Introduction: It is recommended to determine levothyroxine (LT4) dose individually in patients with hypothyroidism. However, higher doses of LT4 therapy are required to achieve target TSH levels in significant number of patients. Oral LT4 absorption occurs in the small intestine, especially in the jejunum and proximal ileum, while a small amount is absorbed in duodenum. Causes of LT4 malabsorption include helicobacter pylori infection, chronic atrophic gastritis, celiac disease, lactose intolerance, pancreatic insufficiency, cirrhosis, nephrotic syndrome, gastrointestinal malabsorptive surgical procedures, short bowel syndrome, drug and diet-related interactions. Here, we present a case of ileostomy with multiple small intestine resection, which is a rare cause of LT4 malabsorption. Case: A 59-year-old male patient was consulted to our endocrinology clinic due to high TSH levels before ileostomy closure from the gastrosurgery clinic. The patient underwent total thyroidectomy in 2009 due to medical recurrence Graves disease and had postoperative hypothyroidism, he was euthyroid with levothyroxine treatment of 175 μg/day. With the diagnosis of rectal cancer in January 2020, the patient underwent a low anterior resection and colostomy. Pathology reported as moderately differentiated adenocarcinoma, followed by chemotherapy and radiotherapy. In October and November 2020, segmental small bowel resection due to radiation ileitis, ileus was performed. Ileostomy was performed in November 2020 for the patient whose colostomy did not work for a long time. Despite medical treatment, ileostomy was planned to be closed after 8 weeks due to the daily discharge of 14 times from ileostomy. It was consulted preoperatively in January 2021 due to TSH:66 mU/l. The oral levothyroxine dose was gradually increased from 150 μg/day to 350 μg/day due to increase in TSH to 80 mU/l, despite appropriate replacement of levothyroxine. When his TSH level was 37 mU/l, free T4 and T3 were normal with 350 μg/day oral levothyroxine, ileostomy was closed in February 2021. The patient’s free T4 and T3 values started to increase in 3 days after ileostomy closure, and levothyroxine dose was gradually decreased. The patient has been followed euthyroid with levothyroxine doşe of 150 μg/day. Conclusion: Intestinal absorption problems may cause high-dose LT4 therapy. The decrease of the intestinal absorption surface and the shortening of the intestinal transit time can be considered among malabsorption mechanisms. Further research should be conducted in the presence of increased serum TSH levels despite high dose LT4 therapy.
Introduction: It is recommended to determine levothyroxine (LT4) dose individually in patients with hypothyroidism. However, higher doses of LT4 therapy are required to achieve target TSH levels in significant number of patients. Oral LT4 absorption occurs in the small intestine, especially in the jejunum and proximal ileum, while a small amount is absorbed in duodenum. Causes of LT4 malabsorption include helicobacter pylori infection, chronic atrophic gastritis, celiac disease, lactose intolerance, pancreatic insufficiency, cirrhosis, nephrotic syndrome, gastrointestinal malabsorptive surgical procedures, short bowel syndrome, drug and diet-related interactions. Here, we present a case of ileostomy with multiple small intestine resection, which is a rare cause of LT4 malabsorption.
Case: A 59-year-old male patient was consulted to our endocrinology clinic due to high TSH levels before ileostomy closure from the gastrosurgery clinic. The patient underwent total thyroidectomy in 2009 due to medical recurrence Graves disease and had postoperative hypothyroidism, he was euthyroid with levothyroxine treatment of 175 μg/day. With the diagnosis of rectal cancer in January 2020, the patient underwent a low anterior resection and colostomy. Pathology reported as moderately differentiated adenocarcinoma, followed by chemotherapy and radiotherapy. In October and November 2020, segmental small bowel resection due to radiation ileitis, ileus was performed. Ileostomy was performed in November 2020 for the patient whose colostomy did not work for a long time. Despite medical treatment, ileostomy was planned to be closed after 8 weeks due to the daily discharge of 14 times from ileostomy. It was consulted preoperatively in January 2021 due to TSH:66 mU/l. The oral levothyroxine dose was gradually increased from 150 μg/day to 350 μg/day due to increase in TSH to 80 mU/l, despite appropriate replacement of levothyroxine. When his TSH level was 37 mU/l, free T4 and T3 were normal with 350 μg/day oral levothyroxine, ileostomy was closed in February 2021. The patient’s free T4 and T3 values started to increase in 3 days after
ileostomy closure, and levothyroxine dose was gradually decreased. The patient has been followed euthyroid with levothyroxine doşe of 150 μg/day.
Conclusion: Intestinal absorption problems may cause high-dose LT4 therapy. The decrease of the intestinal absorption surface and the shortening of the intestinal transit time can be considered among malabsorption mechanisms. Further research should be conducted in the presence of increased serum TSH levels despite high dose LT4 therapy.
Introduction: While cervical lymph nodes are the region where head and neck malignancies frequently metastasize, prostate carcinoma rarely metastasizes to this area. Here, we will present a case with papillary thyroid microcarcinoma whose pathological lymph node cytology in the cervical region was found to be prostate carcinoma metastasis. Case: Since thyroid fine needle aspiration cytology (FNAC) results were nondiagnostic 3 times, an 64-year old male patient underwent bilateral total thyroidectomy. His pathological examination was compatible with papillary microcarcinoma, and was given 100 mci radioactive iodine (RAI) treatment. While post-ablation whole body scan (WBS) revealed the activity involvement compatible with residual tissue in the right lobe region, the diagnostic WBS was found to be normal (TSH, Tg and Anti Tg values are shown in Table 1). In PET-CT, pathological increased activity uptake was detected in the bilateral level IV lymph node area. Neck ultrasonography showed a lymph node with pathological appearance and 8.5×8.7×11 mm in size at left level IV. Cytological examination of this lymph node was compatible with carcinoma metastasis. Also, another pathological looking lymph node on the left level IV with 7.7×9.4×10.8 mm in size was found to be compatible with malignant cytology, carcinoma metastasis (Table 1). An immunohistochemical study of the prostate and thyroid origin (PSA, TTF1) has been conducted in cytology, but a definitive clue for the origin of the tumor has not been obtained. Thereupon, the FNAC was repeated from the level IV lymph node (8.5×8.7× 11 mm) of the patient and nondiagnostic cytology was found, afterall the cell block was applied. Finally, left level IV lymph node cytology was reported to be compatible with prostate adenocarcinoma metastasis. Table-1
Introduction: While cervical lymph nodes are the region where head and neck malignancies frequently metastasize, prostate carcinoma rarely metastasizes to this area. Here, we will present a case with papillary thyroid microcarcinoma whose pathological lymph node cytology in the cervical region was found to be prostate carcinoma metastasis.
Case: Since thyroid fine needle aspiration cytology (FNAC) results were nondiagnostic 3 times, an 64-year old male patient underwent bilateral total thyroidectomy. His pathological examination was compatible with papillary microcarcinoma, and was given 100 mci radioactive iodine (RAI) treatment. While post-ablation whole body scan (WBS) revealed the activity involvement compatible with residual tissue in the right lobe region, the diagnostic WBS was found to be normal (TSH, Tg and Anti Tg values are shown in Table 1). In PET-CT, pathological increased activity uptake was detected in the bilateral level IV lymph node area. Neck ultrasonography showed a lymph node with pathological appearance and 8.5×8.7×11 mm in size at left level IV. Cytological examination of this lymph node was compatible with carcinoma metastasis. Also, another pathological looking lymph node on the left level IV with 7.7×9.4×10.8 mm in size was found to be compatible with malignant cytology, carcinoma metastasis (Table 1). An immunohistochemical study of the prostate and thyroid origin (PSA, TTF1) has been conducted in cytology, but a definitive clue for the origin of the tumor has not been obtained. Thereupon, the FNAC was repeated from the level IV lymph node (8.5×8.7× 11 mm) of the patient and nondiagnostic cytology was found, afterall the cell block was applied. Finally, left level IV lymph node cytology was reported to be compatible with prostate adenocarcinoma metastasis.
TSH; thyroid stimulating hormone, Tg; thyroglobulin, Anti-Tg; anti- thyroglobulin,
WBS; whole body scan, RAI; radioactive iodine
Conclusion: Metastatic prostate adenocarcinoma (PAC) to cervical lymph nodes is rare. If the history is unknown, cases may be misdiagnosed as metastases from cervical neoplasms. Findings showing metastatic PAC to the cervical lymph nodes in FNAC are; the involvement of left-sided cervical lymph nodes and cellular smears consisting of flat layers with granular cytoplasm and uniform polygonal cells arranged in the acini, fuzzy cell borders, and round-oval nuclei with prominent nucleoli.
