious for malignancy, undetermined, benign and nondiagnostic.
Results: There were 144 (53.9%) patients in study group and 123 (46.1%) patients in control group. Malignancy was observed in 16% of study group and 42.3% of control group. In nodules smaller than 3 cm, US-FNAB had a sensitivity of 85.4%, specificity of 40.3%, positive predictive value (PPV) of 52.6% and negative predictive value (NPV) of 78.1%. In nodules bigger and equal to 3 cm, sensitivity of US-FNAB was 72.7%, specificity was 81.6%, PPV was 45.7%, and NPV was 93.3%. Among parameters that may be used to predict malignancy, nodule texture, margin regularity, echogenicity and presence of halo were significantly different between malign and benign nodules.
Conclusion: This study showed that increased nodule diameter is not related with limitations in diagnostic value of US-FNAB. We also found that malignancy rate was smaller in big nodules. This finding reflects the importance of true and rational diagnostic and clinical management while detecting malignancy and deciding surgery.
INTRODUCTION: Nowadays, ultrasonography (USG) is being used indispensableand commonly in the diagnosis ofthyroid diseases. Heterogeneous appearance of thyroid parenchyma is associated with thyroid autoantibody positivity and hypofunctioning of thyroid gland. On the other hand, it is not determined whether thyroid parenchyma appearing quitelynormal echogenicity on USG is related to presence normal thyroid function tests or otherwise.The objective of our study was to evaluate the relationship between normal thyroid USG appearance and thyroid function tests with thyroid autoantibodies.
MATERIAL AND METHODS: Thyroid USG images of 218 patientsand laboratory tests were evaluated prospectively.The participants were classified into two groups,homogeneous/ normoechogenic and the heterogeneous group, according to thyroid parenchyma appearance on USG.
RESULTS: We acquired homogeneous images on 103 cases and heterogeneous images on 115 cases. Thyroid Stimulating Hormone (TSH)level, Anti-Thyroglobulin (Anti-Tg)and Anti-Thyroid peroxidase (Anti-TPO)titres and thyroid volume was found to be significantly higher in heterogeneous parenchyma group (p<0.001). 83 cases with normal USG images (80.5%) had normal TSH levels and 7 cases in this group had positive Anti-Tg (8.4%) and 23 cases had positive Anti-TPO (27.7%)levels. Out of the heterogeneous parenchyma group composed of 115 cases; 46 patients (40%) had high TSH level and 9 of them (19.6 %) had positive Anti-Tg and 35 (76.1%) had positive Anti-TPOlevels. We observed no differencesbetween the groups regarding tofree triiodothyronine (fT3)and free tetraiodothyronine (fT4)levels. Between age and thyroid volume statistically significant and positive correlation was found (r=0.171, p=0.012).
CONCLUSION: The thyroid gland “normal” appearing on USG imaging, probablyaccompanies normal serum thyroid function tests and negativity for thyroid antibodies.According to our results, thyroid USG is a perfect device for predicting normal thyroid functions, which could probably avoid unnecessary future laboratory tests as well.
Table 1. In USG normal and heterogeneousgroup, distribution of antibody positive cases in which TSH levels are normal
BACKGROUND: Riedel thyroiditis is a rare chronic inflammatory disease of the thyroidgland. It is characterized by replacement of normal parenchyma with dense fibrotic tissue. Peripheral tissues might also be affected and this may cause airway obstruction, dysphagia, recurrent laryngeal nervepalsy and hypoparathyroidism. We report a patient with toxic adenoma previously treated with radioiodineand histopathologically confirmed Riedel thyroditis.
CASE: A 61 years old male patient was referred to our clinic because of subclinical hyperthyroidism. He did not have any obstructive symptoms. In physical examination, a 3x2 cm nodule was detected in the leftthyroid lobe. Serum Thyroid Stimulating Hormone (TSH), free triiodothyronine (fT3), free tetraiodothyronine (fT4)and thyroglubulin(Tg)levels were 0.047 µIU/ml (0.4-4 µIU/ml), 2.04 pg/ml (1.57-4.71 pg/ml), 1.03 ng/dl (0.85-1.78 ng/dl) and 6.31 mg/dl (1.15-35 mg/dl), respectively. Antithyroid peroxidase, antithyroglobulin and thyroid stimulating antibodies were negative. Thyroid ultrasonography revealed a 15x20x28 mm isoechoic nodule located in superior and mid portions of the left thyroid lobe. The ultrasonographic features of the nodule were; a thin hypoechoic halo, cytic degeneration areas and macrocalcification. Thyroid scintigraphy showed an active nodule with extranodular suppression of thyroid parenchyma(Figure 1). Radioiodine uptake measurement was 10% after 4 hours and 25% after 24 hours of I-131 administration. The nodule was evalueated with fine needle aspiration biopsy and cytology was found benign. The patient was treated with 20 mCiradioiodine for toxic adenoma.In the posttreatment follow-up, since nodule diameter is increased significantly after 6 monthsof the radioiodine treatment, total thyroidectomy was performed. In histopathological examination, there was marked fibrosis in stroma and some atrophic glands in thyroid tissue. Fibrosis was extending to the surrounding fat tissue and focal chronic inflammatory cells were observed around middle sized veins. With these findings, the patient was diagnosed to have Riedel thyroiditis.
Figure 1. Active nodule in the left thyroid lobe and extranodular supression of thyroid parenchyma
Figure 2. Marked fibrosis in thyroid parenchyma, lymphoid cells and tightened atrophic thyroid follicules : Riedel thyroiditis (H/E x 50).
CONCLUSION: Riedel thyroiditis is a very rare disease of the thyroid gland. To our knowledge, this is the first case with coexistent toxic adenoma and Riedel thyroditis reported in the literature.
BACKGROUND: Cardiac rythm abnormalities are important in acromegaly patients and they can be a cause for sudden death. Establishing the clinic determinants of ventricular arrhythmias is important for the risk assesment in those patients. QT dispersion can be used to detect proarrhythmia. Increased QT dispersion is related with increased risk of arrhythmia. In this study we have aimed to calculate the QT dispersion in acromegaly patients and reveal its correlation with growth hormone (GH), insulin like growth factor-1 (IGF-1).
MATERIAL AND METHOD: 41 acromegaly patients were enrolled in the study. Another 41 patients with similar age, sex and comorbid disease distrubition have constituted the control group. We have evaluated the electrocardiograms (ECG) of the acromegaly patients at the time of diagnosis (baseline) and at the end of follow up (post follow up). Only one ECG was provided from each patient in the control group. The longest (QT max), the shortest QT (QT min), QT dispersion, corrected QT max (QTc max), QTc min and QTc dispersion were calculated.
RESULTS: Baseline QT max, QT dispersion, QTc max and QTc dispersion intervals of the acromegaly patients were significantly longer than the control group. There wasn’t any difference between the groups in terms of QT min and QTc min (Table 1). We have detected that post follow up QTc max and QTc dispersion were significantly shorter compared to baseline intervals (p=0.005 and p=0.024, respectively). There wasn’t any significant difference between baseline and post follow up QT max, QT min, QT dispersion and QTc min intervals (Table 2). There wasn’t any significant difference in between the post follow up QT intervals of acromegaly patients and the control group (Table 3). We have evaluated the relation of QT intervals with GH and IGF-1 in each group. Except the correlation of GH with QTc dispersion in post follow up acromegaly patients (r=-0.438, p=0.011), we could not show any other relation between GH, IGF-1 and the other QT parameters (for all parameters, p>0.05). QT intervals have not been found to be associated with age and BMI of the individuals (for all parameters, p>0.05). We have detected a significant positive correlation between disease duration and QTc dispersion in acromegaly patients (r= 0.440, p=0.009).
CONCLUSION: According to the findings of this study we can claim that QT intervals are beneficial in determining the arrhythmia risk in acromegaly patients and this risk can be reduced after treatment and hormonal control..
Table 1. Comparision of the baseline QT intervals of the acromegaly patients with the control group
QT max (ms)
387.73 ± 25.30
373.73 ± 26.33
QT min (ms)
317.88 ± 22.55
312.46 ± 23.09
QT dispersion (ms)
70.10 ± 10.51
61.76 ± 12.18
QTc max (ms)
422.76 ± 20.82
408.27 ± 17.08
QTc min (ms)
345.59 ± 17.36
339.51 ± 13.34
QT c dispersion (ms)
77.07 ± 12.34
68.02 ± 13.13
Table 2. Comparision of baseline and post follow up QT intervals of the acromegaly patients
Post follow up (n=35)
QT max (ms)
391.42 ± 24.50
383.20 ± 15.22
QT min (ms)
320.88 ± 20.05
317.42 ± 13.55
QT dispersion (ms)
70.82 ± 9.94
65.77 ± 10.59
QTc max (ms)
422.85 ± 20.88
410.23 ± 15.33
QTc min (ms)
344.88 ± 18.28
337.86 ± 13.64
QT c dispersion (ms)
77.85 ± 10.83
71.51 ± 9.83
Table 3. Comparision of post follow up QT intervals of the acromegaly group with the control
Acromegaly- post follow up (n=35)
QT max (ms)
383.20 ± 15.22
373.73 ± 26.33
QT min (ms)
317.42 ± 13.55
312.46 ± 23.09
QT dispersion (ms)
65.77 ± 10.59
61.76 ± 12.18
QTc max (ms)
410.23 ± 15.33
408.27 ± 17.08
QTc min (ms)
337.86 ± 13.64
339.51 ± 13.34
QTc dispersion (ms)
71.51 ± 9.83
68.02 ± 13.13
INTRODUCTION: Well-known environmental factors,which can lead to type 1 diabetes,are viral infections, vaccines, diet, exposure to cow milk in infancy, vitamin D deficiency, drugs, maternal age, preeclampsia and low birth weight, Isotretinoin is an effective drug for acne treatment. It can cause dyslipidemia, elevated liver enzymes, insulin resistance and type 2 diabetes. Our case is type 1 diabetes developed after the use of isotretinoin and represented with diabetic ketoacidosis.
CASE: 18 years-old-male patient has admitted to hospital with complaints of abdominal pain, increased sense of thirst, frequent urination and dry mouth. In physical examination, he was dehydrated with hypotension and dry oral mucosa. He didn’t have family history of diabetes. With further questioning, we have learnt that he was using isotretinoin for acne treatment for seven months. In laboratory examination, his plasma glucose level was 400 mg/dl,and there was heavy ketonuria and acidosis in arterial blood gas. He was hospitalized in endocrinology ward with diagnosis of diabetic ketoacidosis. Hydration with isotonic saline together with insulin infusion, potassium replacement and dextrose infusion were given to the patient. His anti GAD was positive and C-peptid level was very low leading to diagnosis of type 1 diabetes. After amelioration of ketoacidosis, we have skipped intensive insulin therapy and blood glucose levels were regulated.
CONCLUSION: Isotretinoin is related with metabolic syndrome and type 2 diabetes. However, there are few cases of type 1 diabetes in literature. Anti GAD positivity is suggestive of underlying autoimmune mechanisms triggered by the drug. Patients should be monitoredwith frequent glucose measurements during follow up.
Table 1. Labaratory results at the time of diagnosis
INTRODUCTION: Immune supressive patients due to any cause(disease, medication etc.) rarely have autoimmune diseases. In this presentation two patients diagnosed with Graves' disease and subacute thyroiditis while taking cyclosporine therapy will be discussed.
CASE 1: A 47 year-old female patient applied to outpatient clinic with weight loss, sweating and tremor which had been present for the last two months. She had been on cyclosporine therapy for three years because of hypoplastic anemia. Laboratory tests are listed in table 1. Thyroid ultrasound revealed enlarged thyroid gland with diffuse parenchymal heterogeneity. Patient's thyroid scan showedincreased uptake which was diffuse and homogenous in pattern.(Picture 1). On 24-hour radioiodine uptake test 4th hour uptake was 46 % (15-25 %) and 24th hour uptake was 27 % (25-35 %). Based on these clinical and laboratory findings the patient was diagnosed as Graves’ disease. With thyromazol therapy euthyroid state was achieved.
0 - 115 IU/mL
0 - 34 IU/mL
TSH Reseptor Antibody
0 - 14 u/L
CASE 2: A 41 year-old female patient admitted to our clinic with pain and tenderness in the thyroid area. She had been using cyclosporine during the last 2 year period for psoriases. Laboratory tests are listed in table 1. Thyroid ultrasonography showed multiple hypoechoic thyroid nodules with ill-defined margins on the basis of chronic thyroiditis. In the thyroid scan there were supressed areas in nodular pattern and a global nonhomogenous uptake. There was low radioiodine uptake in the 24-hour radioiodine uptake test.(Picture 2). The patient was diagnosed as subacute thyroiditis. Nonsteroidal anti inflamatory drug and beta bloker were given. One month later her thyroid function tests were within normal limits..
CONCLUSION: Cyclosporine is an immune-supressive drug which is also used in the treatment of Graves’ ophthalmopathy. Cyclosporine inhibits calcium, IL-3, IL-4 and IL-5 induced T and B lymphocyte proliferation and cytotoxic T cell egzocytosis but rarely it can be a cause of autoimmune disease by an unknown mechanism of abnormal modulation of the immune system. Patients taking cyclosporine especially those having another autoimmune disease or family history of thyroid disease must be carefully monitorized with thyroid function tests.
Picture 1 Picture 2
INTRODUCTION: Mixed medullary-follicular carcinomas (MMFC) of the thyroid are rare tumors which represents less than 0.15% of all thyroid tumors showing the morphological and immunochemical properties of both parafollicular and follicular cell lineages. Cases were immunoreactive for both calcitonin and thyroglobulin. However, there are discussions in the literature related to histopathological characteristics and originof MMFC. In this paper, we aimed to present our two cases of MMFTK.
CASE 1: A 25-year-old female patient referred us for evaluation of a thyroid mass located on the left lobe. Ultrasonography(US) revealed 38 mm solid isoechoic nodule with well-defined margins on the left lobe. An US-guided fine needle aspiration(FNA) was performed and reported as follicular neoplasm. A total thyroidectomy with central lymph node dissection was performed.Immunostaining revealed that the tumor cells were diffusely positive for calcitonin and chromogranin. Further, there were scattered follicules that stained positively with antibody against thyroglobulin.The histological findings in correlation with the immunoprofile, support a diagnosis of MMFC.Post-operatively calcitonin level was 2.69 pg/ml.Radioactive iodine ablation with 150 mCi and levo-thyroxine supression theraphy had given to the patient.
CASE 2: A 46-year-old female patient admitted with enlargement of a neck mass. US revealed 33 mm solid isoechoic nodule with ill-defined margins and microcalcifications on the left lobe of thyroid.US-guided FNA was reported as thyroid neoplasm with differentiation or anaplastic transformation. Patient’s serum level of calcitonin was 1802 pg/ml (normal <12 pg/ml). Results of blood testing for pheochromocytoma and hyperparathyroidism were within the normal range.Total thyroidectomy with central lymph node dissection was performed. The histological findings were consistent with MMFC with metastatic lymph nodes.The serum calcitonin level dropped to 3,75 pg/ml following the surgery.