Introduction: Type 2 diabetes and hyperlipidemia are primarily managed with lifestyle modifications, self-monitoring of blood glucose, and medication. Patients who are obese and cannot achieve normal blood glucose levels despite diet, exercise, and multiple medications may be considered for bariatric surgery. Many diabetic patients with very high triglyceride levels are at high risk for ASCVD and therefore after triglyceride levels are controlled the patient should be evaluated for cardiovascular disease risk. Bariatric surgery is more effective at inducing weight loss than either diet or medications. Baratric surgrey is alsow associated more robust decrease in serum triglyceride levels and increase in HDL-C levels. Here we describe a bariatric surgery results of obese multidrug hypersensitive patient with a high level of serum triglyceride. Case: 44 years old woman, had Type-2 Diabetes Mellitus and hyperlipidemia for at least 3 years. She had no medication due to multidrug hypersensitive. Her BMI was 39.9, fasting glucose, serum triglyceride, VLDL, HDL, HbA1C are: 166 mg/dl, 2166 mg/dl, 433 mg/dl, 32 mg/dl, 60 mmol/mol respectively. İn addition to Initial treatment of very low-fat diet, we immediately started medication to reduce triglyceride levels into a safe range to prevent triglyceride-induced pancreatitis. After 10 day of receiving fenofibrate and dapagloflozin she had an generalized acute urticaria need hospitalization and first treated with antihistamine drugs. Here serum triglyceride level was 1906 that force us to continue medication tratment with antihistamine drug. After 4 mounth of treatment and weight loss (10 kg) we didn’t reach therapy goals of hyperlipidemıa. The patient had a bariatric surgrey after mutidisplanary consensur. After surgrey she stoped medication and her serum triglyceride measure was 240 mg/dl. Conclusion: We report a case of generalized urticaria probable or very probable induced by fenofibrate underwent bariatric surgery. Approximately 60-70%of patients with obesity are dyslipidemic. The Roux-en-Y gastric bypass and laparoscopic sleeve gastrectomy have been shown to improve A1C, reduce weight, and reduce the number of medications patients need for diabetes management. Comorbidities such as hyperlipidemia and hypertension also may improve. A reduction in medication of hypersensitive patients can be considered an additional benefit of bariatric surgery.
Introduction: Type 2 diabetes and hyperlipidemia are primarily managed with lifestyle modifications, self-monitoring of blood glucose, and medication. Patients who are obese and cannot achieve normal blood glucose levels despite diet, exercise, and multiple medications may be considered for bariatric surgery. Many diabetic patients with very high triglyceride levels are at high risk for ASCVD and therefore after triglyceride levels are controlled the patient should be evaluated for cardiovascular disease risk. Bariatric surgery is more effective at inducing weight loss than either diet or medications. Baratric surgrey is alsow associated more robust decrease in serum triglyceride levels and increase in HDL-C levels. Here we describe a bariatric surgery results of obese multidrug hypersensitive patient with a high level of serum triglyceride.
Case: 44 years old woman, had Type-2 Diabetes Mellitus and hyperlipidemia for at least 3 years. She had no medication due to multidrug hypersensitive. Her BMI was 39.9, fasting glucose, serum triglyceride, VLDL, HDL, HbA1C are: 166 mg/dl, 2166 mg/dl, 433 mg/dl, 32 mg/dl, 60 mmol/mol respectively. İn addition to Initial treatment of very low-fat diet, we immediately started medication to reduce triglyceride levels into a safe range to prevent triglyceride-induced pancreatitis. After 10 day of receiving fenofibrate and dapagloflozin she had an generalized acute urticaria need hospitalization and first treated with antihistamine drugs. Here serum triglyceride level was 1906 that force us to continue medication tratment with antihistamine drug. After 4 mounth of treatment and weight loss (10 kg) we didn’t reach therapy goals of hyperlipidemıa. The patient had a bariatric surgrey after mutidisplanary consensur. After surgrey she stoped medication and her serum triglyceride measure was 240 mg/dl.
Conclusion: We report a case of generalized urticaria probable or very probable induced by fenofibrate underwent bariatric surgery. Approximately 60-70%of patients with obesity are dyslipidemic. The Roux-en-Y gastric bypass and laparoscopic sleeve gastrectomy have been shown to improve A1C, reduce weight, and reduce the number of medications patients need for diabetes management. Comorbidities such as hyperlipidemia and hypertension also may improve. A reduction in medication of hypersensitive patients can be considered an additional benefit of bariatric surgery.
Background: The risk of cancer is relatively higher in Graves’ patients presenting simultaneously with thyroid nodules. Radioiodine (RAI) therapy recommended in intermediate-high risk differentiated thyroid carcinoma may be associated with worsening of a pre-existing Graves’ orbitopathy (GO) or developing a new onset. The impact of RAI therapy in patients with differentiated thyroid cancer on the course of a pre-exisiting GO has not been specifically investigated. we report a sever GO patient treated by recombinant Tsh (RhTSH) for intermediate-risk of papillary thyroid cancers (PTC). Case: A 47-year-old man, presented to our center with exophthalmos and ptosis of eyes. His thyroid function tests and thyroid autoantibodies were as follows: TSH; 0.01 (0.4–4 uIU/ml), FT3; 5.41 (1.6–4.9 pg/ml), FT4; 1.74 (0.78–1.76 ng/dl); anti TPO was positive TSH-R Ab; 1.249. On the ultrasonographic examination of the thyroid gland the paranchyme was heterogeneous and in the right lobe 11.2 × 8.9 mm heterogeneous, iso-hyporechogenic nodule and pathologic lymphadenopathy were detected in levels 4 of neck. US-guided fine-needle aspiration biopsy was performed and the cytological examination were suspicious for papillary thyroid cance of the nodule and malign sitology of the lymph node. Computed tomography scan of orbita demostrated bilateral anterior bulging of bulbus oculi clearly and bilateral enlargement of medial, inferior and superior rectus muscles and also swelling of the optic nerve. In addition to antithyroid and beta blocker, for severe ophthalmopathy intravenous pulse therapy with high doses of methylprednisolone as 500 mg tapered in 24 weeks duration, followed by 250 mg for 24 weeks. He underwent thyroidectomy and a dissection of the santral and right lateral lymph nodules was conducted. The diagnosis were PTC with < 5% of hobnail variant and mestatic lymph nodules was confirmed. Once stabilized of GO under oral methylprednisolone and became euthyroid he reseved 150 mCi RAI with rhTSH with no changes in GO after One month observation. Discussion: The risk of cancer is relatively higher in Graves’ patients in the presence of an accompanying nodular disease. Moreover, some authors reported that thyroid cancer associated with GD seemed to be more aggressive. RAI therapy is recommended in high-risk differentiated thyroid carcinoma, but it might worsen or induce a new onset of GO. Glucocorticoid treatment should be given especially in patients who will receive high doses of RAI. RAI with rhTSH had no difference in GO outcome at first month.
Background: The risk of cancer is relatively higher in Graves’ patients presenting simultaneously with thyroid nodules. Radioiodine (RAI) therapy recommended in intermediate-high risk differentiated thyroid carcinoma may be associated with worsening of a pre-existing Graves’ orbitopathy (GO) or developing a new onset. The impact of RAI therapy in patients with differentiated thyroid cancer on the course of a pre-exisiting GO has not been specifically investigated. we report a sever GO patient treated by recombinant Tsh (RhTSH) for intermediate-risk of papillary thyroid cancers (PTC).
Case: A 47-year-old man, presented to our center with exophthalmos and ptosis of eyes. His thyroid function tests and thyroid autoantibodies were as follows: TSH; 0.01 (0.4–4 uIU/ml), FT3; 5.41 (1.6–4.9 pg/ml), FT4; 1.74 (0.78–1.76 ng/dl); anti TPO was positive TSH-R Ab; 1.249. On the ultrasonographic examination of the thyroid gland the paranchyme was heterogeneous and in the right lobe 11.2 × 8.9 mm heterogeneous, iso-hyporechogenic nodule and pathologic lymphadenopathy were detected in levels 4 of neck. US-guided fine-needle aspiration biopsy was performed and the cytological examination were suspicious for papillary thyroid cance of the nodule and malign sitology of the lymph node. Computed tomography scan of orbita demostrated bilateral anterior bulging of bulbus oculi clearly and bilateral enlargement of medial, inferior and superior rectus muscles and also swelling of the optic nerve. In addition to antithyroid and beta blocker, for severe ophthalmopathy intravenous pulse therapy with high doses of methylprednisolone as 500 mg tapered in 24 weeks duration, followed by 250 mg for 24 weeks. He
underwent thyroidectomy and a dissection of the santral and right lateral lymph nodules was conducted. The diagnosis were PTC with < 5% of hobnail variant and mestatic lymph nodules was confirmed. Once stabilized of GO under oral methylprednisolone and became euthyroid he reseved 150 mCi RAI with rhTSH with no changes in GO after One month observation.
Discussion: The risk of cancer is relatively higher in Graves’ patients in the presence of an accompanying nodular disease. Moreover, some authors reported that thyroid cancer associated with GD seemed to be more aggressive. RAI therapy is recommended in high-risk differentiated thyroid carcinoma, but it might worsen or induce a new onset of GO. Glucocorticoid treatment should be given especially in patients who will receive high doses of RAI. RAI with rhTSH had no difference in GO outcome at first month.
Background: Primary thyroid lymphoma (PTL) is defined as a lymphoma involving only the thyroid gland or the thyroid gland and adjacent (regional) neck lymph nodes. Primary lymphomas of the thyroid are uncommon tumours, representing approximately 5% of the thyroid neoplasms and 2% of extranodal lymphomas. The most characteristic presentation is that of a rapidly enlarging neck mass often associated with dysphagia. The majority of patients are euthyroid and one third of patients have compressive symptoms. The mass is usually fixed to surrounding tissues and half the patients have unilateral or bilateral cervical lymph node enlargement. Abscess formation in the background of thyroid lymphoma with thyrocutaneous fistula is further rare. Reaching the final diagnosis can be delayed if insufficient biopsy material is obtained and it may be difficult to distinguish thyroid lymphoma from anaplastic carcinoma and thyroiditis. The present study describes the case of a patient who was presentad with abscess formation suggesting the possibility of anaplastic carcinoma and finaly diagnosd by diffuse large B-cell lymphoma.
Case: A 73-year-old female presented with anterior neck pain, hoarseness and rapidly expanding mass with abscess formation on here neck. The patient was admitted to our clinic for preoperative thyroid surgery suggesting the possibility of anaplastic carcinoma due to fine needle aspiration cytology of suspicious for malignancy. Her serum TSH was elevated to 47 mU/l and anti TPO was very high. Here neck ultrasound showed a significantly enlarged, diffuse parenchymal inhomogeneity and ill defined border of the thyroid gland. We performed Tru-cut biopsy and histological diagnosis was Diffuse large B-cell lymphoma of the thyroid gland. After 18FDG-positron emission tomography/computed tomography (PET/CT) scanning the patient reseaved 6 regimen of chemotherapy R-CHOP (rituximab, cyclophosphamide, doxorubicin [hydroxydoxorubicin], vincristine [Oncovin], prednisone with antibioticsand she has a good physical condition.
Discussion: Thyroid abscess is a rare clinical situation. It is most commonly associated with pyriform sinus fistula. Abscess formation in the background of thyroid cancer with thyro-cutaneous fistula is further rare. PTL is an uncommon malignancy of the thyroid. PTL occur most commonly in elderly women and are commonly of B-cell origin. Fine needle aspiration has become the procedure of choice for the initial pathological diagnosis of thyroid nodule. However, studies have also shown inconsistent results in the diagnosis of lymphoma of the thyroid. But clinical and radiological suspicion and cytomorphological features can help reaching the correct diagnosis in such cases.
Objective: Radioactive iodine (RAI) therapy is widely used in both diagnosis and treatment of benign and malignant thyroid diseases. It is generally a well tolerated therapy. Bone marrow suppression is often a temporary side effect with a decrease in white blood cells and platelets up to 6–10 weeks. In this study, we aimed to examine hematological changes in patients who received RAI treatment for benign or malignant diseases of the thyroid. Methods: The records of patients who applied to our endocrinology clinic between January 2016 and January 2019 and received RAI treatment for benign or malignant etiologies were evaluated retrospectively. The demographic data of the patients and data on thyroid disease, additional diseases, and the drugs used were recorded, the patients were grouped according to the etiology and the RAI dose they received. Blood count parameters measured before RAI treatment within 7 days, after RAI treatment and at the last control of the patient were recorded and compared in these patients. Results: In the study, data of total 202 patients, including 158 women (77.5%) and 44 men (21.6%), were evaluated. 168 of these patients (82.4%) had received RAI treatment due to malign, and 34 benign (16.7%) etiologies. The median age they received RAI was 45 (20–84), while the median dose of RAI was 75 mCi (10–200). Pre-treatment and first control interval was median 44 (18–93) days, and the median time between pre-treatment and last control was 35 (4–56) months. In comparison of hematological parameters before and after treatment, the median leukocyte count was 7.72 (3.89–19.93) × 109/l before treatment, while it was significantly reduced 6.27 (0.86–14.5) × 109/l at the first control after treatment and 6.78 (3.58–10.8) × 109/l at the last control. Similarly, a decrease in neutrophil and lymphocyte counts was detected after treatment. While the median hemoglobin value was 13.95 (8.8–17.2) g/dl before RAI treatment, it was 13.5 (7.8–17.3) g/dl and 13.5 (6.7–17.6) g/dl at the first and last control after treatment, respectively. The median platelet count was 283 (149–563) × 109/l, and it was 250.5 (134–507) × 109/l at the first post-treatment control and 266.5 (116–539) × 109/l at the last control. While the median value of mean platelet volume(MPV) was 10.8 (8.5–13.8) fL before treatment, it was 10.15 (7.6–13.1) fL and 8.2 (6.6–11.1)fL, respectively, in controls. Conclusion: In our study, a significant decrease was found in the leukocyte, neutrophil, lymphocyte, platelet counts, hemoglobin levels and mean platelet volumes in the post RAI treatment period. According to these findings, it can be thought that the decrease in hematological parameters continues not only in the acute period but also in the chronic period after RAI.
Objective: Radioactive iodine (RAI) therapy is widely used in both diagnosis and treatment of benign and malignant thyroid diseases. It is generally a well tolerated therapy. Bone marrow suppression is often a temporary side effect with a decrease in white blood cells and platelets up to 6–10 weeks. In this study, we aimed to examine hematological changes in patients who received RAI treatment for benign or malignant diseases of the thyroid.
Methods: The records of patients who applied to our endocrinology clinic between January 2016 and January 2019 and received RAI treatment for benign or malignant etiologies were evaluated retrospectively. The demographic data of the patients and data on thyroid disease, additional diseases, and the drugs used were recorded, the patients were grouped according to the etiology and
the RAI dose they received. Blood count parameters measured before RAI treatment within 7 days, after RAI treatment and at the last control of the patient were recorded and compared in these patients.
Results: In the study, data of total 202 patients, including 158 women (77.5%) and 44 men (21.6%), were evaluated. 168 of these patients (82.4%) had received RAI treatment due to malign, and 34 benign (16.7%) etiologies. The median age they received RAI was 45 (20–84), while the median dose of RAI was 75 mCi (10–200). Pre-treatment and first control interval was median 44 (18–93) days, and the median time between pre-treatment and last control was 35 (4–56) months. In comparison of hematological parameters before and after treatment, the median leukocyte count was 7.72 (3.89–19.93) × 109/l before treatment, while it was significantly reduced 6.27 (0.86–14.5)
× 109/l at the first control after treatment and 6.78 (3.58–10.8) × 109/l at the last control. Similarly, a decrease in neutrophil and lymphocyte counts was detected after treatment. While the median hemoglobin value was 13.95 (8.8–17.2) g/dl before RAI treatment, it was 13.5 (7.8–17.3) g/dl and 13.5 (6.7–17.6) g/dl at the first and last control after treatment, respectively. The median platelet count was 283 (149–563) × 109/l, and it was 250.5 (134–507) × 109/l at the first post-treatment control and 266.5 (116–539) × 109/l at the last control. While the median value of mean platelet volume(MPV) was 10.8 (8.5–13.8) fL before treatment, it was 10.15 (7.6–13.1) fL and 8.2 (6.6–11.1)fL, respectively, in controls.
Conclusion: In our study, a significant decrease was found in the leukocyte, neutrophil, lymphocyte, platelet counts, hemoglobin levels and mean platelet volumes in the post RAI treatment period. According to these findings, it can be thought that the decrease in hematological parameters continues not only in the acute period but also in the chronic period after RAI.
Introduction: Thyroid cancer is the most common endocrine malignancy and its overall incidence has increased significantly in the last 30 years. Cancer in adolescents and young adults (AYA) is defined by the National Cancer Institute as diagnoses occurring among those aged 15 to 39 years. Thyroid cancer is the second most common cancer in the AYA population. In this study, we aimed to compare clinical, ultrasonographical, cytological and histopathological features of thyroid carcinoma in patients AYA with older counterparts. Materials and methods: The medical records of patients who underwent thyroidectomy between December 2006 and September 2016 and were diagnosed with thyroid cancer histopathologically were retrospectively reviewed. Patients were subdivided into two age groups: 1539 (Group1 ) and ? 40 years old (Group 2). Thyroid functions, ultrasonographic features of malignant nodules, cytological and histopathological findings were compared in patients with AYA patients and ? 40 years. Results: The study included 229 (22.6%) AYA patients and 784 (77.4%) patients aged ? 40 years. Thyroid functions, thyroid autoantibody positivity and thyroidectomy indications were similar. There were 305 (21.4%) and 1121 (78.6%) malignant foci in Group 1 and 2, respectively. Preoperative US features were similar in the two groups. Cytological results were distributed similarly in two groups (P = 0.512). Of all cancer types, 93.1% in Group 1 and 93.5% in Group 2 were papillary thyroid cancer (P = 0.772). Follicular cancer was found in 2.6% of Group 1 and 2.1% of Group 2 (P = 0.544). Medullary cancer constituted 1% of Group 1 and 1.1% of Group 2 (P = 0.895). Anaplastic cancer was found in 0.4% of Group 1 and 0.4% of Group 2 (P = 0.940). Lymph node metastasis was detected in 9.2% of group 1 and 7.4% of group 2 (P = 0.246). Distant metastasis was not detected in group 1, and it was found in 3 (0.4%) patients in group 2 (P = 0.366). There was not any significant difference in capsular and vascular invasion and extracapsular extension between groups. Conclusion: Previous studies have found that although AYA patients are more likely to be diagnosed with locoregional lymph node involvement compared to older patients, they are less likely to be diagnosed with distant metastases. In our study, the rate of diagnosis of lymph node metastasis was higher and the rate of distant metastasis was lower, but the difference was not statistically significant.
Introduction: Thyroid cancer is the most common endocrine malignancy and its overall incidence has increased significantly in the last 30 years. Cancer in adolescents and young adults (AYA) is defined by the National Cancer Institute as diagnoses occurring among those aged 15 to 39 years. Thyroid cancer is the second most common cancer in the AYA population. In this study, we aimed to compare clinical, ultrasonographical, cytological and histopathological features of thyroid carcinoma in patients AYA with older counterparts.