FİGURE 1. Histopathologic appearance of case 1
FİGURE 2. Histopathologic appearance of case 2
CONCLUSION: The majority of MMFC occurs in a sporadic form, rarely it can be a component of MEN type 2. MMFC,medullary and follicular thyroid cancer behave differently in terms of clinical course and management. Identification of MMFC by FNA may be difficult, the proper immunostaining panel could have showed the different aspects of the mixed tumor.
INTRODUCTION: Pituitary adenomas which co-secrete growth hormone(GH) and thyroid stimulating hormone(TSH) accounts for less than 0.2% of all adenomas of the pituitary. Symptoms of hypertyroidism are usually masked by clinical manifestations of acromegaly. Here we have reported the result of the primary one-year-long medical therapy in a case who was diagnosed to have adenoma co-secreting GH and TSH.
CASE: 70-years-old female patient has admittedto hospital with the complaints of excessive sweating, enlargement of hands and feet. In physical examination there were frontal bossing, coarsening of facial structures and acral enlargement. In hormone tests, GH level was : 17 ng/mL and IGF-1 level was : 607 ng/ml (64-188 ng/mL).GH levels were not suppressed during glucose suppression test. Her serum TSH, fT4 and fT3 levels were elevated. Serum alpha subunit was also high (80 IU/l). In thyroid ultrasonography, we have detected goiter. In thyroid scintigraphy, homogenous diffuse hyperplasia of both lobes was reported. In pituitary MRI,there wasa 13x16 mm sized macroadenoma on the left handside of the pitiutary gland. The diagnosis of acromegaly was made with high suspicion of TSH co-secretion from the adenoma. Since the patient had dilated cardiomyopathy and obstructive sleep apnea syndrome, the operation could not be done. Octreotide LAR was started in a dosage of 30 mg/28 days. The patient was evaluated at the first year of the therapy. IGF-1 level decreased (285 ng/ml) and the size of the adenoma was reduced(11x10 mm). Serum fT4, fT3 and TSH levels were normal together with normalization of serum alpha subunit.
CONCLUSION: Coexistence of GH secreting adenoma and TSHoma is rareIn such cases, transsphenoidal surgery must be the first choice for therapy. However when operation is contraindicated as it occurred in our case or when the lesion cannot be excised completely resulting in residual mass, somatostatin anolnalogues should be used. Sandostatin LAR is the one which the clinicans have the most experience in TSHomas.
Picture 1. 13x16 mm sized adenoma on the left handside of the pitiutary gland
Table 1. Laboratory results of the patient at the time of diagnosis
BACKGROUND: The classic clinic manifestation of primary hyperparathyroidism(PHPT) is osteitis fibrosa cystica, a severe skeletal disease characterized by brown tumors, bone cysts and deformities, due to extremely elevated bone resorption elicited by continuously high parathyroid hormone (PTH) levels. In cardiovascular system there may be shortened QT interval, deposition of calcium in heart valves, coronary arteries, and myocardial fibers. Here, we report a case with PHPT, who have anorexia nervosa, sceletal anomaly, atrial septal defect(ASD) and interatrial septal aneurysm.
CASE: An 18-year-old woman, who has anorexia nervosa has applied for constipation.She had bradycardia, low weight(Body mass index:15 kg/m2), and prognathism. The radiographic finding of the extremities showed that, bilaterally 2 and 5 metacarpals ofthe hands , and bilaterally 1, 3, 4, 5 metatarsals ofthe foots were short. Laboratory tests revealed hypercalcemia, hypophosphatemia and hyperparathyroidism. 24-hour urinary calcium was 504 mg/day. The neck ultrasound revealed a 4.9x6.8x10.4 mm hypoechoic lesion in the outsideofthe thyroid right lobe inferior. Sestamibi scintigraphy results were consistent with parathyroid adenoma. Renal ultrasonography determined milimetric crystaloids in the right kidney. Bone mineral densitometry revealed osteopenia. Her electrocardiography showed shortened QT interval and bradycardia. Echocardiography revealed an ASD and interatrial septal aneurysm. Her pituitary hormonal levels were consistent with panhypopituitarism. She had also evaluated for the eye, ear and nose anomaly, but no pathology was found. After the diagnosis and emergency treatment for hypercalcemia she had underwent parathyroidectomy.Histopathology was consistent with parathyroid adenoma.Postoperative her calcium and parathyroid levels were reduced in normal levels.
CONCLUSION: Our case revealed hypercalcemia and hyperparathyroidism and also unusual manifestations like anorexia nervosa, ASD, interatrial septal aneurysm and sceletal anomaly. In the literature to our knowledge, there is only one case with PHPT and ASD associated with mongoloid features. In conclusion, the patients with PHPT may be evaluated for atypical manifestations of cardiac and sceletal system.
Picture 1. MIBI scan of the patient
Picture 2. A. Hand X-ray of the petient B. Food X-ray of the patient
INTRODUCTION: Giant cell granuloma is a skeletal manifestation seen now rarely in hyperparathyroidism due to early recognition of the disease. Lesions usually occur in the areas of intense bone resorption. They can affect mandible, maxilla, clavicle, ribs and pelvic bones. Most of the patients who have primary hyperparathyroidism are asymptomatic and are discovered incidentally during laboratory examinations. Here we represent a female patient who was referred to endocrinology clinics because of maxillary brown tumor detected by her dentist.
CASE: 30-years-old female patient has admitted to dental clinics with the complaint of oral mass and accompanying symptoms as decreased apetite, weight loss and numbness on the jaw. Biopsy of the oral lesion was consistent with giant cell granuloma. Radiographic imaging has revealed multiple bone cysts on the mandible and maxillary bones. In laboratory exam, severe hypercalcemia and hypophosphatemia were detected. Her serum parathormon level and urinary calcium level were elevated. In ultrasonographic examination, we have detected two parathyroid adenomas on left side and MIBI scan was positive. In bone mineral densitometry, osteoporosis was detected at the lumbar vertebrates. She didn’t have any renal stones in abdominal ultrasonography. We have searched for MEN1 syndrome. There was a microadenoma in pituitary MRI that was provento be nonfunctional with hormone tests. Her upper gastro intestinal endoscopy was normal as the serum gastrin levels. She underwent surgery and all parathyroid glands and thymus were excised then ½ of a paratyhroid gland was seeded on forearm. No complications occurred during or after surgery and she was discharged and referred to her dentist for curettage of the bone cysts.
CONCLUSION: Treatment of hyperparathyroidism is surgery. However, treatment for bone lesions is controversial. They can regress after removal of the adenoma. In the persistent cases, surgical removal of the bone lesion after a short course of steroid therapy is advised.
Picture 1. Bone cysts on mandibula
Picture2. MIBI scan of the patient
BACKGROUND: Fine needle aspiration cytology (FNAC) has been widely accepted as the most accurate, safe and cost-effective method for the evaluation of thyroid nodules. The most challenging category in the FNAC is atypia of undetermined significance (AUS) and follicular lesion of undetermined significance (FLUS). Bethesda System (BS) recommends repeat FNAC in that category due to their low risk of malignancy.In our study; we aimed to investigate the malignancy rate of thyroid nodules of AUS and FLUS and to evaluate the presence of biochemical, clinical and echographic features possibly predictive of malignancy related to AUS and FLUS.
MATERIALS AND METHODS: Data of 268 patients operated for AUS and FLUS cytology were screened retrospectively. Ultrasonographic features and thyroid function tests, thyroid antibodies, scintigraphy and histopathological results were evaluated.
RESULTS: 276 nodules of 268 patient’s results are evaluated. Malignancy rates were 24.3% in the AUS group, 19.8% in the FLUS group and 22.8% in both group. In the evaluation of all nodules the predictive features of malignancy arehypoechogenicity and peripheral vascularization of the nodule. In the AUS group, the predictive feature of the malignancy isonly hypoechogenicity, and peripheral vascularization in the FLUS group.
CONCLUSION: We determined that the malignancy rates in these nodules are higher than the anticipated literature rate. This high ratio may be due to the fact that we studied only the patients who underwent surgery. The ultrasonographic features alone may be insufficient to predict the malignancy, therefore all the clinical and ultrasonographic features must be considered in the evaluation of the thyroid nodules. In addition, we think that, the recommended management of repeat FNAC in these groups must be reconsidered with the clinical and ultrasonographic features.
Table. Ultrasonograpfic features of benign and malignant thyroid nodules
*p: 0.045, **p: 0.003, ***p:0.02, ****p: 0.04, *****p: 0.011, ******p: 0.044
BACKGROUND: Metastatic pituitary tumors are seen rarely and it is hard to differentiate them from the benign lesions of the gland. We have reported a case, with a known maxillary tumor, detected to have a pituitary lesion coincidentally on PET-CT.
CASE: 45 years old male patient with a known history of relapsed maxillary sinus tumor has been referred to our clinics because of thehypophyseal lesion detected to have increased FDG involvement on PET-CT examination. It is learned from the medical history that he was operated for the maxillary sinus tumor 35 years ago and had the second operation last year because of the recurrent disease. Histopathological examination of the lesion was reported as well-differentiated squamous cell carcinoma with perineural and lymphovascular invasion. He received 6 cycles of chemotherapy, conventional external radiotherapy and 66 Gys of tomotherapy(maximum of 30 Gys to the pituitary gland). There was a tissue defect on the right maxillary region, nose and the right eye lid in physical examination. Pitiutary lesion was metabolically active on PET-CT and SUV max value was 11.7(Fig.1). There was also left lung involvement (SUV max: 4.3) compatible with metastasis. We have demanded a pitiutary MRIand detected a 5.4x4.3 mm sized nodular pitiutary lesion on the right side of the gland which was isointense on T1A and T2A images and with late contrast concentration on dynamic sequences. In the labaratory examination GH was0,09 ng/ml, IGF1 was 239 ng/ml, prolactin was 57.6 ng/ml, TSH was 1.9 uIU/ml, FSH was 18.4 mIU/ml, LH was 4.6 mIU/ml, ACTH was 52 pg/ml, cortisol was 15.7 μg/dl. There wasn’t any symptom or sign of diabetes insipitus. The PET-CT control, made one month after radiotherapy, has revealed that the pituitary lesion was less metabolically active after RT (SUV max: 7.1).
Fig 1. İncreased metabolic activity in pituitary on PET-CT
CONCLUSION: It is difficultto differentiate metastatic lesions from the benign lesions of the pituitary gland. Most of the metastatic lesions are asymptomatic although presence of diabetes insipitus or ophtalmoplegia are suspiciousfor metastasis in patients with a known history of a malign tumor. Although there isn’t any specific radiologic sign for metastatic lesions, increased thickness of pituitary stalk, diminished signal intensity of posterior pituitary, isointense appearance on T1 and T2 images, cavernous sinus invasion and sclerotic changes in cella turcica should make the clinician consider presence of a metastatic lesion within the gland. In our case because of the lesion being metabolically active on PET-CT with a high SUV max value, isointense appearance on MRI and a history of previous maxillary sinus malignancy made us suspect pituitary metastasis. However absence of pituitary insufficiency, diabetes insipitus or ophthalmoplegia and decreased metabolic activity (SUV max) on control PET-CT might indicate that the lesion might be benign. Tissue biopsy for the definitive diagnosis could not be performed because of the facial defect of the patient.
INTRODUCTION: Cushing's syndrome may be either corticotropin (ACTH)-dependent or -independent. Ectopic secretion of ACTH by nonpituitary tumors accounts for 10 to 15 percent of ACTH dependent Cushing syndromes. Generally it is difficult to localize the ACTH secreting tumor by conventional imaging methods because these tumors are often small in size. Neuroendocrine tumor cells exhibit somatostatin receptors on their cell surfaces. By using this feature 111-In-octreotide scan is an alternative diagnosing method. Here we present a case of ectopic ACTH syndrome diagnosed with octreotide scan.
CASE PRESENTATION: A 26 year old male patient presented with moon face, purplish striae, supraclavicular fat pads and proximal muscle weakness. Laboratory tests were as follows:
136 - 145 mmol/L
3,5 - 5,1 mmol/L
24 hour urinary free ccrtisol
0.0 - 60 µgr/gün
Cortisol after 1 mg Dexamethasone supression test
<1,8 μg /dL
Cortisol after 2 day 8 mg Dexamethasone supression test
<1,8 μg /dL
0 - 60 pg/mL
Pituitary magnetic resonance imaging (MRI) revealed no mass. Inferior petrosal sinus sampling was negative with no increase in ACTH after CRH administration. On thorax computerized tomography (CT) there was a 14 mm nodule in the middle lobe of the right lung. The patient was a heavy smoker. There was no pathology on 18-FDG positron emission tomography scan. But 111-In -Octreotide scan depicted the neuroendocrine tumor located in the right lung.
Following surgey there was no need for antihypertensive treatment or insulin therapy any more and hypokalemia did not recurr.
CONCLUSION: The last step of approaching to a patient with ACTH dependent Cushing Syndrome is to detect the source of ACTH secretion. As most of the ACTH secreting tumors arise from thorax it is important to start evaluation from this anatomic localisation. CT or MRI is the first imaging modality of choise. The sensitivity of CT to detect a small tumor such this is 53 % whereas it is 37 % in MRI. The senstivity of octreotide scan in detecting ACTH secreting tumor is approximately 30-53 %. It is the last but not least choise of non invasive procedure on the way going to surgery as in our case.
BACKGROUND: Atypical tumors were identified in 15% of pituitary adenomas, and they tended to be aggressive, invasive macroadenomas. World Health organization (WHO)classification of atypical pituitary adenomas include; Ki-67 proliferative index greater than 3%, excessive p53 immunoreactivity, and ≥ 2 mitotic figures per 10 high-powered fields. Pituitary carcinomas are extremely rare tumors with cerebrospinal or extracranial metastasis.
CASE: A 31 years old man with symptoms of stuffy nose and snore, presented to our policlinic due to the solid lesion on paranasal sinus tomography. Tomography showed a soft tissue lesion with 38 Haunsfield Unit (HU). Pituitary imaging revealed a mass, which lead to destruction of bone structures, suppression of optic chiasm, extending to suprasellar cistern and right nasal cavity. Except increased prolactin (470 ng/ml),hormonal levels were in normal ranges. Also macroprolactin was negative. Nasal punch biopsy showed an atypical pituitary adenoma with atypical and 8 mitotic figures in the 10 high-powered fields. Ki-67 labeling index 2-3%, p53 immunoreactivity was 1%. 18-Fluoro-Deoxy-Glucose Positron Emission Tomography determined increased activity in this lesion with 6.4 SUV-max. No distant metastasis was determined. Cabergolin 0.5 mg/ twice a week was begun and then he underwent to operation. Histopathological result was a pituitary adenoma with diffuse staining PRL. Ki-67 index was 1%, whereas p53 immunoreactivity was 10%. Postoperative prolactinlevel reduced to 65 ng/ml and no solid lesion was seen in postoperative imagining. His medical treatment is now ongoing.
CONCLUSION: Because of the atypical and ≥2 mitotic activity, necrosis in the nasal punch biopsy, also 38 HU solid lesion in tomography and absent of distant metastasis, we thought primarily atypical adenoma in this case. Although histopathological result is consistent with benign prolactinoma, it must be considered that its biological behavior may be progressed to malignancy after several years.