Materials and methods: The medical records of patients who underwent thyroidectomy between December 2006 and September 2016 and were diagnosed with thyroid cancer histopathologically were retrospectively reviewed. Patients were subdivided into two age groups: 1539 (Group1 ) and ? 40 years old (Group 2). Thyroid functions, ultrasonographic features of malignant nodules, cytological and histopathological findings were compared in patients with AYA patients and ? 40 years.
Results: The study included 229 (22.6%) AYA patients and 784 (77.4%) patients aged ? 40 years. Thyroid functions, thyroid autoantibody positivity and thyroidectomy indications were similar. There were 305 (21.4%) and 1121 (78.6%) malignant foci in Group 1 and 2, respectively. Preoperative US features were similar in the two groups. Cytological results were distributed similarly in two groups (P = 0.512). Of all cancer types, 93.1% in Group 1 and 93.5% in Group 2 were papillary thyroid cancer (P = 0.772). Follicular cancer was found in 2.6% of Group 1 and 2.1% of Group 2 (P = 0.544). Medullary cancer constituted 1% of Group 1 and 1.1% of Group 2 (P = 0.895). Anaplastic cancer was found in 0.4% of Group 1 and 0.4% of Group 2 (P = 0.940). Lymph node metastasis was detected in 9.2% of group 1 and 7.4% of group 2 (P = 0.246). Distant metastasis was not detected in group 1, and it was found in 3 (0.4%) patients in group 2 (P = 0.366). There was not any significant difference in capsular and vascular invasion and extracapsular extension between groups.
Conclusion: Previous studies have found that although AYA patients are more likely to be diagnosed with locoregional lymph node involvement compared to older patients, they are less likely to be diagnosed with distant metastases. In our study, the rate of diagnosis of lymph node metastasis was higher and the rate of distant metastasis was lower, but the difference was not statistically significant.
Introduction: Extramedullary plasmacytoma (EMP) is a plasma cell neoplasm of extraosseous tissues. Less than 5% of all plasma cell neoplasms develop extramedullary. EMP is most common in the upper respiratory tract and oral cavity. The thyroid gland is one of the extremely rare regions. It is more common in men and the average age at diagnosis is 55. Primary thyroid plasmacytoma is one of the rare thyroid neoplasms. It often manifests as a rapidly growing mass in the neck and cause symptoms due to mass pressure. Pathological evaluation is particularly important. At the diagnosis of thyroid plasmacytoma, multiple myeloma must be ruled out. Here we present our case of thyroid plasmacytoma diagnosed by tru-cut biopsy. Case: A 71-year-old female patient, with hypothyroidism and multinodular goiter since 2014, presented with a 6-month history of dyspnea and neck swelling. She had type 2 diabetes mellitus, hypertension, and coronary artery disease. Thyroid gland was grade 3, fixed nodules were bilateral palpable. Thyroid function tests were euthyroid on levothyroxine treatment and thyroid autoantibodies were positive. An ultrasound scan of the thyroid revealed an enlarged thyroid with thyroid nodules on the right and left lobes, extending to the isthmus with a significant increase in size compared to previous controls. Fine needle aspiration cytology was benign. Due to suspicion of thyroid lymphoma, tru-cut biopsy was performed which suggested plasma cell neoplasia and plasmacytoma. Hematology consultation was made, as a result of the tests, multiple myeloma and other plasma cell disorders were excluded. The patient was evaluated as extramedullary plasmacytoma. In the council of endocrinology and metabolism, hematology, general surgery, nuclear medicine and radiation oncology departments operation was preferred. Bilateral total thyroidectomy was performed, histopathology reported as plasma cell neoplasm. Radiotherapy was not considered to be given to the patient as she had no residue in the examinations performed in the postoperative period. The patient has been followed in remission for one year. Conclusion: Primary thyroid plasmacytoma is a rare thyroid neoplasm. Clinical examination and imaging methods are usually not determinative in diagnosis, pathological evaluation is at the forefront of diagnosis. Even if fine needle aspiration biopsy is benign, patients should be evaluated for tru-cut biopsy in case of clinical suspicion. In the begining, multiple myeloma must be ruled out. Regular follow-up of the patient is necessary, as conversion to multiple myeloma may occur rarely.
Introduction: Extramedullary plasmacytoma (EMP) is a plasma cell neoplasm of extraosseous tissues. Less than 5% of all plasma cell neoplasms develop extramedullary. EMP is most common in the upper respiratory tract and oral cavity. The thyroid gland is one of the extremely rare regions. It is more common in men and the average age at diagnosis is 55. Primary thyroid plasmacytoma is one of the rare thyroid neoplasms. It often manifests as a rapidly growing mass in the neck and cause symptoms due to mass pressure. Pathological evaluation is particularly important. At the diagnosis of thyroid plasmacytoma, multiple myeloma must be ruled out. Here we present our case of thyroid plasmacytoma diagnosed by tru-cut biopsy.
Case: A 71-year-old female patient, with hypothyroidism and multinodular goiter since 2014, presented with a 6-month history of dyspnea and neck swelling. She had type 2 diabetes mellitus, hypertension, and coronary artery disease. Thyroid gland was grade 3, fixed nodules were bilateral palpable. Thyroid function tests were euthyroid on levothyroxine treatment and thyroid autoantibodies were positive. An ultrasound scan of the thyroid revealed an enlarged thyroid with thyroid nodules on the right and left lobes, extending to the isthmus with a significant increase in size compared to previous controls. Fine needle aspiration cytology was benign. Due to suspicion of
thyroid lymphoma, tru-cut biopsy was performed which suggested plasma cell neoplasia and plasmacytoma. Hematology consultation was made, as a result of the tests, multiple myeloma and other plasma cell disorders were excluded. The patient was evaluated as extramedullary plasmacytoma. In the council of endocrinology and metabolism, hematology, general surgery, nuclear medicine and radiation oncology departments operation was preferred. Bilateral total thyroidectomy was performed, histopathology reported as plasma cell neoplasm. Radiotherapy was not considered to be given to the patient as she had no residue in the examinations performed in the postoperative period. The patient has been followed in remission for one year.
Conclusion: Primary thyroid plasmacytoma is a rare thyroid neoplasm. Clinical examination and imaging methods are usually not determinative in diagnosis, pathological evaluation is at the forefront of diagnosis. Even if fine needle aspiration biopsy is benign, patients should be evaluated for tru-cut biopsy in case of clinical suspicion. In the begining, multiple myeloma must be ruled out. Regular follow-up of the patient is necessary, as conversion to multiple myeloma may occur rarely.
Background: Ultrasonography and fine needle aspiration biopsy are frequently used in the diagnosis of thyroid cancer. However, supportive data might be required in case of diagnostic difficulty. In this study, we investigated whether there is a relationship between thiol/disulfide homeostasis and cytological and histopathological diagnosis of thyroid nodules. Materials and methods: A total of 119 participants were included in the study (81 euthyroid nodular goiter patients and 28 age and body mass index matched healthy volunteers). The patient group consisted of individuals scheduled for thyroidectomy. Thyroidectomy indications were giant nodule, cytological diagnosis and patient preference. Patients with diseases that would affect thiol/disulfide homeostasis were excluded. Cytological findings, histopathology results were evaluated. Native thiol, total thiol, and disulfide concentrations were measured, and disulfide/native thiol, disulfide/total thiol and native thiol/total thiol ratios were calculated. Thiol/disulfide levels were analyzed with automated spectrophotometric method. Results: There was no significant difference in oxidative stress parameters between different Bethesda categories. However, the increasing Bethesda categories were weakly positively correlated with the disulfide/native thiol (r: 0.241, p:0.030) and disulfide/total thiol (r: 0.250 p: 0.024). The disulfide concentration was 16.07±9.28 μmol/l in histopathologically benign, 19.85±11.28 μmol/l in malignant, and 14.87±7.62 μmol/l in the control group (P<0.001, f=11.724). Disulfide/native thiol was calculated as 3.58±2.0 in the benign group, 5.50±2.85 in the malignant group, and 3.41±1.70 in the control group (P < 0.001, f=8.415). Disulfide/total thiol was significantly higher in the malignant compared to benign and control groups (4.96±2.24, 3.27±1.80 and 4.96±2.24, respectively, P <0.001, f=9.49). Conclusion: Oxidative stress parameters were significantly higher in thyroid cancer. A weak positive correlation was detected between Bethesda categories and the disulfide/native thiol ratio and the disulfide/total thiol ratio. In case of diagnostic difficulties, additional benefit can be obtained from thiol/disulfide measurement.
Background: Ultrasonography and fine needle aspiration biopsy are frequently used in the diagnosis of thyroid cancer. However, supportive data might be required in case of diagnostic difficulty. In this study, we investigated whether there is a relationship between thiol/disulfide homeostasis and cytological and histopathological diagnosis of thyroid nodules.
Materials and methods: A total of 119 participants were included in the study (81 euthyroid nodular goiter patients and 28 age and body mass index matched healthy volunteers). The patient group consisted of individuals scheduled for thyroidectomy. Thyroidectomy indications were giant nodule, cytological diagnosis and patient preference. Patients with diseases that would affect thiol/disulfide homeostasis were excluded. Cytological findings, histopathology results were evaluated. Native thiol, total thiol, and disulfide concentrations were measured, and disulfide/native thiol, disulfide/total thiol and native thiol/total thiol ratios were calculated. Thiol/disulfide levels were analyzed with automated spectrophotometric method.
Results: There was no significant difference in oxidative stress parameters between different Bethesda categories. However, the increasing Bethesda categories were weakly positively correlated with the disulfide/native thiol (r: 0.241, p:0.030) and disulfide/total thiol (r: 0.250 p: 0.024). The disulfide concentration was 16.07±9.28 μmol/l in histopathologically benign, 19.85±11.28 μmol/l in malignant, and 14.87±7.62 μmol/l in the control group (P<0.001, f=11.724).
Disulfide/native thiol was calculated as 3.58±2.0 in the benign group, 5.50±2.85 in the malignant group, and 3.41±1.70 in the control group (P < 0.001, f=8.415). Disulfide/total thiol was significantly higher in the malignant compared to benign and control groups (4.96±2.24, 3.27±1.80
and 4.96±2.24, respectively, P <0.001, f=9.49).
Conclusion: Oxidative stress parameters were significantly higher in thyroid cancer. A weak positive correlation was detected between Bethesda categories and the disulfide/native thiol ratio and the disulfide/total thiol ratio. In case of diagnostic difficulties, additional benefit can be obtained from thiol/disulfide measurement.
Background: We aimed to determine clinicopathological features that can predict lymph node metastasis (LNM) in papillary thyroid microcarcinomas (PTMC). Methods: Medical records of 872 patients with papillary thyroid cancer >1 cm (PTC >1 cm) and 1184 patients with papillary thyroid microcancer (PTMC) (£1 cm) were reviewed retrospectively. Demographical, clinical and histopathological features of (PTC >1 cm) and PTMC were compared. Association between clinicopathological features and LNM in PTMC was investigated. Results: The median age of patients with PTMC was significantly higher than patients with PTC>1 cm (49 vs 46 years old, P < 0.001). Multifocality, capsular invasion, vascular invasion, extrathyroidal extension (ETE) and LNM were more frequent in patients with PTC>1cm compared to patients with PMTC (P <0.001 for each). In PTMC group, those with LNM had significantly higher proportion of multifocality, capsular invasion, vascular invasion and ETE compared to those without LNM (P = 0.007, <0.001, P = 0.011 and P <0.001, respectively). Multifocality and ETE were significant factors for LNM with logistic regression analysis. Multifocality increased the risk of LNM by 1.737 times (95% CI: 1.079–2.979) and ETE increased the risk by 3.528 times (95%: 1.914–6.503). Primary tumor diameter ≥5.75 mm was predictive for LNM with a sensitivity of 0.782 and a specificity of 0.517 in PTMC. Conclusion: LNM should be investigated more carefully in patients with PTMC in the presence of tumor diameter≥5.75 mm, multifocality or ETE.
Background: We aimed to determine clinicopathological features that can predict lymph node metastasis (LNM) in papillary thyroid microcarcinomas (PTMC).
Methods: Medical records of 872 patients with papillary thyroid cancer >1 cm (PTC >1 cm) and 1184 patients with papillary thyroid microcancer (PTMC) (£1 cm) were reviewed retrospectively. Demographical, clinical and histopathological features of (PTC >1 cm) and PTMC were compared.
Association between clinicopathological features and LNM in PTMC was investigated.
Results: The median age of patients with PTMC was significantly higher than patients with PTC>1 cm (49 vs 46 years old, P < 0.001). Multifocality, capsular invasion, vascular invasion, extrathyroidal extension (ETE) and LNM were more frequent in patients with PTC>1cm compared to patients with PMTC (P <0.001 for each). In PTMC group, those with LNM had significantly higher proportion of multifocality, capsular invasion, vascular invasion and ETE compared to those without LNM (P = 0.007, <0.001, P = 0.011 and P <0.001, respectively). Multifocality and ETE were significant factors for LNM with logistic regression analysis. Multifocality increased the risk of LNM by 1.737 times (95% CI: 1.079–2.979) and ETE increased the risk by 3.528 times (95%: 1.914–6.503). Primary tumor diameter ≥5.75 mm was predictive for LNM with a sensitivity of 0.782 and a specificity of 0.517 in PTMC.
Conclusion: LNM should be investigated more carefully in patients with PTMC in the presence of tumor diameter≥5.75 mm, multifocality or ETE.
Purpose: Poorly differentiated thyroid carcinoma (PDTC); is a rare type of thyroid cancer with a high risk of recurrence, metastasis, and death. Pleural effusion due to thyroid cancer has seldom been reported. In this report, we present a case with PDTC related malignant pleural effusion. Case: A 66-year-old male patient presented with neck swelling and shortness of breath. At another center, thyroid ultrasonography revealed a multinodular goiter and an irregularly circumscribed lymphadenopathy on the left level IV. He had multiple lung metastases in thorax computed tomography (CT). Positron emission tomography/computed tomography (PET-CT) detected “hypermetabolism in malignant nodules in the thyroid, multiple metastatic lymph nodes in the neck and bilateral metastatic lung nodules.” Cytology of lymph nodes at the right level 3,4,6–2a junction was malignant. The patient underwent bilateral total thyroidectomy, bilateral central lymph node dissection, and right modified radical neck dissection with a final pathologic diagnosis of “poorly differentiated thyroid carcinoma, right lateral and central tumor positive lymph node.” Upon persistence of dyspnea, thoracentesis was performed for a left-sided pleural effusion, which in the end had exudative characteristics. [blood thyroglobulin (Tg): 23960 ng/ml, Tg with pleural fluid dilution > 30000 ng/ml]. Cytology confirmed carcinoma infiltration. In the follow-up, mediastinal, lung, and pleural metastases in addition to effusion in the left hemithorax persisted. We performed pleurodesis after the initial tube thoracostomy. During follow-up pleural fluid cell-block was performed due to continued pleural effusion and reported as carcinoma metastasis. 200 mCi RAI treatment was given after preparation with recombinant thyroid stimulating hormone (TSH). After the comparative PET-CT revealed progression, transthoracic lung biopsy performed and reported as carcinoma metastasis. After these results tyrosine kinase inhibitor (sorafenib) was initiated to the patient. Conclusion: The most common sites of distant metastasis of PDTC are the lungs and bones. It constitutes about 85% of deaths related to the disease. Less than 1% of malignant pleural effusions are associated with thyroid cancers. Pleural fluid thyroglobulin level and immunohistochemical staining may enhance the diagnostic process.
Purpose: Poorly differentiated thyroid carcinoma (PDTC); is a rare type of thyroid cancer with a high risk of recurrence, metastasis, and death. Pleural effusion due to thyroid cancer has seldom been reported. In this report, we present a case with PDTC related malignant pleural effusion.
Case: A 66-year-old male patient presented with neck swelling and shortness of breath. At another center, thyroid ultrasonography revealed a multinodular goiter and an irregularly circumscribed lymphadenopathy on the left level IV. He had multiple lung metastases in thorax computed tomography (CT). Positron emission tomography/computed tomography (PET-CT) detected “hypermetabolism in malignant nodules in the thyroid, multiple metastatic lymph nodes in the neck and bilateral metastatic lung nodules.” Cytology of lymph nodes at the right level 3,4,6–2a junction was malignant. The patient underwent bilateral total thyroidectomy, bilateral central lymph node dissection, and right modified radical neck dissection with a final pathologic diagnosis of “poorly differentiated thyroid carcinoma, right lateral and central tumor positive lymph node.” Upon persistence of dyspnea, thoracentesis was performed for a left-sided pleural effusion, which in the end had exudative characteristics. [blood thyroglobulin (Tg): 23960 ng/ml, Tg with pleural fluid dilution > 30000 ng/ml]. Cytology confirmed carcinoma infiltration. In the follow-up, mediastinal, lung, and pleural metastases in addition to effusion in the left hemithorax persisted. We performed pleurodesis after the initial tube thoracostomy. During follow-up pleural fluid cell-block was performed due to continued pleural effusion and reported as carcinoma metastasis. 200 mCi RAI treatment was given after preparation with recombinant thyroid stimulating hormone (TSH). After the comparative PET-CT revealed progression, transthoracic lung biopsy performed and reported as carcinoma metastasis. After these results tyrosine kinase inhibitor (sorafenib) was initiated to the patient.
Conclusion: The most common sites of distant metastasis of PDTC are the lungs and bones. It constitutes about 85% of deaths related to the disease. Less than 1% of malignant pleural effusions are associated with thyroid cancers. Pleural fluid thyroglobulin level and immunohistochemical staining may enhance the diagnostic process.
Background: Our aim was to compare the effectiveness of five different risk-stratification systems using the ultrasonographical features of thyroid nodules in determining malignant histopathology.
Methods: The preoperative ultrasonography (US) features of 6925 nodules of 3030 patients who underwent thyroidectomy between 2007 and 2014 were analyzed retrospectively. The nodules were classified according to Kwak-TIRADS (Thyroid imaging reporting and data system), European Thyroid Association-TIRADS (EU-TIRADS), Korea-TIRADS, American Society of Clinical Endocrinologists (AACE), American Thyroid Association (ATA).1362 nodules (1042 patients) that could be scored in all of these systems were included. Malignancy rate, specificity, sensitivity, positive predictive value (PPV) and negative predictive value were calculated.
Results: In the nodules with high risk scored,malignant histopathology rate were 50%, 27.7%, 32.2%, 29.9%, 31.9% in Kwak-TIRADS, EU_TIRADS, Kore-TIRADS, AACE, ATA, respectively (Table 1). Area under curve (AUC) was higher than 0.5 for all systems (P <0.001,Table 2). When determining optimal cut-off for each system, sensitivity, specificity, PPV, and NPV were about 60%, 75%, 27–30% and 92%, respectively (Table 2). EUTIRADS had significantly lower AUC (corrected P<0.05). AUC of Korea-TIRADS was lower than that of ATA (corrected-P<0.001). AUCs of Kwak-TIRADS, AACE, and ATA were similar and significantly higher than the others (Table 2).