Table 1. Laboratory parameters of the patient before and after operation
0 - 5 ng/mL
Picture 1. Pituitary imaging of the patient before and after operation
Picture 2. A: Atypical mitotic figure of the lesion on histopathological specimen B: Diffuse staining with PRL
INTRODUCTION: Primary thyroid lymphoma is a rare tumor which represents 1-5% of all thyroid malignancies, and 1-2.5% of all lymphomas. Prompt recognition is important because the management of this potentially curable disease is different from the treatment of other neoplasms of the thyroid gland. Cancer complicates between 0.02 and 0.1% of all pregnancies. Thyroid lymphoma is very rarely encountered during pregnancy and there are only a few case reports in the modern literature. Here we present a case of thyroid lymphoma in a young pregnant woman and review the pertinent literature.
CASE: A 28-year-old female patient presented with a neck swelling, pain and respiratory distress while she was in the 17th week of her first pregnancy. Ultrasonographic and elastosonographic images of left thyroid lobe wasshown in Figure 1. Subtotal thyroidectomy was performed and combined histological and immunohistochemical analyses led to the diagnosis of diffuse large B cell lymphoma with a high proliferation index (Ki-67: 80%) and positive CD20 (Figure2 and3), CD10 and BCL6. Chemotherapy (cyclophosphamide, doxorubicin, vincristine and prednisone (CHOP), 6 cycles every 4 weeks) was planned and the patient underwent the first 4 cycles without vincristine. Twenty weeks after the initiation of chemotherapy she had cesarean delivery of a healthy, full-term male infant. Four additional courses of chemotherapy were administered, after which the patient was reevaluated. She had no complaints and a total body CT did not show relapse of the disease.
Figure 1. Ultrasonographic and elastosonographic images of left thyroid lobe
Figure 2.Immunohystochemical examination with Ki67
Figure 3.Immunohystochemical examination with CD 20
DISCUSSION: Thyroid lymphoma occurs primarily in middle-aged to older aged females. Diffuse large B cell lenfoma is the most frequent histologic subtype of thyroid lymphomas. Patients with primary thyroid lymphoma usually present with compressive symptoms such as dyspnea, dysphagia and hoarseness. The co-existence of thyroid lymphoma and pregnancy is a rare condition. The unusuality of this condition becomes more clear when it is considered that only approximately 100 cases of non-Hodgkin lymphoma in pregnancy have been reported so far. If diagnosed during early pregnancy, the pregnancy should be terminated and chemotherapy started immediately. In advanced pregnancy, chemotherapy should be started as early as possible. In conclusion our case is a one of the few examples of thyroid lymphoma associated with pregnancy and it was successfully managed with a combination of surgery and chemotherapy.
AIM: According the Bethesda classification for reporting thyroid fine-neddle aspirations (FNAs), atypia of undetermined significance (AUS) is a category with limited reported follow-up and outcome data. True malignancy rate in AUS is not definitely known, because not all of them are histologically checked and also litherature reports have heterogeneous data. Therefore, this classification is grey zone for clinicians who struggle the correct therapeutic approach to thyroid nodules. In this study, our aim was to evaluate the ultrasonographic features and histopathologic results of the thyroid nodules which are defined as AUS and contribute to the therapeutic approach of these nodules.
METHODS: We evaluated 95 nodules of 92 patients, who have nodular or multinodular goiter and had diagnosed AUS at least in one nodule with fine-neddle aspiration (FNA). Patients’ thyroid function tests, ultrasonographic features of the nodules and histopathologic results were evaluated.
RESULTS: 81.1 % of patients were female, 18.9 % were male. Mean age was 47.5 ± 12.1 years. In the ultrasonographic features presence of microcalcification, border irregülarity, peripheral vascularisation and absence of hypoechoic halo was respectively 28.4 %, 47.4 %, 20 % and 60 %. 43.2 % nodules were hypoechoic and 47.4 % were solid. According to the histopathology, 63.2 % of nodules (n=60) were benign, 36.8 % (n=35) were malign. In malign nodules papiller carcinom, well-differentiated thyroid neoplasm, follicular carcinom and hurthle cell carcinom were found respectively 88.6 %, 5.7 %, 2.9 %, 2.9 %. In malign nodules mean tumour size was 1.2 ± 1.1 cm. No lymph node methastasis was found. Vascular invasion, capsular invasion, extracapsular invasion and multicentrity was positive respectively; 11.4 %, 28.6 %, 20 %, 31.4 %. According to the malign or benign histopathologic features of nodules were shown in table 1.
Table 1. Histopathologic Features of Benign and Malign Nodules
CONCLUSION: In AUS, maligancy rate is reported 25 % of operated patients, but it is thought 5-10 % of the total. In our study we found this ratio 36.8 %. Our high ratio may be due to few and heterogeneous litherature data outcomes. So, this high malignancy ratio in AUS nodules, have to be considered in the decision of operation .
AIM: In the Bethesda Classification (BC), which is used in cytopathologic evaluation of thyroid nodules, follicular lesion of undetermined significance (FLUS) does not involve sufficient cellular atypia for follicular neoplasia or malignancy, while it doesn’t comprise the cytologic benign criteria. Therefore, there is no consensus for those nodules to follow-up and therapeutic approaches. In this study, we aimed to determine the ultrasonographic features and histopathologic results of the thyroid nodules which are defined FLUS in BC.
METHODS: We evaluated 64 nodules of 62 patients, who have nodular or multinodular goiter and had diagnosed FLUS at least in one nodule with fine-neddle aspiration (FNA). Operation endication was decided upon to the nodule size, suspected ultrasonographic feature (border irregularity, solid, hypoechoic nodule, presence of microcalcification), high elastosonographic score and strain index and family history of thyroid cancer.
RESULTS: 87.5 % of patients were female, 12.5 % were male. Mean age was 46.5 ±12.6 years. 51.6 % of nodules were located in the right lobe, 45.3 % in the left lobe and 3.1 % were in the istmus. According to the echogenity and component 43.8 % of nodules were hypoechoic, 57.8 % were solid. Microcalcification, peripheral vascularisation and border irregularity positivity were respectively; 25.5 %, 17.2 % and 59.4 % of nodules. After operation, 68.7 of nodules (n = 44) were benign, 31.3 % (n = 20) were malign. In malign nodules mean tumour size was 1.4 ± 1.3 cm. Vascular invasion, capsular invasion, extracapsular invasion, multicentrity and lymph node metastasis was positive respectively; 15 %, 15 %, 5 %, 35 %, 5 %. According to the malign or benign histopathologic features of nodules were shown in table 1.
Table 1 . Histopathologic Features of Benign and Malign Nodules
CONCLUSION: In our study, we found malignancy rate 31,3 % in FLUS compared to the 5 - 20 % reported by different studies. Therefore, we think that, in the diagnostic and therapeutic approach of the FLUS nodules that challenge the clinician, this high ratio of malignancy must be kept in mind.
AIM: The Hurthle cell is characterized cytologically as a large poligonal cell with abundant eosinophilic, granular cytoplasm and a large hyperchromatic nucleus with a prominent nucleolus. Hurthle cells are present in a variety of nonneoplastic and nonneoplastic conditions involving the thyroid and are not specific for any disease process. In this study, we aimed to evaluate ultrasonographical and elastosonographical characteristics, cytological results and histopathological features of nodules in patients with Hurthle cells in cytological examination and operated for various reasons.
MATERIAL AND METHOD: Patients admitted to Endocrinology and Metabolism Out-patient Clinic in Ankara Ataturk Education and Research Hospital between June 2009 and June 2010 and detected to have Hurthle cells in thyroid fine needle aspiration biopsy (FNAB) were included in the study. 57 patient /57 nodule recruited for the study. TSH, fT3, fT4, Tg and, Anti-TPO, Anti-TgAb were studied. Thyroid US, elastosonography, ultrasound guided FNAB, is performed. 14 cytomorphologic features examined to distinguish benign Hurthle cell lesions (BHCL) from Hurthle cell neoplasms (HCN). Operation indications in nodules including Hurthle cells cytologically were large nodule diameter, compression symptoms and increase in diameter of nodules with time. Nodules with a FNAB result of Hurthle cell neoplasm were operated because of high suspicion of malignancy. Histopathological evaluation was made by the same pathologist who evaluated cytopathology.
RESULTS: There were 57 patients with a mean age of 46.12±11.69 years. Among 57 nodules with Hurthle cells in cytological examination, 49 (86%) were classified as Bethesda 1 and 8 (14%) were classified as Bethesda 3. Histopathologically, 45 (78.9%) nodules were benign and 12 (21.1%) were malignant. When nodules were grouped according to Bethesda results, nodule volume, ultrasonographic features in gray-scale and vascularization pattern were similar in two groups. There was no signicant difference in terms of elastosonographic scoring and mean strain index (SI) between groups. Elastosonography scores determined in transverse axis were found to be more predictive for malignancy compared to scores determined in longitudinal axis (p=0.023 and p=0.867, respectively). However, calculated mean SI in longitudinal and transverse axis was significantly higher in malignant tumors than benign (p<0.05) ( Table 1). Cytological features were compared in benign and malignant nodules histopathologically . Nuclear groove, transgressing blood vessel (TBV) and absence of colloid were observed with a higher frequency in malignant nodules compared to benign nodules (p<0.05). ( Table 2).
CONCLUSION: Thyroid nodules containing Hurthle cells are composed of a wide range of pathologic entities, including Hashimoto thyroiditis, Hurthle cell adenomas , Hurthle cell carcinomas , oncocytic variant of papillary carcinoma and medullary carcinoma. Nuclear groove, transgressing blood vessel and absence of colloid were observed with a higher frequency in malignant nodules compared to benign nodules. In our study , SI values of malignant nodules were significantly higher than those of benign evaluated by elastosonography . Therefore. Higher SI values obtained during elastosonographical examination in malignant nodules compared to benign nodules suggest that SI might be used as a parameter to predict malignancy. SI determined by elastosonography will reduce unnecessary operations and surgical procedures.Since malignancy rate in our patient group was 21.1%, we think total or near total thyroidectomy should be preferred in nodules with Hurthle cells in cytological examination.
Table 1. Comparision of mean elastosonographic scores and strain index values according to histopathology results
Transvers Score %
Longitudinal Skor %
Table 2. Comparative data of cytologic features of nodules according to of histopathologic results
Nuclear groove %
Aim: Neopterin is a mareker of inflammation secreted from monocytes and macrophages. It is found to be increased in malignant diseases. The aim this study was to evaluate the urine neopterin levels in thyroid cancer.
Materials and methods: Sixty nine patients with thyroid cancer, 76 patients with benign thyroid pathology and 33 healthy subjects were evaluated. First morning urine samples were collected from the patients and the normal subjects for neopterin and creatinin measurment and stored at -20°C until analyzed.
Results: Neopterin levels were 149.3 (15.2-1602.2) μmol/mol creatinin in the malignant group, 32.0 (5.2-275.6) μmol/mol creatinin in the benign group and 9.2 (2.7-78.7) μmol/mol creatinin in normal subjects. Urinary neopterin levels were significantly higher in patients with throid cancer than patients with benign thyroid pathologies and normal subjects. There was 22 (%31.9) patients with chronic thyroiditis and 47 (%68.1) patients without chronic thyoiditis in the malignant. Urinary levels of neopterin didn’t differ in both groups (168.6 (21.3-716.8) μmol/mol creatinin and 135.3 (15.2-1602.2) μmol/mol creatinin respectively,P=0.381). Patients who had capsul invasion, vascular invasion and lymph node invasion had a higher urine neopterin level although not statistically significant.
Conclusion: Urinary neopterin levels are high in thyroid cancer and this result is not affected from the presence of chronic thyroiditis.
Declaration of interest: The authors declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project.
Funding: This research did not receive any specific grant from any funding agency in the public, commercial or not-for-profit sector.
AIM: Thyroid fine needle aspiration biopsy (FNAB) is an important diagnostic methodtoevaluate thyroid nodules. In FNAB cytological examination; it is reported that 70%of nodules is benign, 4% malignant, 10%suspiciousand 17% insufficient material (non-diagnostic). Despite all this, the biopsy of thyroid nodules reported as nondiagnostic at least 2 or 3 times causes indication for the operation. We aimed to assess ultrasonographical and histopathological data of thyroid nodules with repeated non-diagnostic cytology results.
MATERIAL AND METHOD: Seventy-five patients with nodular thyroid disease were enrolled in this study. Thyroid fine needle aspiration biopsy (FNAB) results were reported as non-diagnostic at least for 2-3 times in these patients. Operation indications were large nodule, ultrasonographically suspicious nodule, high elastosonography score or strain index and family history of thyroid cancer. Demographical features of these patients and ultrasonographical features of nodules were evaluated.
RESULTS: 53 (70.7%) patients were female and 22 (29.3%) were male. There were 59 patients with multinodular goiter (MNG), 8 patients with nodular goiter (NG), 7patients with Graves disease and MNG. 45 patients (60%) were euthyroid, 25(33.3%) had hyperthyroidism and 5 (6.7%) had hypothyroidism. In 41 patients (54.7%) nodules were localized in the right lobe, while in 34 (45.3%) patients in the left lobe (Table 1). Ultrasonographically, microcalcification was found in 30 nodules (40.0%) and macrocalcification was found in 20 nodules. Irregular margins were observed in 45 (60%) nodules and hypoechoic halo was observed in 28 (37.3%) nodules. 17(22.7%) nodules had peripheral vascularization and 1 (1.3%) nodule had peripheral macrocalcification. Histopathologically 57 (76%) nodules were benign and 18 (24%) were malignant. Of malignant nodules 17 (94.4%) were papillary carcinoma, whereas 1 was follicular carcinoma. Mean tumor diameter was 0.77±0.63 (range 0.1-2.2) cm. Vascular invasion, capsular invasion, extracapsular extension and multicentricity were detected in 1 (5.6%), 5 (27.8%), 1 (5.6%) and 6 (33.3%) patients, respectively.
CONCLUSION: In our study we found the rate malignancy 24% as high for thyroid nodules which were performed FNA biopsy and reported repeated non-diagnostic cytology results. Therefore, we conclude that when treatment is planned for the patients that have non-diagnostic cytology possibility of high rate of malignancy as we found in this study may be considered.
Table 1. Ultrasonography features and histopathological findings in patients with repeated non-diagnostic cytology results
AIM: Evaluation of thyroid noduleswith ultrasound hasbeenrecently become very important. Ultrasonographically; solid nodule, hypoechogenicity, microcalcifications, macrocalsifications, border irregularity, intranodular vascularity is associated with increased risk of malignancy, In this study, we aimed to evaluate the cytological findings of the thyroid nodules in which macrocalcification is determined with ultrasonography.
MATERIAL AND METHOD: We retrospectively evaluated 907 nodules of 269 patients with nodular or multinodular goiter and macrocalcification at least in one nodule. The nodules without macrocalcifications in the same patients were taken as the control group. Thyroid function tests, ultrasonographical features and cytological results of the nodules were evaluated in all subjects. Cytological findings are classified as benign, non-diagnostic, suspicious and malignant.