Conclusion: Risk-stratification systems have variable efficiency in predicting malignancy risk since they are operator dependent and require experience in that field. The sensitivity was found to be lower than the previous studies which might be due to retrospective evaluation of US reports rather than real time risk scoring.
Table-1.Distribution of benign and malignant nodules according to riskstratification systems
1:Row percentage; 2:Column percentage
Aim: Euthyroid Sick Syndrome (ESS) is a thyroid disease appeared in critical and noncritical illnesses. ESS can be seen in patients with end stage renal disease (ESRD). In this study, we aimed to evaluate the frequency of ESS before and after renal transplantation in patients with ESRD, and its association with oxidative stress by evaluating thiol-disulphide levels. Material and Method: In this study, free triiodothyronine (fT3), free thyroxine (fT4) and thyroid stimulating hormone (TSH) levels were recorded before and after renal transplantation in patients with ESRD. ESS was diagnosed in patients with unresponsive TSH to low fT3 and/ or fT4 levels, Thiol and disulphide parameters of patients before and after transplantation were also recorded. Results: One- hundred twenty one patients were included in the study. Of these, 69 (57%) were males and 52 (43%) were females. The mean age was 45±12.61 years. ESS was detected in 39 (32%) of 121 patients. Of 39 patients, 24 (61%) had ESS before transplantation and 15 (39%) after transplantation. Frequency of ESS was 19.8% in patients followed with ESRD. Sixteen of 24 (66.7%) patients with ESS before transplantation reached to normal thyroid functions after transplantation. After transplantation, patients with ESS had significantly higher urea and creatinine (respectively, P = 0.025 and P = 0.009), and lower fT4, fT3, total protein, and albumin (P = <0.001; for all parameters) compared to patients without ESS. Patients with ESS before transplantation had also significantly higher creatinine levels compared to patients without ESS (P = 0.034). Free T4 and fT3 levels were significantly low (P <0.001 for both). Thiol- disulphide levels of 20 patients with ESS at any time compared with 68 patients without ESS. We found that native thiol and total thiol were low significantly in patients with ESS (respectively, P = 0.025 and P = 0.044). Conclusion: Our study is the initial study evaluating the oxidative stress and antioxidation status in etiology of ESS in patients with renal transplantation. Presence of markedly low level of antioxidation in these patients supports the possible role of oxidative stress in etiology of ESS.
Aim: Euthyroid Sick Syndrome (ESS) is a thyroid disease appeared in critical and noncritical illnesses. ESS can be seen in patients with end stage renal disease (ESRD). In this study, we aimed to evaluate the frequency of ESS before and after renal transplantation in patients with ESRD, and its association with oxidative stress by evaluating thiol-disulphide levels.
Material and Method: In this study, free triiodothyronine (fT3), free thyroxine (fT4) and thyroid stimulating hormone (TSH) levels were recorded before and after renal transplantation in patients with ESRD. ESS was diagnosed in patients with unresponsive TSH to low fT3 and/ or fT4 levels, Thiol and disulphide parameters of patients before and after transplantation were also recorded.
Results: One- hundred twenty one patients were included in the study. Of these, 69 (57%) were males and 52 (43%) were females. The mean age was 45±12.61 years. ESS was detected in 39 (32%) of 121 patients. Of 39 patients, 24 (61%) had ESS before transplantation and 15 (39%) after transplantation. Frequency of ESS was 19.8% in patients followed with ESRD. Sixteen of 24 (66.7%) patients with ESS before transplantation reached to normal thyroid functions after transplantation. After transplantation, patients with ESS had significantly higher urea and creatinine (respectively, P = 0.025 and P = 0.009), and lower fT4, fT3, total protein, and albumin (P = <0.001; for all parameters) compared to patients without ESS. Patients with ESS before transplantation had also significantly higher creatinine levels compared to patients without ESS (P = 0.034). Free T4 and fT3 levels were significantly low (P <0.001 for both). Thiol- disulphide levels of 20 patients with ESS at any time compared with 68 patients without ESS. We found that native thiol and total thiol were low significantly in patients with ESS (respectively, P = 0.025 and P = 0.044).
Conclusion: Our study is the initial study evaluating the oxidative stress and antioxidation status in etiology of ESS in patients with renal transplantation. Presence of markedly low level of antioxidation in these patients supports the possible role of oxidative stress in etiology of ESS.
Introduction: Steroid cell tumors (SCTs) are a rare subgroup of sex-cord tumors of the ovary that account for less than 0.1% of all ovarian tumors. They are classified into three categories based on the cell origin: stromal luteoma, Leydig-cell tumor, and not otherwise specified (NOS). NOS tumors are the most common subtype and comprise the largest proportion of cases (60%).The clinical presentations are not specific, including abdominal pain, distention and bloating. However, the more significant presentations are those associated with the hormonal activity and virilizing properties of the tumor. The cornerstone of SCT-NOS treatment is surgery. Case: A 55-year-old female came to our hospital in November 2020 with months’ history of increasing facial and truncal hair. She also had hypertension and diabetes mellitus. In the medical history of the patient, she had been operated for papillary thyroid cancer, sleeve gastrectomy, total abdominal hysterectomy and left salpingo-oophorectomy 30 years ago. Physical examination revealed obesity (body mass index, 37.3 kg/m2).She had a Ferriman–Gallwey score of 24. Abdominal ultrasound identified a 40 × 20 mm solid, right ovarian mass.Biochemical data shows the levels of folicle stimulating hormone and luteinising hormone were as high as 52.1 U/l and 33.3 U/l, respectively. Serum adrenocorticotropic hormone, cortisol, estradiol, serum prolactin, dihydroepiandosterone sulfate were found within reference intervals.Total and free serum testosterone levels were found to be as high as 450 ng/dl (normal 7–49 ng/dl) and 19.99 (normal<4.2 pg/ml), respectively. Magnetic resonance imaging with contrast confirmed the ultrasound findings and detected no adrenal gland enlargement or tumor.The right salpingooophorectomy was done, and the specimen was sent to our department for histopathological examination. On surgical staging laparotomy, it was found that there was an enlarged (3×3×2 cm) right ovary with both solid and cystic component and normal ovarian contour.Microscopically, mitotic activity 2–3/10, mild atypia, and no significant necrosis. Immunohistochemistry revealed a result of MelanA(+), ER (+), CD56(+), Calretinin (+), Inhibin-α (+), ki-67 (5–6%+). Histological features were consistent with SCTs-NOS type.At post-operative follow-up, her total serum testosterone and serum free testosterone level had gone down to 13 ng/dl and 0.73 pg/ml, respectively. Conclusion: SCTs, NOS, are rare ovarian tumors which can be difficult to diagnose. Careful history and physical examination, in addition to laboratory values and imaging studies, are helpful in making the diagnosis.They are usually benign, unilateral and are characterized by hyperandrogenism and virilization. SCTs should be considered in differential diagnosis among women presenting with symptoms of virilization.
Introduction: Steroid cell tumors (SCTs) are a rare subgroup of sex-cord tumors of the ovary that account for less than 0.1% of all ovarian tumors. They are classified into three categories based on the cell origin: stromal luteoma, Leydig-cell tumor, and not otherwise specified (NOS). NOS tumors are the most common subtype and comprise the largest proportion of cases (60%).The clinical presentations are not specific, including abdominal pain, distention and bloating. However, the more significant presentations are those associated with the hormonal activity and virilizing properties of the tumor. The cornerstone of SCT-NOS treatment is surgery.
Case: A 55-year-old female came to our hospital in November 2020 with months’ history of increasing facial and truncal hair. She also had hypertension and diabetes mellitus. In the medical history of the patient, she had been operated for papillary thyroid cancer, sleeve gastrectomy, total abdominal hysterectomy and left salpingo-oophorectomy 30 years ago. Physical examination revealed obesity (body mass index, 37.3 kg/m2).She had a Ferriman–Gallwey score of 24. Abdominal ultrasound identified a 40 × 20 mm solid, right ovarian mass.Biochemical data shows the levels of folicle stimulating hormone and luteinising hormone were as high as 52.1 U/l and 33.3 U/l, respectively. Serum adrenocorticotropic hormone, cortisol, estradiol, serum prolactin, dihydroepiandosterone sulfate were found within reference intervals.Total and free serum testosterone levels were found to be as high as 450 ng/dl (normal 7–49 ng/dl) and 19.99 (normal<4.2 pg/ml), respectively. Magnetic resonance imaging with contrast confirmed the ultrasound findings and detected no adrenal gland enlargement or tumor.The right salpingooophorectomy was done, and the specimen was sent to our department for histopathological examination. On surgical staging laparotomy, it was found that there was an enlarged (3×3×2 cm) right ovary with both solid and cystic component and normal ovarian contour.Microscopically, mitotic activity 2–3/10, mild atypia, and no significant necrosis. Immunohistochemistry revealed a result of MelanA(+), ER (+), CD56(+), Calretinin (+), Inhibin-α
(+), ki-67 (5–6%+). Histological features were consistent with SCTs-NOS type.At post-operative follow-up, her total serum testosterone and serum free testosterone level had gone down to 13 ng/dl and 0.73 pg/ml, respectively.