RESULTS: There were 215(79.9%) female and 54(20.1%) male patients. Macrocalcification was present in 420 nodules (Group1). No macrocalcification was observed in 487 nodules (Group 2) (Table-1). Group 1 was furtherly divided into two groups. Group 1A: nodules with peripheral macrocalcification (n=53) and group 1B: nodules with intranodular macrocalcification (n=367). Mean nodule size in group 1A, 1B and 2 were 12.94±6.26 milimeter (mm), 25.50±14.27 mm and 15.72±7.53 mm, respectively (p<0.001)(Table-2). In ultrasonography, prevalence of peripheral irregularity and presence of halo were similar in Group 1 and 2. Microcalcification was observed in 61.4% of nodules in group 1 and 17.5% of nodules in group 2 (p<0.001). Rate of solid nodules was significantly lower in group 1 compared to group 2 (11.7% vs 49.9%, p<0.001). We observed that malignant and suspicious cytology results were significantly higher in group 1 compared to group 2 (p=0.004 and p=0.003, respectively) (Table- 1). In group 1A, only rate of suspicious cytology results was higher than group 2 (p=0.010) (Table 2). In group 1B, both suspicious and malignant cytology results were higher compared to group 2 (p=0.007 and p=0.003, respectively) (Table- 3).
CONCLUSION: This study showed that presence of macrocalcification and particularly presence of intranodular macrocalfication was associated with higher malignant and suspicious cytology results. We think presence of macrocalcification in ultrasonography should not be always taken in favour of benignity in contrast to the usual opinion and FNAB should also be performed in these nodules.
Table 1. Comparison of thyroid nodules with and without macrocalcifications
Table 2. Comparison of thyroid nodules with peripheral macrocalcifications and without macrocalcification
Table 3. Comparison of thyroid nodules with intranodular macrocalcifications and without macrocalcifications
INTRODUCTION: Radioactive treatment after surgery forms the basis of treatment of differentiated thyroid cancers (DTC) and also used as permanent theraphy of hyperthyroidism. Iodide is being transported into the thyrocytes by the NIS system that located on the thyrocytes' cell membran.NIS system also has been shown at the gastric mucosa. H. pylori prevalence of 90% in developing countries, as well as the wide variety of drugs are given intensive treatments because of high morbidity. In addition, the development of resistance for antibioticis is now common and frequent recurrence so researchers has led to finding new and more effective treatment. In this study we proposed to analyse the effect of low and high dose radio-iodine treatment on helicobacter pylori eradication.
MATERIAL AND METHOD: Total 87 patients included for study. The patients investigated detailed about medications and gastrointestinal symptoms Patients have neither dyspeptic symptoms nor any usage of H2 receptor bloker,proton pump inhibitor,antiasit or any form of antibiotics. Undergoing gastric surgery were excluded . Urea breath test before and 2 months after radio-iodine treatment have been made for detection of Helicobacter pylori eradication.
FINDINGS: The radio-iodine treatment has been planned to give as permanent threapy to 76 patient (%87,4) with hyperthyroidism and 11 patient(%12,6) with differantial thyroid cancer. The average dose of given radio-active iodine to patients for ablation purposes is 115±3.3 mCi and 22.7±1.4 mCi. Before RAI treatment,in the group of DTC the urine breath test (UBT) result of the 44 patients had positive HP and 32 of them had negative HP, and for hyperthyroid patients 4 of them had positive HP and 7 of them had negative HP. All patientshaving initial positive test results, had also Positive control test results at the 2nd month of the RAI treatment(%100). (Table 1). Both patient group having initial negative test results, had also negative control test results (Table 1).
Table 1. Rodyoaktif iodine-treated patients before and after treatment of urea breath test (UBT) results
After treatment UBT
The frequency of H. pylori in developing countries has been increasing steadily. Development of resistance to the treatments and frequent recurrences due to explored ways to more effective treatment. There are some literature studies show that RAI treatment is effective on HP eradication. Our results indicate that low and high dosage of RAI treatment does not have any effect on HP eradication in early period.
AIM: In this study, we aimed to evaluate thyroid functions, thyroid antibody positivity, thyroid ultrasonography (US) findings and prevalance of thyroid cancer in patients with colon cancer and benign colon polyps. Also, we aimed to compare prevalance of thyroid diseases in two groups.
MATERIAL AND METHOD: This study was designed as a prospective study by Department of Endocrinology and Metabolism Clinic in Ankara Ataturk Research and Education Hospital. 57 patients with colon cancer and 50 patients with colon polyps that were referred from gastroenterology and medical oncology clinics between October 2010-January 2011 were included in the study. Patients with colon cancer were operated previously, followed in remission and were not taking chemotherapy or radiotherapy actively. Colon polyp group included patients diagnosed to have polyps during routine colonoscopy examination. In two groups, TSH, FT3, FT4, anti-TPO and anti-Tg antibodies and Tg were measured. All patients were evaluated with thyroid US and thyroid fine needle aspiration biopsy (FNAB) was performed in indicated nodules. Cytology results were classified as benign, nondiagnostic, suspicious and malignant.
RESULTS: There were 57 (53.27%) patients with colon cancer (22 female, 35 male) and 50 (46.23%) patients with colon polyps ( 17 female, 33 male). There was no difference in terms of age and sex distribution between groups (p=0.622 and p=0.529, respectively). Ultrasonographically, nodular and multinodular goiter was observed in 30 (52.63%) patients with colon cancer and 29 (56%) patients with polyp. Thyroiditis was observed in 14 (24.56%) patients with colon cancer and 16(32%) patients with polyp (Table 1). FNAB is performed to 23 patients with colon cancer and 14 patient with colon. FNAB is performed to cytology was reported as malignant in 1 patient with cancer and in 1 patient with polyp. In these 2 patients and in another colon cancer patient with suspicious FNAB result, thyroid cancer was confirmed histopathologically. Presence of thyroid disease defined as thyroid dysfunction or positive antithyroid antibody or presence of nodule or thyroiditis in US was found in 44 (77.19%) patients with cancer and 44 (88.0%) patients with polyp (p= 0.228 ).
Table 1. Thyroid ultrasonography findings according to colon pathologies
CONCLUSION: This study showed that thyroid dysfunctions, thyroid US findings and prevalance of thyroid cancer are similar in patients with colon cancer and colon polyps. Since thyroid pathologies are observed in more than 2/3 of patients in both groups, we think laboratuary examinations for thyroid functions and thyroid antibodies and thyroid US should be a part of investigation in patients with colon cancer and colon polyps.
AIM: Antineutrophil cytoplasmic antibody (ANCA) positivity is usually determined in medium and large vessel vasculitis. This antibody has two different forms. Cytoplasmic ANCA (PR3-ANCA) occurs against proteinase -3, while perinuclear ANCA (MPO-ANCA) occurs against myeloperoxidase and bactericidal-permeability increasing proteins. The presence of ANCA is mostly seen in systemic vasculitis and also in drug induced vasculitis. There is no sufficient data about prevalance of positivity ANCA and development of antithyroid antibodies after treatment. In this study our aim was to investigate MPO-ANCA and PR3-ANCA levels in Graves patients using propylthiourasil (PTU)..
MATERIAL AND METHOD: 52 Graves patients (9 men,41 women) using PTU and 37 healthy control group were included in the study. TSH , fT3, fT4, anti TPO, anti Tg, tiroglobulin (Tg), MPO-ANCA ve PR3-ANCA levels of patients and control groups were evaluated.
RESULTS: Mean level of PR3-ANCA in Graves group was significantly higher than control group (p=0.025). No significant difference was found between levels of MPO-ANCA (p=0.109) ( Table-1). Positive correlation was observed between Anti-TPO, AntiTG with PR3-ANCA in patient group (respectively, p=0.001, r=0.447; p=0.030, r=0.310). No correlation was observed between Anti-TPO, AntiTG with MPO-ANCA. No correlation was observed between TSH, fT3, fT4, Tg levels with MPO-ANCA and PR3-ANCA. Longer duration of treatment in the patient group showed increased levels of PR3-ANCA (p=0.024, r=0.314). Positive anti-Tg was detected in 33 patients with Graves' disease (anti-Tg> 4.11 IU/ml) and in 10 patients in the control group. PR3-ANCA levels in anti-Tg positive patients were higher than those with negative (p=0,006). Positive anti-TPO was detected in 34 patients with Graves' disease (anti-Tg> 5.61 IU/ml) and in 6 patients in the control group. There was no statistically significant difference forMPO-ANCA and PR3-ANCA levels between Anti-TPO-positive and negativecases. MPO-ANCA and PR3-ANCA were positive in two Graves patients while only MPO-ANCA positive in two patients. ANCA positivity in Graves' patients was detectedto be 7.6%.In the control group of patients there were nopositive MPO-ANCA and PR3-ANCA patients.
Table 1: Comparison of laboratory values of the groups
Graves group (n=52)
Control group (n=37)
Anti TPO (IU/ml)
Anti Tg (IU/ml)
CONCLUSION: PTU may cause ANCA positivity but vasculitis not develop in all cases. ANCA positivity mechanism due to PTU is unknown. PTU related ANCA positivity is reported 4.1-64%. In our study PTU induced ANCA positivity rate in patients with Graves' was 7.6%. There are publications reporting the correlation between ANCA production and duration of treatment with PTU and thyroid autoantibodies. In our study we also detected correlation between ANCA production and duration of treatment with PTU and thyroid autoantibodies. In our study, higher ANCA levels were found in Graves patients recieving long term PTU treatment.
AIM: Hypogonadism occurs as a result of testicular failure and/or insufficient pituitary stimulation. Various hypothalamo-pituitary abnormalities or lesions can contribute to hypogonadism. Benign or malignant tumoral lesions of cellar or paracellar region may be associated with hypogonadism. Therefore, patients with hypogonadism should be evaluated with pituitary magnetic resonance imaging (MRI). In this study, we aimed to investigate hypothalamo-pituitary MRI findings in patients with hypogonadism.
MATERIAL AND METHOD: Forty nine patients with hypogonadism followed in our clinic were included in the study. Pituitary MRI findings in these patients were evaluated retrospectively.
RESULTS: There were fourty two (79.4% ) patients with hypogonadotrophic hypogonadism and seven (20.6%) patients with hypergonadotrophic hypogonadism. 80.9% of patients with hypogonadotrophic hypogonadism were male and 19.1 % were female. Distribution of pituitary MRI findings of these patients were as follows: 59.5% normal, 16.7% pituitary microadenoma, 11.9% partial empty sella, 4.7% pituitary macroadenoma, 2.4% empty sella, 2.4% ectopic neuropituitary, and 2.4% empty sella and ectopic neuropituitary (Table 1). In the hypergonadotrophic group all of the patients were male. In this group pituitary MR findings were normal in 71.4%, ectopic neuropituitary in 14.3% and pituitary microadenoma in 14.3% (Table 1).
CONCLUSION: In half of the patients with hypogonadotrophic hypogonadism, Pituitary MRI findings may be normal. In these patients, if clinic and laboratory results are harmonious, to determine the diagnosis dynamic tests are required and appropriate therapy must be done, even if pituitary MRI is normal. In the hypergonadotrophic hypogonadic patients, although etiology is not associated with hypothalamus and / or pituitary gland, we can find pathologic pituitary MRI results. So, we suggest, to carry out hipothalamo-pituitary imagining with hypergonadotrophic patients.
Table 1. Hypothalamo-pituitary MRI findings in patients with hypogonadism
PITUITARY MRI FINDINGS
N = 42
N = 7
Partial Empty Sella
Ectopic neuropituitary,Empty Sella
Aim: The relationship between hyperprolactinoma and insulin resistance has been shown in many studies. It is also known that hyperprolactinoma causes changes in carbohydrate and lipid metabolism. The aim of our study is to evaluate insulin resistance in patients with prolactinoma and see the effect of treatment on insulin resistance and karotis intima media thickness (CIMT).
Material and methods: Twenty-two female patients diagnosed biochemically and radiographically with prolactinoma were included in the study. None of the patients were treated previously. Median age of the patients was 30.0+- LDL-cholesterol, HOMA score, prior to treatment and 6 months after starting treatment. The body mass index (BMI) was measured and CIMT was evaluated for each patient prior to and 6 months after the treatment.
Conclusion: Treatment with cabergolin causes decrease in HOMA score and decrease in CIMT after 6 months of treatment independant from the decrease in BMI.,
Results: The prolactin levels before and after treatment was 145.5+-66.4 and 12.4+-7.2 μg/l respectively (P<0.001). This decrease was not related to the decrease in BMI(r=-0.057, P=0.808). HOMA score before and after treatment was 1.25 (0.22-4.5) and 1.02 (0.24-4.1) respectively (P=0.024). This decrease was not related to the decrease in prolactin levels (r=-0.248 vs P=0.279). Homocystein levels before and after treatment was 13.8 (7.0-28.0) and 8.5 (2.3-26.4) (P<0.001) respectively. CIMT before and after treatment was 0.58+-0.15 and 0.52+-.12 (P<0.05) respectively. The decrease in CIMT was not found to be related with the decrease in prolactin levels, HOMA score and BMI (r=0.250, P=0.274).
Declaration of interest: The authors declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project.
Funding:This research did not receive any specific grant from any funding agency in the public, commercial or not-for-profit sector.
AIM: Obesity is quickly growing health problem and associated with many comorbid disease. One of them is abnormalities seen in calcium metabolism. It is reported that vitamin D deficiency can be seen in obese people. It is thought that Vitamin D deficiency can effect insulin sensitivity and can be a risk factor for impaired glucose tolerance (IGT) and diabetes mellitus (DM). Parathormone (PTH) increase seen in obese people can be attributed to vitamin D deficiency but there are some publications report that PTH increase is independently related with obesity. In this study our aim was to investigate the relationship between obesity and vitamin D and hyperparathyroidism.
MATERIAL AND METHOD: 127 healthy persons included in this study and anthropometric measurements were performed. Body fat mass and fat percentage is determined. Study group were divided into four groups according to body mass index. Group 1 (n=35) BMI 18,5-24,9 kg/m², Group 2 (n=35) BMI 25-29,9 kg/m², Group 3 (n=35) BMI 30-34,9 kg/m², Group 4 (n=22) BMI 35-40 kg/m². Serum calcium (Ca), phosphorus (P), parathormone (PTH), 25(OH)D, fasting glucose and fasting insulin levels were evaluated.
RESULTS: Antropometric measurements of the groups are listed in Table-1andlaboratory dataarelisted in Table-2. Serum Ca levels of Group 2 were significantly higher thanGroup 3 and Group 4, respectively (p= 0.049 and p=<0.001). Vitamin D levels of Group 4 were significantly lower than group 2 (p= 0.033). In all groups, fasting glucose and fasting insulin levels showed a statistically significant increase with the increase ofwaist circumference (respectively, p= 0.004, r= 0.254 and p= 0.001, r= 0.290). Statistically significant decrease in waist circumference was observed with increasing vitamin D levels (p = 0.049, r = -0.178),but serum Ca decreasewas not statistically significant. With the increase in BMI,statistically significant increase were determined in fasting glucose and fasting insulin levels (respectively, p= 0.001, r= 0.296 and p= 0.003, r= 0.259)while significant decreasewere determined in serum Ca and vitamin D levels(respectively, p=0,040, r=-0,181 ve p= 0,016, r= -0,214). Negative correlation was determined betweenbody fat massand serum Ca and vitamin D levels(p= 0.021, r= -0.204, p= 0.026, r=-0.199), whereas no significant correlation was determined between body fat massand PTH levels. Fasting glucose levels showed a statistically significant increase with increasing serum Ca levels(p=0.010, r=0.226)while no significant correlation was determined between fasting glucose levels and P, PTH and vitamin D levels.
CONCLUSION: The literature suggests that low vitamin D levels in obesity is negative correlated with BMI, waist circumference and fat mass. In our study, significant decrease was observed in vitamin D and serum Ca levels while body fat mass. Statistically significant decrease in the level of vitamin D was determined with increasing waist circumference although there was no significant reduction in serum Ca levels. Negative correlation was observed between body fat mass and serum Ca and vitamin D levels. The findings of our study support that there is a negative correlation between vitamin D levels and waist circumferance and body fat mass. There are publications indicating that increase in PTH isnt depending on decrease of vitamin D, it is directly associated with obesity. But in our study there was no association between obesity and PTH levels. It is tought that vitamin D deficiency may be a risk factor for IGT and DM and can affect insulin sensitivity. However, in our study no significant relationship was observed between fasting glucose levels and vitamin D levels. In conclusion, our results support the view that vitamin D deficiency in obese individuals isn’t related with insulin resistance.
Table 1:Antropometric measurements of the groups
Fat mass (kg)
Fat percentage (%)
Table 2: Laboratory results of the groups
Fasting glucose (mg/dl)
Serum P (mg/dl)
INTRODUCTION: Measles virus infections generally occur in childhood, but infections in adolescence and adulthood can lead to complications. Here we present an adult patient with positive measles serology who was diagnosed with new onset type 1 diabetes and bilateral facial paralysis.
CASE: A previously well 28-year-old woman had suffered from fever, nausea, vomiting and generalized fatique for one day before being transferred to our emergency department in a confused state. Physical findings on admission were height 150 cm and body weight 88 kg, with a body mass index of 39 kg/m2. She had a fever of 38 Celsius degrees. Laboratory data on admission are demonstrated in Table 1. She was treated by intravenous infusion of saline and insulin and eventually switched to intensive insulin therapy four times a day. On the second day of hospitalisation she developed weakness on both sides of her face. On physical examination, there was bilateral facial nerve paralysis. An electroneuromyography demonstrated bilateral axonal neuropathy of the facial nerve and confirmed the diagnosis. We performed serological testing for several viral antibodies. The results revealed significant elevation of the measles IgM and IgG titers but no abnormal results were shown in any of the other serological tests (Table 2). One week later, the patient’s facial weakness had improved spontaneously with no residual weakness.
Table 1. Laboratory data on admission.
Complete Blood Count
23.4 x 104/µl
Arterial Blood Gas Analysis on 2 L/min oxygen by mask
Table 2. The results of serological testing for viral antibodies (IU/ml)
Varicella zoster virus
Herpes Symplex virus
Data on T1DM comes from the Swedish Childhood Diabetes Study which showed a significantly higher rate of children who developed diabetes and were not vaccinated against measles. The authors hypothesized that measles vaccine could have a protective effect or that measles infection could be a diabetogenic agent. The differential diagnosis of the causes for bilateral facial paralysis covers a wide field, including genetic, infectious, traumatic, neoplastic, metabolic, neurological, vascular, iatrogenic and idiopathic etiologies. Measles is not among the well documented infectious etiologies but three adult patients with acute renal failure and bilateral facial paralysis have been reported. Our patient had an atypical presentation of measles, as expected in adults, because of fever and positive measles IgG and IgM antibodies. Our case is interesting due to coexistence of bilateral facial paralysis, new onset T1DM and positive measles serology. And there is not a similar case in the literature. Although there are limitations with respect to the true relation between measles and these two manifestations, this clinical picture should be kept in mind as a possible atypical presentation of measles infection in adults.
INTRODUCTION: Hypertrygliceridemia is responsible from 1-4% of all acute pancreatitis cases. Risk of pancreatitis increases if plasma tryglyceride levels are above 1000-2000 mg/dl. Medical therapy is usually insufficient for cases of hyperlipidemia with serious and recurrent pancreatitis attacks. Here,we have reported a case of recurrent pancreatitis due to hypertriglyceridemia which was resistant to medical treatment and could be effectively controlled with single time plasmapheresis therapy
CASE: 45 years old female patient has been referred to our endocrinology clinics because of hypertrygliceridemia. We have learned from the history of the patient that she had underwent cholecystectomy in an another hospital in 2005 to which she had admitted with the complaints of abdominal pain and diagnosed to have acute billiary pancreatitis. After cholecystectomy she had to be hosptalized in almost every 2-3 months because of recurrent pancreatitis attacks. Hypertyglyceridemia was recognised in the detailed routine laboratory tests. Her plasma triglyceride level was above 2000 mg/dl despite she has received gemfibrosil and fenofibrate alternately since March of 2006 and she had her last pancreatitis attack one month before her referral to us. In our clinics, the patient’s liver enzymes, serum acute phase reactants (crp), serum amylase and lipase levels were found to be normal. The patient’s serum triglyceride level was 9000 mg /dl and she has received single time plasmapheresis therapy in volume of 4 liters and in exchange of albumin. One day after single-time plasmapheresis her trigyceride level has decreased to 600 mg/dl and on the third day it was 400 mg/dl.Patient has been discharged with fenofibrate therapy.
RESULTS: Acute pancreatitis occuring secondary to hypertriglyceridemia is generally treated with agressive hydration and pain control and its prognosis is not different from the others. Serious or recurrent pancreatitis can be indications for plasmapheresis. Plasmapheresis is able to reduce serum triglyceride levels effectively and it also removes serum active enzyme, proteases and proinflammatory molecules from the circulation. Altough there are reports about the effectiveness of plasmapheresis in prevention of recurrent pancreatitis attacks , there is no consensus about the appropriate frequency and number of plasmapheresis which should be applied to a patient with high triglyceride levels. In our case after single time plasmaphersis and fenofibrate therapy, our patient’s triglyceride level has returned to the normal range and she hasn’t had any recurrent attacks for the four months. We have thought that plasmapheresis is cost effective because it reduces the need for hospitalization.
Table 1.LABORATORY TEST RESULTS
AIM: Primary hyperparathyroidism (PHP) is a disease characterized by hypercalcemia and accompanying with increase in parathyroid hormone (PTH) levels. In this study our aim was to evaluate clinical and laboratory findings of our primary hyperparathyroid patients and detect complications caused by hyperparathroidism.
MATERIAL AND METHOD: 83 primary hyperparathyroid patients (73 women,10 men) were included in this study. Serum calcium (Ca), phosphorus (P), parathormone (PTH), 25(OH)D, 24 hour urine Ca and P levels, bone mineral density and renal ultrasonography were evaluated.
RESULTS: The mean age at diagnosis was 52.4±9.6 years. Laboratory values of patients are summarized in Table-1. Hypercalciuria was detected in 27 patients (%32.5) while nephrolithiasis was determined in 17 patients (%20.5). In 16 patients (%19.3) BMD was normal. In 31 patients (%37.3) osteopenia, in 36 patients (%43.4) osteoporosis was determined. Vit D deficiency was found in 38 patients (%45.8). 9 patient (10.8%) had normal thyroid ultrasonography, 23 patient (27.7%) had chronic thyroiditis, 11 patient (13.3%) had nodulary goitre and 40 patient (48.2%) had multinodulary goitre. With these results operation were recomended to 44 patients (%47). In 3 patients atypical parathyroid adenoma and in 4 patients (16%) incidental papillary thyroid microcarsinoma were detected in histopathological evaluation.
Table 1: Laboratory data of our patients
Serum Ca(mg/dl )
25-OH vitamin D3 (µg/l )
24 hour Ca (mg/day)
CONCLUSION: In recent years primary hyperparathyroidism is detected in asymptomatic phase and fewer complications are found. In 70-80% of PHP patients no symptoms and signs are observed. They are detected incidentally only with the hypercalcemia. The most common finding in symptomatic patients is nephrolithiasis. Overt skeletal disease is rare but incidence of osteoporosis-related fracture is increasing. We detected nephrolithiasis in 20.5% patients, osteopenia in 37.3% and osteoporosis in 43.4% of patients. Frequently seen vitamin D deficiency and elderly patients may have contributed to the high prevalence of osteopenia and osteoporosis. The risk of multigland involvement and bigger adenoma is higher in cases accompanied by a lack of Vitamin D. In our study, vitamin D deficiency was observed in 45.8% of PHP patients. Thyroid malignancies accept medullary thyroid carcinoma are reported in 2.1-4.3% of patients who were operated for PHP. In our study, 16% incidental papillary microcarcinoma was detected.
AIM: In recent years, primary hyperparathyroidism (PHP) is frequently detected in asymptomatic patientsdue to the routine measurement of serum calcium (Ca) levels.As a result of this; metabolic effects cause increased cardiovascular morbidity began to gain importance instead of the classic signs in PHP patients. There are publications showed the increasedincidence of insulin resistance, impaired glucose tolerance (IGT), anddiabetes mellitus (DM)in PHP. In this study our aim was to investigate frequency of impaired glucose tolerance, undiagnosed diabetes mellitus and presence of insulin resistance by HOMA.
MATERIAL AND METHOD: 55 primary hyperparathyroid patients (50 F, 5 M ) without known glucose tolerance were included in this study. The control group (52 F,3 M) was with similar BMI, normocalcemic, without known glucose tolerance. Serum calcium (Ca), serum phosphorus (P), parathyroid hormone (PTH), vitamin D, fasting glucose and fasting insulin levels were measured in PHP patients and the control group. 75 gr oral glucose tolerans test (OGTT) was performed to PHP patients and control group. Second hour glucose and insulin levels were measured in theOGTT.Insulin resistance was calculated by HOMA-IR (fasting glucose (mg/dl) x fasting insülin (mU/l)/ 405).
RESULTS: There was no significant differences between PHP and control group according to the fasting glucose, fasting insulin and HOMA-IR levels. Second hour glucose and insulin OGTT value were significantly higher than control group (respectively, p= 0.001, p= 0.020) (Table-1). While IGT was detected in 6 PHP patients (11.3%), there is no IGT in control group (p= 0.013). Diabetes mellitus (DM) didn’t detected in OGTT in PHP patients. In PHP group there were positive corelation between Ca levels and fasting plasma glucose (p= 0.005, r= 0.376). There was no statistical corelation between serum Ca levels and fasting insulin levels and HOMA-IR. In PHP group there was negative corelation between PTH levels and vitamin D levels (p= 0.023, r= -0.306) while there was no corelation between PTH and fasting glucose and fasting insulin levels and HOMA-IR. In PHP group there was negative corelation between vitamin D levels and fasting glucose (p= 0.040, r= -0.278). There was no statistical corelation between vitamin D levels and fasting insulin levels and HOMA-IR. Mean serum Ca level (11,16±0,76 mg/dl) of BGT group was statistically higher than non BGT group’s serum Ca levels (10,35±0,78 mg/dl) (p= 0.020).
CONCLUSION: PHP is considered to change glucose tolerance by decreasing insulin sensitivity. There are publications reporting increased frequency of BGT and DM in PHP. In our study we verified the increased frequency of BGT in PHP patients and the prevalance of BGT was 11.3%. But we didn’t found DM in OGTT and no increased insulin rezistance. In our study we observed positive corelation between serum Ca levels and fasting glucose. Serum Ca levels were higher in BGT group than non BGT group. This situation support the opinion of risk factor of serum Ca in glucose metabolism. It is reported that vitamin D defiency could be risk factor for BGT and DM and can effect insulin sensitivity. In our study we found negative corelation between vitamin D levels and fasting glucose in PHP group. This suggest that vitamin D defiency can effect glucose metabolism. As a result frequency of BGT is increased in PHP patients. Increase in serum calcium levels effect the glucose metabolism and cause glucose intolerance.
Table 1: Laboratory results of the groups
Serum Ca (mg/dl )
Serum P (mg/dl )
Fasting glucose (mg/dl)
OGTT second hourglucose (mg/dl)
OGTT second hourinsülin (uIU/ml)
OBJECTIVE: We aimed to find out whether the presence of Hurt-hle cells alters the expected Bethesda distribution and neoplasia rate.
METHOD: From 8720 FNAC reports, made between January 2009 and October 2010, cytology reports containing Hurthle or oncocytic cells were evaluated. The Bethesda distributions were noted and compared with thyroidectomies.
RESULTS: Nine hundred and fourteen patients with 953 FNACs (10.93% of total FNACs) were found. Of the 895 diagnostic nod-ules, 764 (85.36%) were benign, 86 (9.6%) AUS/FLUS, 32 (3.5%) SFN, 12 (1.34%) SFM and one (0.11%) malignant. This Bethesda distribution was different to the distribution of our 2-year diagnos- tic FNAC series without Hurthle cells (P < 0.001). This difference was due to a decrease in benign and increase in AUS/FLUS and SFN group ratios (P < 0.001 for all).One hundred and twenty-eight cases had thyroidectomy; 35 (27.3%) were neoplastic and 93 (72.7%) were benign. Among neoplastic nodules, 3 were Hurthle cell carcinoma, 8 Hurthle cell adenoma, 17 papillary thyroid carci-noma, 3 papillary microcarcinoma, 3 follicular carcinoma and 1 well-differentiated thyroid carcinoma. Twenty-two of the benign nodules were Hashimoto thyroiditis and 71 MNG with Hurthle metaplasia. On cytopathological correlation, 9.3% of benign, 46.2% of AUS/FLUS and 70.0% of SFN diagnoses had neoplastic matching nodules on thyroidectomy. On cytopathological correlation of our whole FNAC series of 2 years, neoplastic ratios of benign nodules were 6.3%, of AUS/FLUS 31.5%, and of SFN 45.0%.
CONCLUSION: We found that the distribution of Bethesda classiÞca-tion is changed when Hurthle cells are present. Benign, AUS/FLUS and SFN groups also have increased corresponding neoplastic nod-ules. According to our results, Hurthle cells in FNAC may be a mar-ker of increased incidence of neoplasia.
OBJECTIVE: Our aim was to correlate the Bethesda classiÞcation of thyroid FNAC with thyroidectomy results.
METHOD: Between Janurary 2009 and October 2010, 582 patients had thyroidectomy. From these patients 2222 nodules had been sampled with US-guided FNAC before operation. We compared Bethesda class with histopathologic diagnosis of each corresponding nodule.
RESULTS: Among 2222 nodules in 582 patients 1136 (51.1%) were benign, 130 (5.9%) AUS/FLUS, 40 (1.8%) suspicious for follicular neoplasia (SFN), 62 (2.8%) suspicious for malignancy (SFM), 26 (1.2%) malignant and 828 (37.3%) non-diagnostic including cyst ßuids and thyoiditis. Thyroidectomy diagnosis were grouped into benign and neoplastic categories which include follicular adenoma, follicular carcinoma, Hu¬rthle cell adenoma, Hu¬rthle cell carcinoma, medullary carcinoma, papillary carcinoma, papillary microcarcino-ma, well differentiated thyroid carcinoma, well differentiated thy-roid neoplasm of uncertain malignant potential.Neoplastic lesions were found in 6.3% with benign FNAC, and 31.5% with AUS/ FLUS, 45.0% with SFN, 80.6% with SFM, 96.2% malignant and 7.9% with non-diagnostic FNAS. Forty-seven neoplastic lesions in 45 thyroidectomies did not have previous FNAC: 43 papillary mi-crocarcinomas, three papillary carcinomas and one well differenti-ated carcinoma giving an incidental malignancy rate of 7.7%.