Conclusion: SCTs, NOS, are rare ovarian tumors which can be difficult to diagnose. Careful history and physical examination, in addition to laboratory values and imaging studies, are helpful in making the diagnosis.They are usually benign, unilateral and are characterized by hyperandrogenism and virilization. SCTs should be considered in differential diagnosis among women presenting with symptoms of virilization.
Introduction: Glucagonoma is an extremely rare type of functional pancreatic neuroendocrine tumor that is characterized by distinctive clinical manifestations such as diabetes mellitus, weight loss, deep vein thrombosis, and necrolytic migratory erythema which represents the hallmark clinical sign of glucagonoma syndrome. Here, we report the case of a 53-year-old male patient who presented with high amilase and lipase levels. In further investigation a pancreatic tumor was determined and after pancreatic surgery it was diagnosed as glucagonoma. Case: A 53-year-old male patient was examined routinely in cardiology. In the laboratory analysis, amilase and lipase were detected as above the upper limit of normal [amilase: 212 (Normal range: 30–118 U/l), lipase: 224 (Normal range: 12–53 U/l)]. He did not have any symptoms or signs associated with pancreatitis. Glycosylated A1c was 6.5%. In his past history he did not have diabetes mellitus. In the family history, he reported that his mother had diabetes. He referred to our outpatient clinic for prediabetes. Furtherly, 75 gr oral glucose tolerance test was performed. It was evaluated as impaired fasting glucose (0.min glucose: 115 mg/dl, 120.min glucose: 93 mg/dl). In the investigation of pancreatic enzyme abnormalities, abdominal ultrasound was performed. In the ultrasound, Grade 2 hepatosteatosis and a heterogenous weakly hypoechoic solid mass located in proximal pancreatic body which was 20x14.5 mm in diameter were detected. In abdominal MRI, a 21x16 mm mass located in posterior part of the pancreatic body which was mildly hyperintense in T2A and hypointense in T1A images was reported, and in contrasted images the tumor was found as prominent minimally according to parachyme, and had also diffusion restriction. For the investigation of neuroendocrine tumor, Ga-68 DOTA-PEPTIDE PET/CT was performed and it demonstrated a high pathologic Ga-68 enhancement in the pancreatic mass (SUVmax: 21.92). Then, the patient was operated. Distal pancreatectomy and splenectomy was performed. The histopathology was reported as grade 1 glucagonoma. Postoperatively, he had diabetes mellitus, he was under insulin treatment. His postoperative amilase, lipase values were normal. The postoperative glucagon value was 248 (normal range: 25–250 pg/ml). Conclusion: Glucagonoma is a rare pancreatic neuroendocrine tumor. Most common presentation is the skin lesions. Our patient was diagnosed after investigation of biochemical abnormality. He presented atypically as he did not have most typical presentations like most patients in the literature.
Introduction: Glucagonoma is an extremely rare type of functional pancreatic neuroendocrine tumor that is characterized by distinctive clinical manifestations such as diabetes mellitus, weight loss, deep vein thrombosis, and necrolytic migratory erythema which represents the hallmark clinical sign of glucagonoma syndrome. Here, we report the case of a 53-year-old male patient who presented with high amilase and lipase levels. In further investigation a pancreatic tumor was determined and after pancreatic surgery it was diagnosed as glucagonoma.
Case: A 53-year-old male patient was examined routinely in cardiology. In the laboratory analysis, amilase and lipase were detected as above the upper limit of normal [amilase: 212 (Normal range: 30–118 U/l), lipase: 224 (Normal range: 12–53 U/l)]. He did not have any symptoms or signs associated with pancreatitis. Glycosylated A1c was 6.5%. In his past history he did not have diabetes mellitus. In the family history, he reported that his mother had diabetes. He referred to our outpatient clinic for prediabetes. Furtherly, 75 gr oral glucose tolerance test was performed. It was evaluated as impaired fasting glucose (0.min glucose: 115 mg/dl, 120.min glucose: 93 mg/dl). In the
investigation of pancreatic enzyme abnormalities, abdominal ultrasound was performed. In the ultrasound, Grade 2 hepatosteatosis and a heterogenous weakly hypoechoic solid mass located in proximal pancreatic body which was 20x14.5 mm in diameter were detected. In abdominal MRI, a 21x16 mm mass located in posterior part of the pancreatic body which was mildly hyperintense in T2A and hypointense in T1A images was reported, and in contrasted images the tumor was found as prominent minimally according to parachyme, and had also diffusion restriction. For the investigation of neuroendocrine tumor, Ga-68 DOTA-PEPTIDE PET/CT was performed and it demonstrated a high pathologic Ga-68 enhancement in the pancreatic mass (SUVmax: 21.92). Then, the patient was operated. Distal pancreatectomy and splenectomy was performed. The histopathology was reported as grade 1 glucagonoma. Postoperatively, he had diabetes mellitus, he was under insulin treatment. His postoperative amilase, lipase values were normal. The postoperative glucagon value was 248 (normal range: 25–250 pg/ml).
Conclusion: Glucagonoma is a rare pancreatic neuroendocrine tumor. Most common presentation is the skin lesions. Our patient was diagnosed after investigation of biochemical abnormality. He presented atypically as he did not have most typical presentations like most patients in the literature.
Background: Pituitary xanthogranulomas are extremely rare tumors of the sellar region. A cystic mass lesion was found in the pituitary MRI of our patient diagnosed with central diabetes insipidus (DI). We aimed to present a case who was operated for a pituitary mass and diagnosed with sellar xanthogranuloma. Case presentation: 37-year-old female patient was applied to our outpatient clinic with complaints of polydipsia, polyuria and headache for 8 months. The anterior pituitary hormone levels were in normal. Plasma osmolarity: 291 mOsm/kg, urine osmolarity: 130 mOsm/kg, urine density: 1006 and serum electrolytes were in normal range. Pituitary MRI revealed a cystic mass lesion with prominent hyperintense mucoid content in T1-weighted sequences with a diameter of approximately 10 × 11 mm and completely obliterating the neurohypophysis in the posterior of the adenohypophysis. Also the cystic mass lesion showed expansion towards the posterior suprasellar system. Her visual field examination was found normal. The patient was admitted to our clinic for the water deprivation test. Complete central DI was diagnosed. Desmopressin treatment was started on. The clinic and laboratory findings of DI were improved after desmopressin treatment. The patient was evaluated by neurosurgery department. Transsphenoidal surgery was performed for the mass lesion in the pituitary. The pathology result was reported as sellar xanthogranuloma. Desmopressin therapy was continued in the postoperative period. Clinical and laboratory findings were found normal under desmopressin treatment. Pituitary MRI performed 3 months after the operation, no finding of residual-recurrent adenoma was detected in the sellar region. Conclusion: Sellar xanthogranulomas are very rare seen intracranial tumors. They have not any typical radiological feature. Patients can present with clinical signs such as headache, visual disturbance, vomiting, DI and hypopituitarism.
Background: Pituitary xanthogranulomas are extremely rare tumors of the sellar region. A cystic mass lesion was found in the pituitary MRI of our patient diagnosed with central diabetes insipidus (DI). We aimed to present a case who was operated for a pituitary mass and diagnosed with sellar xanthogranuloma.
Case presentation: 37-year-old female patient was applied to our outpatient clinic with complaints of polydipsia, polyuria and headache for 8 months. The anterior pituitary hormone levels were in normal. Plasma osmolarity: 291 mOsm/kg, urine osmolarity: 130 mOsm/kg, urine density: 1006 and serum electrolytes were in normal range. Pituitary MRI revealed a cystic mass lesion with prominent hyperintense mucoid content in T1-weighted sequences with a diameter of approximately 10 × 11 mm and completely obliterating the neurohypophysis in the posterior of the adenohypophysis. Also the cystic mass lesion showed expansion towards the posterior suprasellar system. Her visual field examination was found normal. The patient was admitted to our clinic for the water deprivation test. Complete central DI was diagnosed. Desmopressin treatment was started on. The clinic and laboratory findings of DI were improved after desmopressin treatment. The patient was evaluated by neurosurgery department. Transsphenoidal surgery was performed for the mass lesion in the pituitary. The pathology result was reported as sellar xanthogranuloma. Desmopressin therapy was continued in the postoperative period. Clinical and laboratory findings were found normal under desmopressin treatment. Pituitary MRI performed 3 months after the operation, no finding of residual-recurrent adenoma was detected in the sellar region.
Conclusion: Sellar xanthogranulomas are very rare seen intracranial tumors. They have not any typical radiological feature. Patients can present with clinical signs such as headache, visual disturbance, vomiting, DI and hypopituitarism.