CONCLUSION: We believe that less than expected amount of malig-nancy in our series is due to higher incidence of US-guided FNACs in our center. Our results show a malignancy risk of AUS/FLUS
OBJECTIVE: We investigated whether detailed cytomorphological examination differentiates benign and neoplastic nodules in pres-ence of Hu¨rthle cells.
METHOD: Between January 2009 and October 2010, 128 cases with Hu¨rthle cells in thyroid FNAC had thyroidectomy. The thyroid FNACs were reviewed for cytological features and patterns. Results were compared with thyroidectomy.
RESULTS: Presence of binuclear cells (p=0.014), macronucleoli (p=0.023), large cell dysplasia (p=0.038), small cell dysplasia (p<0.001), nuclear budding (p<0.001), increased ratio of nuclear enlargement (p=0.017), cellular discohesion (p=0.001) and Hurthle cells (p=0.004) were more in neplastic nodules. Increased colloid (p=0.015) and lymphocyte (p=0.018) ratios were more in benign nodules. Presence of capillaries, transgressing vessels, ratios of cellularity and macrophages were no different between benign and neoplastic nodules. In multivariate analyses, the likelihood of corresponding neoplastic nodules increased 4.20 times in the presence of nuclear budding (P = 0.016), 7.05 times in the presence of small cell dysplasia (P = 0.005) and 5.83 times in the presence of cellular discohesion in more than 50% of cells (p=0.033). A microfollicular-rich pattern was not observed in Hu¨rthle cell nodules but was in follicular neoplasms; a pleomorphic nuclear pattern was common in papillary thyroid carcinoma; and a macrophage-rich pattern only in multinodular goitre.
Conclusion: We found that detailed cytomorphological examina-tions are likely to predict histomorphological outcome, especially in the presence of nuclear budding, small cell dyplasia and cellular discohesion. We conclude that if clinical and radiological features are also added, histopathologic outcome of FNAC with Hu¨rthle cells can be predicted even more precisely.
OBJECTIVE: We aimed to determine our atypical/follicular lesion of undetermined significance (AUS/FLUS) rate and outcome.
METHOD: Between January 2009 and October 2010, among 7658 patients with 19 569 nodules, 524 (2.7%) nodules were diagnosed as AUS/FLUS. After exclusion of patients with simultaneous nod-ules that were suspicious for follicular neoplasm or malignancy and that were malignant, 368 (4.8%) patients were diagnosed as AUS/ FLUS. These US-guided FNACs were matched with repeat FNACs and thyroidectomies.
RESULTS: Seventy-two (19.6%) of 368 patients had directly under-gone thyroidectomy for suspicious radiological or clinical features. Among these 27 (37.5%) had neoplastic nodules: five follicular adenomas, two follicular carcinomas, nine papillary microcarcino-mas, 10 papillary carcinomas and one well differentiated thyroid neoplasm of undetermined malignant potential. Seventy-four (20.1%) of 368 patients had repeated FNACs: on the second FNAC, 47 (63.5%) were benign, three suspicious for follicular neoplasm, one malignant and 23 (31.1%) non-diagnostic. None had AUS/ FLUS diagnosis on second FNAC; but two had AUS/FLUS in a third and one in a fourth. Sixteen (21.6%) of patients with repeated FNAC had thyroidectomy. All had benign or non-diagnostic nod-ules in subsequent FNACs: three were neoplastic (one papillary mi-crocarcinoma, one follicular carcinoma and one follicular adenoma) on thyroidectomy. Eight patients with second FNACs are on follow up without thyroidectomy or another FNAC. Overall 88 of 368 patients had undergone thyroidectomy and 30 (34.1%) were found to be neoplastic.
CONCLUSION: Our AUS/FLUS rate was below the expected maxi-mum. However our overall neoplastic rate of AUS/FLUS on follow up (34.1%) was higher than expected.
Introduction: Type 1 diabetes mellitus (DM) is frequently associated with other autoimmune diseases. In this study, we aimed to evaluate thyroid autoantibodies, celiac antibodies and antiparietal antibody in patients with type 1 DM.
Methods: Thyroid antithyroid peroxidase (anti-TPO) and antithyroglobulin (anti-Tg) antibodies, antiinsulin, antiislet cell and anti-glutamic acid decarboxylase (antiGAD) antibodies, antiparietal antibody, antiendomisium, antigliadin IgA and IgG antibodies were obtained from the records in patients diagnosed and followed with type 1 DM in our clinic. Also, thyroid functional status and serum vitamin B12 levels were evaluated. In available patients, thyroid ultrasonography (US) findings were recorded.
Results: One hundred and sixty-one patients with type 1 DM were included in the study. Antibodies related to type 1 DM were obtained in 117 patients and 63 (53.80%) had positive anti-GAD, 4 (3.42%) had positive antiinsulin, 13 (11.11%) had positive antiislet cell antibodies. Thyroid functions were normal in 138 (85.71%) patients, 18 (11.18%) had hypothyroidism and 5 (3.11%) had thyrotoxicosis. Anti-TPO antibody was positive in 55 (34.16%), Anti-Tg was positive in 31 (19.25%) patients, and in 58 (36.02%) patients at least one of these antibodies was positive. Thyroid US was performed in 113 patients, 59 (52.21%) had normal thyroid US findings, 49 (43.37%) had chronic thyroiditis with or without nodules, 18 (15.93%) had solitary or multiple nodules. Celiac antibodies were positive in 15 (14.42%) of 104 patients. Among 77 patients with available antiparietal antibody, it was positive in 9 (11.69%) and negative in 68 (88.31%) patients. Forty-six (28.57%) patients had vitamin B12 levels lower than 250 pg/ml.
Conclusion: Autoantibodies related to various diseases may be observed with high frequency in patients with type 1 DM. It seems reasonable to screen for concomitant thyroid diseases, celiac disease and vitamin B12 deficiency by measuring specific antibodies in a patient newly diagnosed with type 1 DM.
We have presented two cases of allergic reactions developed due to usage of insulin aspart.
CASE 1: 40 years old female patient has admitted to emergency with diabetic ketoacidosis. Parenteral hydration with saline solution and insulin infusion has been given to her in ER. After ketoacidosis picture has improved, mixture of insulin asparte and insulin asparte protamine was started as maintenance therapy. After the application of second insulin dosage, itchy and erythematouspapulopustular lesions have developed all over the patient’s body. Therapy with insulin analogue was terminated immediately and human insulin was started instead. Punch biopsy was performed from the lesions. According to the pathological examination the diagnosis of Ig E mediated allergic reaction has been made. Right after corticosteroid and antihistaminic therapy was started, the lesions regressed and disappeared.
CASE 2: The second patient is 75 years old female patient who has admitted to emergency department of our hospital with hematuria, erythematous papulopustular lesions and distruption of general well being. Ten days before this clinical picture developed, intensive therapy with insulin aspart and insulin detemir had been prescribed to patient for blood sugar regulation. We have stopped analogue insulins and started human insulin. We have performed punch biopsy from the skin lesions. Biopsy result was compatible with leucocytoclastic vasculitis. We have started glucocorticoid and antihistaminic therapy immediately however the patient has died because of the concomitant acute renal failure picture.
CONCLUSION: Allergic reactions occurring due to insulin injection may present with localized or systemic reactions. Systemic allergic reactions might be IgE mediated, anaphylactic or due to IgG mediated insulin resistance or rarely it might show itself with the clinical picture of serum sickness. Although analogue insulins have reduced the incidence of immune mediated allergic reactions, clinicians still can experience few cases one in a while.
Nontraumatic rhabdomyolysis is mostly caused by drugs, alcohol consumption or compression of muscles. Severe hyperosmolarity rarely can cause rhabdomyolysis. Our case has santral diabetes insipidus that has admitted with the clinical picture of rhabdomyolysis.
CASE: 26 years old male has admitted to our clinic with the complaint of weakness, nausea, vomitting, polydipsia, polyuria, difficulty in walking and tendency to sleep. Neurologic examination was normal. In laboratory glucose:166 mg/dl, Na:168 mEq/L, Urea:19 mg/dl, Cr:1.6 mg/dl , K:2.8 mEq/L, CK:2916 IU/L, plasma osmalality 348 mosmol/L, and urine density 1005 were. Serum CK level have increased progressively up to 15000 IU/L during the follow up. We have thought that rhabdomyolysis might have been due to hyperosmolality caused by high Na and low K levels. We have administered hypotonic fluids and followed the urine output and fluid intake of the patient. His general condition was not well enough to tolerate fluid restriction test and he had severe polyuria that is why we have directly made the desmopressin administration test. Plasma osmolality was 348mosmol/L before desmopressin administration and it regressed to 330mosmol/L thereafter. Urine osmolality has increased to 330mosmol/L from 77mosmol/L after desmopressin administration. Amount of urine per hour has decreased significantly after desmopressin. Consequently the patient has been diagnosed to have central DI. In pituitary MRI a lesion was detected at the level of hypothalamus in right anterolateral neighborhood of 3rd ventricule and 14x18x11in size. It was interpreted as low grade glial lesion. Desmopressin was started po 0.1 mg three times daily and clinical picture has improved thereafter. Serum Na, K and CK levels have returned to normal values after the treatment.
CONCLUSION: Rhabdomyolysis is a rare but very important complication of hyperosmolality due to DI. CK levels should be monitor strictly in hyperosmolar states.
AIM: Celiac disease is closely related with other autoimmune diseases. Our purpose is to examine the existence of endocrine diseases in Celiac patients.
MATERIAL AND METHOD: Celiac patients admitted to gastroenterology clinic were referred to our endocrinology clinic between the dates of September of 2009 and June of 2010.This patient group was evaluated to see as if they had autoimmune thyroiditis, type 1 DM, primary hypoparathyroidism and primary adrenal insufficiency.
RESULTS: 27 patients were registered in our study and 6 of them (22%) were male where as 21 (77.8%) of them were female. Mean age was 35±11 years (20-61). Mean body mass index was 22.61±4.45 kg/m2 (17.9-34.9). We have detected chronic thyroiditis in 6 and type 1 diabetes mellitus in 2 of patients. All patients with endocrinopathy were female. Plasma cortisol levels were normal. We have made low dose ACTH test to all patients and the results were normal. Moreover we have detected vitamin D deficiency in 23 of the patients (85.2%) and there was secondary hyperparathyrodism in 17 of these patients. We haven’t detected primary hypoparathyroidism in any patient. In addition to endocrinopathies we have detected vitamin B12 deficiency in 13(48.1%) patients and in 3(11.1%) of them antiparietal antibody was positive.
DISCUSSION: Endocrinological pathologies especially type 1 DM, autoimmune thyroiditis, rarely Addison’s disease, chronic autoimmune hepatitis, primary billiary cirhosis, cystic fibrosis and lastly SLE have been known to accompany celiac disease. We have detected in our study group that the occurrence rate of Type 1 DM in celiac patients was 7.4% and chronic thyroiditis was 22%. We assume that periodic screening for endocrinopathies should be done in Celiac patients.
Small cell lung cancer (SCLC) is accepted as a neuroendocrine tumor and usually accompanied with paraneoplastic syndromes. Our case has been diagnosed as SCLC and the only finding of disease was hyponatremia.
CASE: 44 years of female patient has admitted because of nausea, vomitting and fatigue. Serum Na level was 116 mEq/L. The patient hospitalized for further investigation. In physical examination BP was 140/80 mmHg, HR was 72 beats/min. Patient didn’t have complaints such as coughing, sputum, weight loss, dispnea or chest pain. Serum glucose level 101 mg/dl, urea 9 mg/dl, Cr: 0.6 mg/dl and K: 4.1mEq/L were. Plasma osmolality was measured as 226 mosm/L, urine osmolality was 306 mosm/L, urine dansity was 1013 and Na in 24 hour collection of urine was 147 mmol/ L. In imaging of brain with MRI there were hyperintense lesions located in white matter which were interpreted as finding of encephalomyelitis or demyelinating disease. It could be related to hyponatremia. In abdominal MRI images adrenal glands were normal. Plasma cortisol and 17-OH Progesterone responses to short ACTH stimulating test, pitiutary hormones, cortisol and growth hormone response to insulin tolerance test were normal. We thought all these results could be due to SIADH. In thorax CT we have detected multiple nodules biggest 6mm in dimension and multiple enlarged hilar and mediastinal lymph nodes biggest in 23 mm in size. Endobronchial biopsy was taken from the enlarged lymph nodes Histopathology results were compatible with SCLC metastasis and patient was referred to an oncology clinics.
SIADH syndrome occurs in oncology patients due to ectopic production of hormone by cancer itself, complications or treatments. Early recognition of it is important in order to reduce morbidity and mortality. It should be kept in mind that hyponatremia might be first sign of cancer as it is in our case.
Introduction: Although incidentalomas in endocrine glands such as pituitary, adrenal or thyroid are well defined, parathyroid incidentaloma is a rare concept. In this study, we aimed to determine the prevalence of suspicious parathyroid lesions and true parathyroid incidentalomas in patients referred for thyroid ultrasonography (US) and investigate the possible factors that might cause inadvertent suspicion of a parathyroid adenoma.
Methods: Patients suspected to have parathyroid lesions during thyroid US were recorded prospectively between August 2009 and January 2010. Patients referred for parathyroid US and patients with known high serum calcium or parathyroid hormone (PTH) levels were excluded. Suspected parathyroid lesions were defined as hypoechoic homogeneous solid lesions with regular margins located outside the thyroid lobe, most commonly inferior to the thyroid gland.
Results: Thyroid US was performed in 6528 patients during the study period. There were 78 patients (1.19%) (73 female and 5 male) with suspected parathyroid lesion and the mean age was 45.32±12.59. The diagnosis of a true parathyroid adenoma was confirmed six (7.69%) patients. Mean serum calcium, phosphorus and PTH levels were 10.57±0.48 mg/dl, 3.03±0.52 mg/dl and 182.91±46.62 pg/ml respectively in patients with true adenoma. Among 72 patients with false positive parathyroid lesion, antithyroid peroxidase antibody was positive in 50 (69.4%), antithyroglobulin antibody was positive in 46 (63.9%) and one of these antibodies were positive in 59 (81.9%) patients. Also, 46 (63.9%) of 72 patients had thyroid dysfunctions (43 hypothyroidism and 3 hyperthyroidism) and 59 (81.9%) had chronic thyroiditis ultrasonographically.
Conclusions: Parathyroid incidentaloma was detected in 0.09% of patients referred for thyroid US. Presence of clinically or ultrasonographically chronic thyroiditis seems to be the major factors related to inadvertent interpretation of a hypoechoic lesion as a parathyroid pathology during thyroid US. Most of these lesions are probably lymphadenopathies that may occur commonly in patients with chronic thyroiditis.
Introduction: Increased exposure to sunlight and high serum levels of Vitamin D were reported to relate with decreased risk of various cancer types, such as prostate, breast and colon. Vitamin D receptor and 1α-hydroxylase expression were shown in papillary thyroid carcinoma. In this study, we aimed to evaluate serum 25-OH vitamin D levels in patients with benign and malignant thyroid nodules
Methods: Patients admitted to our thyroid clinic were recruited for the study. Thyroid ultrasonography and serum 25-OH vitamin D measurement were done in all patients and controls. Because serum 25-OH vitamin D levels may change with seasons, blood samples were taken in April-May 2009 and 2010. Results were compared in patients with histopathologically proven thyroid papillary cancer, patients with histopathologically or cytologically proven benign thyroid nodules and patients without thyroid nodules. Patients with diseases related to bone metabolism and thyroid dysfunctions were excluded.
Results: There were 31 patients with histopathologically proven papillary thyroid cancer, 128 patients with cytologically or histopathologically proven benign nodules and 269 patients without any nodule. Of 428 subjects, 360 (84.1%) were female and 68 (15.9%) were male and sex distibution were similar in three groups (P=0.079). Mean serum 25-OH vitamin D levels were 16.91±10.42, 16.35±9.02 and 17.19±10.74 μ/l in malignant, benign and control groups, respectively (P=0.746). Including all subjects, although mean serum vitamin D levels were higher in males compared to females, the difference did not reach statistical significance.
Conclusion: Serum 25-OH vitamin D levels, here in this study, were shown not to differ in patients with benign nodules, malignant nodules and patients without nodules. Possible effect of vitamin D metabolism and receptors on thyroid papillary cancer that was suggested in previous in vitro and in vivo studies seems to be independent from serum 25-OH vitamin D levels.
Introduction: Follicular variant papillary thyroid carcinoma (FVPTC) is the most common variant of papillary thyroid carcinoma (PTC) after classical PTC (CPTC). In this study, we aimed to compare functional status, ultrasonographical features, cytological results and histopathological characteristics of patients with CPTC and FVPTC.
Methods Patients: Diagnosed with CPTC and FVPTC in our clinic were reviewed retrospectively. Data of preoperative thyroid functional status, thyroid autoantibodies and ultrasonographical features were obtained from the records. Sensitivity of fine needle aspiration biopsy (FNAB) was calculated and histopathological features were compared in two variants.
Results: There were 322 (80.1%) CPTC and 80 (19.9%) FVPTC patients and sex distribution, mean age, thyroid functions and autoantibody positivity rates were similar. 228 CPTC and 62 FVPTC patients had preoperative US examination. Echogenicity, texture, presence of microcalcifications and macrocalcifications were similar in two groups. A hypoechoic halo was observed more frequently (15.4 vs 29%, P=0.012) and marginal irregularity was observed less commonly (81.6 vs 67.7%, P=0.018) in FVPTC lesions. Among 261 CPTC and 73 FVPTC patients with preoperative FNAB results, rate of malignant cytology was significantly higher in CPTC (37.2 vs 19.2%, P=0.004) and rate of suspicious cytology was significantly higher in FVPTC (35.6 vs 53.4%, P=0.006). When only malignant cytology was treated as true positive, sensitivity of FNAB in CPTC and FVPTC was 37.2 and 19.2%, respectively (P=0.004). Mean tumor diameter was markedly higher in FVPTC compared to CPTC (16.04±13.44 vs 10.88±9.88 mm, P<0.001). There was no difference in terms of multicentricity, capsule and vascular invasion, extrathyroidal involvement and lymph node invasion.
Conclusion: FVPTC tends to have more benign features in US and less malignant results in cytology. Higher tumor size in FVPTC compared to CPTC might be explained by the recognition of clinical importance of these lesions after reaching particular sizes due to benign US features.
AIM: Thyroid pyramidal lobe and thyroglossal duct cysts were reported to be associated with increased risk of thyroid cancer. In this study, we aimed to evaluate ultrasonography (US) guided fine needle aspiration biopsy (FNAB) cytology results of pyramidal lobe and thyroglossal duct cysts.
MATERIAL AND METHODS: Patients with pyramidal lobe and thyroglossal duct cysts detected in US were included. Thyroid functions, thyroid autoantibodies, Tc 99m thyroid scintigraphy and US guided FNAB cytology results were evaluated
RESULTS: There were 79 (97.5%) female and 2 (2.5%) male patients with a mean age of 52.0±12.3 (20-82). Thyroglossal duct remnant was observed in 26 (32.1%) and pyramidal lobe in 55 (67.9%) patients. There were 74 (91.4%) patients with a previous history of thyroidectomy and all were histopathologically benign. In 7 patients, there was not a history of thyroid operation. FNAB results of all thyroglossal duct and pyramidal lobe were benign
CONCLUSION: Pyramidal lobe is an embryological remnant of thyroglossal duct and its incidence varies between 15-75% in surgical and autopsy series. It was reported that this tissue becomes hypertrophic under the influence of increased thyrotrophin in thyroidectomized patients. Thyroglossal duct cysts develop in front of the neck. Increased risk of occult malignancy risk was reported in solid lesions, particularly when they include ectopic thyroid tissue. In our series, we did not observe any malignant cytology result.
Introduction: In this study, we aimed to compare GH values obtained in oral glucose tolerance test (OGTT) and intravenous glucose tolerance test (IVGTT) in healthy individuals.
Material and methods: Data of 18 healthy volunteers were analysed (10 male and 8 female). Firstly all subjects were evaluated with 75 g oral glucose tolerance test. In another day, intravenous glucose tolerance test was performed. Serum glucose, insulin and GH levels obtained during two tests were measured.
Results: Basal GH levels had a wide distribution ranging from 0.00005 μg/l (0.05 pg/ml) to 0.768 μg/l (768.92 pg/ml) (median 0.0145 μg/l). Mean nadir GH level during OGTT was 0.0376 μg/l (between 0.00011 and 0.387, median 0.0016, S.D.: 0.095, S.E.M.: 0.038) and it was obtained at 60th minute. Nadir GH level during IVGTT was observed at 10th minute and it was 0.112 μg/l (between 0.0005 and 0.770, median 0.0053, S.D.: 0.242, S.E.M.: 0.057). There was statistically significant difference between GH levels at 10th minute in IVGTT and at 60th minute in OGTT (Z=2.201, P=0.028). GH level at 10th minute in IVGTT was higher than GH level at 60th minute in OGTT.
Conclusions: Effect of gastroenteropancreatic pathway which may show individual differences can be eliminated by IVGTT. GH suppression by IVGTT may be used in the diagnosis and follow-up of patients with acromegaly. Higher nadir GH levels in IVGTT indicates that nadir GH levels suggested for remission in acromegalic patients are relatively low. Our results show that there may be need to revise the remission criteria for acromegaly.
Introduction: Polycystic ovary syndrome (PCOS) is a common disorder characterized by chronic anovulatory oligo-amenorrhea and signs of hyperandrogenism. In this study, we aimed to determine prevalence of thyroid nodules and autoimmune thyroid diseases in patients with PCOS.
Methods: Patients diagnosed with PCOS in our endocrinology clinic were included in the study. In patients with irregular menses and/or hirsutism, the diagnosis of PCOS was made by high serum LH/FSH ratio, high serum free testesteron levels and/or polycytic ovaries in pelvic ultrasonography. Serum thyrotropin, free thyroid hormones, antithyroid peroxidase (AntiTPO) and antithyroglobulin (AntiTg) antibody levels were evaluated. Thyroid ultrasonography was performed in all subjects by the same examiner. Thyroid fine needle aspiration biopsy (FNAB) was carried out when indicated.
Results: There were 107 women with PCOS with a mean age of 23.96±5.70. Seventeen (15.9%) patients had hypothyroidism and 2 (1.8%) had hyperthyroidism. 30.5% patients had positive AntiTPO, 30.5% had positive AntiTg and 37.8% had positive AntiTPO or AntiTg antibodies. Thyroid nodules were detected in 29 (27.1%) patients, 10 had solitary and 19 had multiple nodules. FNAB was performed in 11 patients with nodules; 10 were cytologically benign and 1 was malignant (papillary thyroid carcinoma was confirmed histopathologically). Totally, in 54 (50.5%) patients, there was a thyroid related disease such as positive thyroid antibodies, thyroid dysfunctions or nodules. Insulin resistance calculated with HOMA-IR was ≥2 in 47 (43.9%) and <2 in 60 (56.1%) patients. Nodule prevalence, thyroid dysfunctions, thyroid autoantibody positivity and thyroid volume did not differ between PCOS patients with and without insulin resistance.
Conclusion: Thyroid pathologies are observed in half of the patients with PCOS. Measurement of thyroid hormones are usually a part of investigation in PCOS patients, but we think serum thyroid autoantibodies and presence of thyroid nodules should also be searched in these patients.
INTRODUCTION: Recent studies have shown that GLUT-1 expression in malignant cells increases favoring the increase of glucose in to the cells. Detecting intranodular glucose amount might predict malignancy of the thyroid nodule. The aim of this study was toevaluate the glucose content of thyroid nodules during USG guided fine needle aspiration biopsy (FNAB).
SUBJECTS AND METHODS:
42 patients with suspicious thyroid nodules were selected from our Thyroidout patient clinic who were to undergo Ultrasound-guided FNAB. All these patients underwent total thyroidectomy and confirmed thyroid papillary carcinoma histopathologically.
US and US guided FNAB
Ultrasonography was performed using Esaote color Doppler US(MAG Tecnology Co,Ltd.Model :796FDII Yung-ho City,Taipei Taiwan) and superficial probe (Model No:LA523 13-4, 5,5-12,5 MHz ) for the evaluation of nodules in the thyroid gland. US guided FNAB was performed using a General Electiric Logiq pro 200(Model number 2270968, GE Healtcare Korea, Seongnam -SI, Gyean GGI-DO ,Korea) and a 5,5-7,5 MHz probe was used. FNAB was performed on an extended neck using a 27 gauge needle. The needle was connected to a 2 ml syringe. After the aspiration, the aspirate was expelled onto glass slides and smeared for cytological examination. The sample needle was not thrown. Instead the remaining in the needle was rinsed three times with 250 µl normal saline and the washout was placed in an epandorph tube for glucose measurement. After FNAB procedure, a blood sample was taken from the brachial vein of the patient via a syringe and needle similar to the one used in FNAB. Than the syringe was changed with another syringe with the same properties and the blood sample was expelled out. The remaining blood in the syringe was diluted with 250 µl normal saline. All these procedures were also applied to the serum of the patient. For each patient there were four different samples in which glucose was to be studied.
The results were compared with the patients’ venous blood glucose level, cytological and/or histopathological diagnosis to see if there was any relationship.
RESULTS: Glucose content of 42 nodules of 42 patients was investigated. On cytological examination 21 of 42 nodules had benign, 8 nodules had malignant (proven histopathologically), and 13 nodules had nondiagnostic cytology. One patient atypical cells on cytological examination and refused operation. The cytological evaluation of 5 of the nodules with indeterminate cytology revealed colloidal material only, 8 nodules revealed colloidal material with a few benign follicular epithelial cells. The ratio of serum glucose level/glucose content of the nodule which had benign, malign and indeterminate cytological results were 64.00±24.00, 52.02±22.00, 67.00±27.70 respectively (p=0,371). Although not statistically significant the ratio of serum glucose level/glucose content of the malign nodules were lower than the other groups suggesting that the intranodular glucose content was higher than serum glucose content in this group. There was no relationship between the ratio of serum glucose level/glucose content of the nodule and anti TPO and anti Tg levels (p=0,199 and p=0,202 respectively). Also there was no difference between the ratio of serum glucose level/glucose content of the nodule and the content (solid, partially cystic) between the 3 groups (p=0151).
CONCLUSION: By measuring intranodular glucose content we have for the first time made an initial effort to evaluate the clinical significance of intranodular glucose content and to see if it there is any difference between malignant, benign and nondiagnostic nodules. Here in this study although our study population is small and the results are not statistically significant malignant nodules have higher glucose levels. It may be possible to predict if a nodule is weather benign, malign or nondiagnostic by looking immediately during FNAB. We think that this may be a new technique in the follow up of thyroid nodules and needs further investigation with a larger patient group with more standardized methods.
INTRODUCTION: The incidence of thyroid cancer is increasing parallel with the incidence of metabolic syndrome. One of the reasons for the increased incidence of thyroid cancer all over the world might be insulin resistance. The purpose of this study was to investigate the incidence of metabolic syndrome and insulin resistance in patients with differentiated thyroid cancer (DTC).
SUBJECTS AND METHODS: Fourty-one patients between the ages of 18-65 with DTC were included in the study. Forty one patients operated because of eutyhroid nodular or multinodular goitre and pathology benign were chosen as the control group. Blood samples were taken after an overnight fasting from an antecubital vein between 08.00 h and 10.00 h at resting position. Measurements were done before operation and when patients were euthyroid in patient group. Fasting plasma glucose (FPG), insulin, thyrotropin (TSH), free triiodothyronine (FT3), free thyroxine (FT4), total cholesterol, high density lipoprotein (HDL) and triglyceride (TG) measurements were done in all cases. Weight, height, body mass index (BMI) and body fat ratio was determined. Homeostatic model assessment (HOMA) index was used to evaluate insulin resistance. Patients with HOMA-IR>2.5 were accepted to have insulin resistance.
RESULTS: Mean age, sex distribution, height, weight, waist circumference and BMI were similar in two groups. Fourteen (34.1%) patients in each group met metabolic syndrome criteria. Insulin resistance evaluated with HOMA-IR was similar in two groups (p=0.80). Mean TSH was significantly higher in Group 2 compared to Group 1 (p=0.02), while fT3 and fT4 did not differ between groups. However, high TSH was determined as a risk factor for DTC with an Odds ratio of 0.581 in 95% confidence interval (p=0.029). Presence of metabolic syndrome was determined as a risk factor for DTC with an Odds ratio of 0.227 in 95% confidence interval (p=0.047). There was no statistically significant difference in terms of HOMA-IR between patients with microcarcinoma and macrocarcinoma (p=0.08).
CONCLUSION: In this study, the first time in the literature we evaluated prevalence of insulin resistance and metabolic syndrome preoperatively in euthyroid patients with DTC. HOMA-IR wassignificantly higher in patients with DTC compared to control group. However, HOMA-IR was similar in patients with microcarcinoma and macrocarcinoma. Our results suggest that patients with thyroid nodules should be evaluated for the presence of insulin resistance and metabolic syndrome which may be considered as modifiable risk factors for thyroid cancer.
Table1. Demographic, anthropometric and laboratory data of study group
Total Kol (mg/dL)
HDL Kol (mg/dL)
Objective: In this study, we aimed to determine prevalence of gestational diabetes mellitus (GDM) in patients with gestational transient thyrotoxicosis (GTT) and investigate the relation between GTT and anthropometric measurements and biochemical parameters
Methods: Fifty two pregnants with GTT (18-42 years old) and 100 healthy pregnants (19-37 years old) were included in the study. Weight, height and body mass index (BMI) were meaured and fasting plasma glucose (FPG), uric acid, LDL-cholestereol, HDL-choloesterol, triglyceride (TG), hemoglobin Alc (HbA1c), thyroid stimulating hormone (TSH), free thyroxine (FT4), free triiodothyronine (FT3), anti-thyroid peroxidase antibody (Anti-TPO), anti-thyroglobulin antibody (Anti-Tg), TSH receptor antibody (Trab) were studied in all subjects. Conventional thyroid ultrasonography was performed. After basal and first hour glucose were evaluated with 50 gram oral glucose tolerance test (OGTT) at the 24-28th gestational weeks, all subjects were also evaluated with 100 gram OGTT in the following week.
Results: Mean age of 52 GTT pregnants was 28.46±5.45 and BMI was 21.66±2.92 kg/m2. Mean age and BMI of 100 healthy pregnants were 26.17±3.75 and 21.12±1.48kg/m2, respectively. Age, BMI, FPG, TG and uric acid were similar in GTT and healthy pregnants (p>0.05). We found significantly higher HbAlc, LDL-cholesterol and HDL-cholesterol in GTT pregnants (p< 0.001, p< 0.001 and p=0.034, respectively). 50 gram OGTT was positive in 14 (26.9%) GTT pregnants and in 10 (10%) healthy pregnants (p=0.01). TSH was significantly lower in pregnants with positive 50 gram OGTT compared to pregnants without glucose intolerance (p=0.001). Also, pregnants with both positive 50 gram and 100 gram OGTT (n=9) had lower TSH compared to pregnants without glucose intolerance, but the difference was not statistically significant (p>0.05).
Conclusion: GTT is a transient abnormality that can be seen in the early periods of pregnancy. However, like other hyperthyroidism states, it seems to have effect on carbohydrate metabolism later in pregnancy.
Objectives: We aimed to compare early total thyroidectomy with the anti-thyroid treatment regimens, in patients with moderate to severely active Graves' orbitopathy (GO) prospectively.
Methods: The inclusion criteria: Hyperthyroidism and GO developed in the last six months, thyroid volume ≥15 mL, no previous treatment except local interventions for GO. GO activity has been defined as clinical activity score (CAS) ≥3 and carrying at least one of the following criteria; Proptosis ≥21 mm in one eye, ≥2 mm difference between two eyes, presence of diplopia, lid aperture ≥9 mm. Initially, all the patients were made euthyroid (TSH 0.4-1 mlU/L). Pulse methylprednisolone of total 4.5 gr were given intravenously to all patients before randomization. In the first group, patients were sent to total thyroidectomy and TSH levels were kept within 0.4-1 mlU/L with levothyroxine. Second group of patients were followed with anti-thyroid drugs and with the addition of levothyroxine, when necessary, to keep TSH within 0.4-1 mlU/L.
Results: 12 patients were randomized to total thyroidectomy (TT) group and 11 patients were randomized to medical antihyroid treatment (AT) group. There were no difference between the two groups with respect to age, gender, smoking habit, duration of hyperthyroidism and GO, thyroid volume, TSH, free T4, anti-TPO, anti-Tg and TRAb levels initially. When the TT group was compared with AT group, thyroid antibodies were significantly decreased in TT group while there was no significant difference with respect to proptosis, lid aperture, CAS and diplopia between groups. However in TT group additional pulse methylprednisolone treatment was given to 3 (25%) patients and urgent orbital decompression was applied to 2 (17%) of those patients.
Conclusion: Although the significant decrease of thyroid autoantibodies were achieved in TT group, this was not reflected as an beneficial effect on the course of GO during the 15 months follow-up period.
Aim: We aimed to compare early total thyroidectomy performed within six months of Graves' orbitopathy (GO) with the anti-thyroid treatment, in patients with moderate to severely active GO prospectively and evaluate the clinical course of eye disease.
Materials and Methods: The patients with moderate to severely active GO were enrolled in the study fulfilling the following criteria: Hyperthyroidism and GO developed in the last six months, thyroid volume ≥15 ml, no previous treatment except local interventions for GO. GO severity has been defined as clinical activity score (CAS) ≥3 with at least one of the following criteria; Proptosis ≥21 mm in one eye, ≥2 mm difference between two eyes, presence of diplopia , lid aperture ≥9 mm. Initially, all patients were made euthyroid with anti-thyroid drugs and TSH levels were kept within the range 0.4-1 mlU/L. Pulse methytprednisolone of total 4.5 gr was given intravenously to all patients before randomization to two groups. In the first group, patients were sent to total thyroidectomy and their TSH levels were kept within the range 0.4-1 mlU/L with levothyroxine (LT4). Second group of patients were followed with fixed dose (20-50 mg) of anti-thyroid drugs and with the addition of LT4, when necessary, to keep TSH within the range 0.4-1 mlU/L. Patients were asked for smoking habits, family history of GO. CAS, proptosis, lid aperture and diplopia were evaluated. TSH, freeT4, TSH receptor antibody (TRAb), anti-TPO and anti-Tg levels were measured. These are the preliminary results of the study ongoing for more than 12 months
Results: 12 patients with a mean age of 44±8.7 years were randomized to the total thyroidectomy (TT) group and 10 patients with a mean age of….
INTRODUCTION: Previous studies has shown that thyroid blood flow varies cyclically during the normal menstrual cycle in females of reproductive age and that thyroid physiologic characteristics change during different reproductive phases of a woman’s life. The aim of this study is to evaluate the changes in thyroid stimulating hormone (TSH) levels through four different periods of menstrual cycle which is a sample of infradian rhythm; and to investigate the relationship between thyroid volume and doppler parameters of inferior thyroid artery according to TSH and sex hormone alternations in healthy women.
MATERIALS AND METHODS: Twenty-two healthy women having regular menstrual cycles between 21 and 38 years were included in this study. Each participant was evaluated at the 3rd day (menstrual bleeding period), 7th day (follicular phase), 14th day (periovulatory period) and 21st day (luteal phase) of their menstrual cycle. All examinations were performed after a 12 hours fasting time, between am 06:00- 08:00. Blood samples were collected for plasma estradiol (E2), progesterone (PG), luteinizing hormone (LH), follicle stimulating hormone (FSH), thyroid-stimulating hormone (TSH), free triiodothyronine (fT3), free thyroxine (fT4), thyroglobuline (Tg).Conventional ultrasonography and power doppler ultrasonography were carried out(Figure 1).
RESULTS: Mean age of these 22 women was 28,72±5,72 years. The statistical alternations of the mean values of TSH, Tg, peak systolic velocity (PSV), resistance index (RI), pulsatility index (PI) and thyroid volumes at the 3rd day, 7th day, 14th day and 21st days of menstrual cycle were examined. It was detected that there was a statistically significant in TSH, thyroid volume and PSV at the 14th day compared to the 3rd and 7th days(Table 1). With a minimal increase at the 21st day; any statistically significant change could not be found in PI values during menstrual cycle. Compared with the 3rd day; there was a statistically significant decrease in RI value at the 14th and 21st days. Also compared to the 3rd day; there was a statistically significant increase in Tg levels at the 7th and 14th days. During menstrual cycle, there was no significant change in fT3 and fT4 levels. In addition; during this period, no statistically significant correlation was detected between TSH levels and LH, FSH, PG, E2, Tg levels; and yet between TSH levels and PSV, RI, PI, thyroid volume..
CONCLUSION: Through menstrual cycle; with thyroid volume, TSH, and Tg, also some changes occur in blood flow parameters of inferior thyroid artery. Power doppler measurements are used for differential diagnosis of certain thyroid diseases. In this case; we believe that it is appropriate to evaluate the female patients during the follicular phase while performing doppler or population studies.
Figure 1. The velocity waveform is displayed above the baseline to indicate the arterial blood flow. The figure shows the measurement of the blood flow velocity in the inferior thyroid artery (left).
Figure 2.Changes of mean values of RI, PI and TSH at the 3rd, 7th, 14th and 21st days of menstrual cycle
Figure 3. Changes of mean values of thyroid volume and PSV at the 3rd, 7th, 14th and 21st days of menstrual cycle
Table 1. Statisticallyalternations of the mean values of TSH, Tg, PSV, RI, PI and thyroid volumes at the 3rd, 7th, 14th and 21st days of menstrual cycle
Days of MS
3rd vs 7th
3rd vs 14th
3rd vs 21st
7th vs 14th
7th vs 21st
14th vs 21st
INTRODUCTION: Thyroid gland abscess is an uncommon condition, with fewer than 300 cases reported in the literature. Its rarity is attributed to the remarkable resistance of the thyroid gland to infections because of its protective mechanisms, which include a rich blood supply, goodlymphatic drainage, high iodine content, and the protective capsule surrounding the gland. The most common mechanism of thyroid infection is transmission of an infection via a pyriform sinus fistula. We report the case of thyroid abscess in a patient with Type 2 Diabetes Mellitus (DM).
CASE: A 65 years old male patient with Type 2 DM admitted our out-patient clinic with the complaint of tiredness, high blood sugar and swelling in right side of the neck. He was on oral antidiabetic treatment and his glucose levels couldn’t be regulated since two months. His blood pressure was 110/70 mm Hg, heart rate was 81 beats /min and his temperature was 36.80°C. On physical examination, a 1x2 cm nodule was found on the right thyroid lobe. Thyroid ultrasonography revealed a nodule cystic in appearance with a solid component at the right lobe. In laboratory examination, serum TSH, fT3 and fT4 were in normal ranges. The thyroglobulin antibody and thyroid proxidase antibody tests were negative. In cytologic evaluation, needle aspiration of the drained 2 ml pus showed a large number of polymorphonuclear leukocytes. There were no microorganisms on microscopic examination and no growth on culture. Tuberculosis DNA PCR was negative. High sensitive CRP, ESR and leukocyte count was in normal limits. Baryum esophagogram was normal, no fistula could be determined. Two months after the diagnosis total thyroidectomy was performed and histopathological examination revealed chronic inflammatory reaction surrounding the right thyroid nodule with fibrosis. No microorganism could be identified. The patient was diagnosed as a sterile and restrained thyroid abscess with unknown origin.
DISCUSSION: In our case the patient was diabetic and his blood sugar was not regular. This may have made the patient prone to infection. There are several routes of spread of infection to the thyroid gland. Many sources have been reported including hematogenouse and lymphatic spread, direct penetration from adjacent structures, neck injuries. The most frequent reason of thyroid abscess is congenital pyriform sinus fistula. If thyroid abscess is not diagnosed and treated quickly, septicemia, retropharengeal abscess, tracheal or esophageal rupture, suppurative mediastinitis can be occur. In the peresent case the pus obtained by FNAB from the nodule showed no microorganisms on microscopic examination and no growth on culture. Tuberculosis DNA PCR was also negative. A prime cause of infection could’nt be found. Our case was followed for 2 months. An antibiotic therapt was initiated but there was no change in size of the nodule. None of the inflammatory markers were elevated during this period. Although some of the authors donot recommend thyroidectomy, it was the only treatment choice.This case is reported because of the rarity of the condition.
Figure 1. Cytologic evaluation: Abscess formation with colloid material, hystiocytes and polymorphonuclear leucocytes. X400 Giemsa
Figure 2. Histopathologic evaluation: Chronic inflammation and fibrosis surrounding on ruptured colloid nodule. X40 HE
INTRODUCTION: The thyroid gland is not an uncommon organ for metastatic spread from distant neoplasms at autopsies, but it is rare to be found in clinical situations. It has been reported that <2% of clinically detectable thyroid cancers are of metastatic origin. The most common malignancies that metastasis to the thyroid are melanoma, renal cell carcinoma, breast carcinoma, lung carcinoma and head and neck carcinomas. Although metastases from gastrointestinal tract malignancies are unusual, the majority of them are from esophageal or colonic primary. To our knowledge, there are only 5 cases of esophageal carcinoma with thyroid gland metastases in the literature. We present a new case of esophageal squamous cell carcinoma metastases to the thyroid gland.
CASE: A 57-year-old male patient was admitted for evaluation of an enlarged mass on the right neck, which was just noticed by the patient. There was no history of previous irradiation to the neck or chest. No associated symptoms of neck pain, dysphagia, or hypo or hyperthyroidism were identified. On physical examination, a nontender, well-circumscribed, 2.0 cm nodule was found on the right thyroid. The patient was clinically euthyroid. The thyroglobulin antibody and microsomal antibody tests were negative. Serum thyroglobulin and calcitonin levels were within normal limits. Ultrasonography revealed hypoechoic nodules on the right and left thyroid and lymph nodes with microcalsifications in the right cervical region of the neck (level III). Ultrasound guided fine needle aspiration cytology from the nodules and lymph nodes revealed the presence of a metastatic squamous cell carcinoma. On neck computed tomography (CT) there was 30 mm lesion in the subcarinal localization which deplased the esophagus to the right(Figure1).On thorax CT, there were multiple metastatic noduler lesions. An esophagogastroduadenoscopy revealed a lobulated lesion in the cervical esophagus distal to the vocal cords. Cytological assessment from multiple biopsies confirmed an esophageal squamous cell carsinoma. The extent of the disease didn’t allow surgery. The patient is currently undergoing chemoradiation. In this report, we present an unusual case of metastatic squamous cell carcinoma from the esophagus to the thyroid. We think that thyroid nodules in a patient with a history of malignancy should be considered to be secondary thyroid cancer.
Figure 1. 30 mm lesion in the subcarinal localization which deplased the esophagus to the right
Figure 2. Images of nodule with elastosonography and real time B mode ultrasonography
Figure 3. Squamous cell carcinoma diagnosed at proximal eusophagus (H&E, 100x), composed of neoplastic cells with pleomophism, hypechromasia, prominent nucleoli and increased mitotic figures (inlet, H&E 630x).
Figure 4. Discohesive areas with high mitotic activity (also inlet, 1000x). Note the presence of cytoplasmic vacuolization and tad pole figures (MGG, 400x). thyroid and LAP
INTRODUCTION: Oncocytic (presence of Hurthle Cell) changes in thyroid follicular epithelial cells might be seen both in benign and malign thyroid lesions. Our aim in this study is to investigate malignancy rate in nodules that are found to have Hurthle cell after fine needle aspiration biopsy (FNAB) and were operated for various reasons.
MATERIALS AND METHODS: Forty-four patients who has been evaluated in our thyroid diseases clinics between January 2009 and January 2010 and decided to undergo operation were assessed. These patients were asked to have operation for big nodule size, development in nodule sizes during follow up, compression symptoms or for permanent treatment of hyperthyroidism. Presence of Hurthle cell was demonstrated in cytological examination of all patients, preoperatively. Thyroid ultrasonography and ultrasound guided FNAB results were recorded. Patients reported to have these FNAB results were excluded. All patients undertake total thyroidectomy.
RESULTS: Thirty-eight of the patients were female and 6 were male. Mean age was 48±12 (19-70) years. Of the patients; 33 had euthyroid multinodulary goiter, 6 had euthyroid nodulary goiter, 1 had toxic diffuse multinodulary goiter, 1 had toxic diffuse nodulary goiter and 3 had toxic multinodulary goiter. Thyroid malignancy was detected in 6 (18.2%) patients, postoperatively. Of these, papillary microcarcinoma was determined in 4 and follicular carcinoma in 2. At least one of the thyroid antibodies was positive in 38% of cases who were found to have benign histopathology and 87.5% of malign cases (p=0.019). Both in malign and benign group, 25% cases were found to have lymphocytic thyroiditis in histopathological examination.
Table 1. Demographic characteristics of the patients
38 / 6
Mean Age (year)
48 ± 12
Soliter Nodul/ Multiple Nodul
7 / 37
39 / 5
Benign/ Malign (B / M)
38 / 6 (18.2%)
Positive Thyroid antibodies % (B / M)
38.0 / 87.5 (p=0.019)