Introduction: Pituitary gland tumors constitute approximately 10–15% of primary brain tumors, and posterior pituitary tumors are extremely rare. Granular cell tumor (GCT) is a low grade non-neuroendocrine neoplasm. Here, we will present our case who was found to have GCT during follow-up of diabetes insipidus (DI). Case: A 23-year-old male patient applied to our outpatient clinic for routine control. 12 years ago, he was diagnosed with growth hormone deficiency and central hypothyroidism during tests performed for short stature, and used growth hormone and levothyroxine treatments, and it was learned that these treatments were discontinued after puberty, and he had been using desmopressin for partial DI for 10 years. He was using desmopressin 240 mg/day at presentation. His height and weight were 165 cm and 60 kg, his blood pressure was 120/80 mm Hg, and his pulse was 72 beats/min. Systemic examination was normal. Serum Na level was 142 mEq/l, serum osmolality was 291 mOsm/kg, spot urine osmolality was 693 mOsm/kg, and urine density was 1020 (Table 1). On the neurohypophysis lodge, a high-signal lesion area (granular cell tumor?) was observed with magnetic resonance imaging in T1A and T2A series with 1.4 × 1 × 0.6 cm dimensions, which created convexity at the base of the sella contour. When the pituitary images of previous years were examined, it was reported that neurohypophysis was normal in 2010 and 2016, tubular structure showing loss of signal in all sequences in the neurohypophysis (vascular structure?) was observed in 2013, and in 2019, it was determined that a lesion (lipoma?, terotoma?, dermoid cyst?) was detected in the neurohypophysis lodge, which showed suppression (?) in a fat-suppressed sequence of 13 × 7 mm in size, and did not form a distinct opacification pattern in dynamic study. He was evaluated in a multidisciplinary council and follow-up was planned. Discussion: DI was seen in 3–5% of GCT cases. In our case, no tumor was observed on neurohypophysis at the time of diagnosis, but GHT was detected during follow-up. We are of the opinion that periodic pituitary imaging in DI cases may increase the possibility of detecting rare tumors such as GHT.
Introduction: Pituitary gland tumors constitute approximately 10–15% of primary brain tumors, and posterior pituitary tumors are extremely rare. Granular cell tumor (GCT) is a low grade non-neuroendocrine neoplasm. Here, we will present our case who was found to have GCT during follow-up of diabetes insipidus (DI).
Case: A 23-year-old male patient applied to our outpatient clinic for routine control. 12 years ago, he was diagnosed with growth hormone deficiency and central hypothyroidism during tests performed for short stature, and used growth hormone and levothyroxine treatments, and it was learned that these treatments were discontinued after puberty, and he had been using desmopressin for partial DI for 10 years. He was using desmopressin 240 mg/day at presentation. His height and weight were 165 cm and 60 kg, his blood pressure was 120/80 mm Hg, and his pulse was 72 beats/min. Systemic examination was normal. Serum Na level was 142 mEq/l, serum osmolality was 291 mOsm/kg, spot urine osmolality was 693 mOsm/kg, and urine density was 1020 (Table 1). On the neurohypophysis lodge, a high-signal lesion area (granular cell tumor?) was observed with magnetic resonance imaging in T1A and T2A series with 1.4 × 1 × 0.6 cm dimensions, which created convexity at the base of the sella contour. When the pituitary images of previous years were examined, it was reported that neurohypophysis was normal in 2010 and 2016, tubular structure showing loss of signal in all sequences in the neurohypophysis (vascular structure?) was observed in 2013, and in 2019, it was determined that a lesion (lipoma?, terotoma?, dermoid cyst?) was detected in the neurohypophysis lodge, which showed suppression (?) in a fat-suppressed sequence of 13 × 7 mm in size, and did not form a distinct opacification pattern in dynamic study. He was evaluated in a multidisciplinary council and follow-up was planned.
Discussion: DI was seen in 3–5% of GCT cases. In our case, no tumor was observed on neurohypophysis at the time of diagnosis, but GHT was detected during follow-up. We are of the opinion that periodic pituitary imaging in DI cases may increase the possibility of detecting rare tumors such as GHT.
Na; Sodium, K: Potassium, TSH: Thyroid stimulating hormone, st4: Thyroxine, GH: Growth hormone,
IGF1:Insulin-like growth factor, FSH: Follicle stimulating hormone, LH: Luteinizing hormone, ACTH:Adrenocorticotropic hormone
Introduction: Pituitary adenomas secreting TSH (TSHoma) are a rare cause of hyperthyroidism. They account for approximately 0.5–3 % of functioning pituitary tumours and much less than 1% of all cases of hyperthyroidism. TSHoma should be considered in all hyperthyroid patients, especially those with diffuse goitre and no extrathyroidal signs of Graves’ disease.
Case 1: A 30-year-old female applied to the internal medicine department with complaints of palpitations, diarrhea, sweating and weight loss. In repeated examinations, high levels of TSH, fT3 and fT4 were detected, TSH, fT3 and fT4 values examined in 3 different centres and again found to be high.The serum sex hormone-binding globulin concentration was slightly elevated. In family screening, no thyroid dysfunction was detected. In pituitary MRI, 5 mm adenoma was detected.The serum α-subunit level was 2.4 ng/ml (normal < 1.2), and the α-subunit/TSH molar ratio (α-subunit ×10/TSH) was 4.3 (normal < 1).We performed an analysis for mutations in the THRB gene; no mutations found. The serum TSH concentration didn’t increase in response to the thyrotropin-releasing hormone, while a fall in serum TSH concentrations was detected in response to administered T3. Since the tests showed discordance, a short course of long-acting (LAR) somatostatin analogue (SSA) was administered. Thyroid function tests returned to normal with LAR-SSA therapy and strengthened the diagnosis of TSHoma. Surgery was planned.
Case 2: A 35-year-old male patient was referred to the endocrinology department when elevated TSH, fT3 and fT4 values were detected in the smoking cessation outpatient clinic. Repeated examinations in the same centre and two different centres showed high TSH, fT3 and fT4 levels. No thyroid dysfunction was found in first-degree relatives.The serum sex hormonebinding globulin concentration was normal,and the serum α-subunit level was 0.7 ng/ml (normal<0.5). In pituitary MRI, 7 mm adenoma was detected. The serum TSH concentration didn’t increase in response to the thyrotropinreleasing hormone,while a fall in serum TSH concentrations was detected in response to administered T3. Since the tests showed discordance,a short course of LAR-SSA was administered. Thyroid function tests returned to normal with LAR-SSA therapy and strengthened the diagnosis of TSHoma. Surgery was planned.
Conclusion: Most TSHomas are detected as pituitary macroadenomas. The presence of a microadenoma on MRI is not specific for a TSH-secreting tumour and can be seen as an incidental finding in 10 per cent of normal individuals. The rutin tests used for the differential diagnosis of TSHoma and Thyroid hormone resistance sometimes may be discordant. In such cases, performing
the LAR-SSA test strengthen the diagnosis.
Introduction: Pituitary apoplexy is seen in 1.5–27.7% of pituitary adenomas. Common etiologies include hypertension, diabetes mellitus, radiotherapy, contrastenhanced MR, surgery, drugs, anticoagulant, antithrombotic, estrogen, head trauma and pregnancy. SARS-CoV-2 had spread rapidly, and caused COVID-19 pandemic. Although it mainly causes respiratory problems, there may also be extrapulmonary involvement. COVID-19 infection is associated with hemorrhagic complications, cardiac and renal infarction and cerebrovascular hemorrhage. In this report, we present a patient who was followed up with microprolactinoma and developed hemorrhagic degeneration in adenoma after Covid-19 infection.
Case: A 26-year-old female patient was found to have serum prolactin of 94.19 mg/l (4.79–25.3) in the tests performed due to menstrual irregularity and complaints of galactorrhea by provocation. Control prolactin was 104 mg/l, and macroprolactin was negative. Other anterior pituitary hormones, kidney and liver function tests were normal. A 4 × 6 mm microadenoma was detected on pituitary gland in pituitary MRI. Cabergoline 0.5 mg/week was initiated in March 2019 with the diagnosis of microprolactinoma. The pituitary MRI taken in February 2021 revealed a 7 × 5.5 mm lesion in the adenohypophysis with the presece of hemorrhagic degeneration. There were no complaints of severe headache, nausea, vomiting, or visual impairment during system inquiry. Anterior pituitary hormone levels were normal. Medical history showed that she was diagnosed with Covid-19 in September 2020. She used hydroxychloroquine sulfate 2 × 200 mg (5 days) and enoxaparin sodium 2 ×0.6 mg (10 days) and then acetylsalicylic acid for 10 days. It was thought that hemorrhagic degeneration might be due to the antiaggregant/antithrombotic treatment she had received or the Covid-19 infection itself.
Discussion: Case reports of pituitary apoplexy following Covid-19 infection have been presented in the literature. It is unclear whether this infection occurs as a contributing factor to pituitary apoplexy or coincidentally. It is possible that coronavirus infection could cause an acute hemorrhagic infarction of the gland. This risk increases with anticoagulant and antiaggregant treatments used during Covid-19 infection. Although bleeding into adenomas is spesific to macroadenomas, it should be kept in mind that it may also occur with microadenomas.
Background: Mucormycosis is an opportunistic fungal infection that can be aggressive and mortal. Diabetic ketoacidosis(DKA) is a risk factor for mucormycosis. We present a case with mucormycosis presenting with newly diagnosed diabetes mellitus and DKA.
Case presentation: A 34-year-old male patient presented with confusion and vomiting. He had no comorbiditiy. On admission the patient was afebrile, hypotensive (85/55 mm/hg) and had tachycardia (120/bpm). Laboratory investigations revealed hyperglycemia (673 mg/dl), severe metabolic acidosis (pH:6.86, bicarbonate:2.6 mmol/l) and urinary ketones. The patient was intubated due to cardiac arrest and followed up in the intensive care unit for 15 days. After that, the patient with newly diagnosed diabetes was admitted to our clinic for blood glucose regulation. During follow up, he described a feeling of swelling in the left half of the face and blurred vision. There was an erythematous appearance on the left eyelid. Diagnostic nasal endoscopy showed widespread crusting filling left nasal cavity and necrosis in the adjacent septum and middle meatus
which was suggestive of mucormycosis. Paranasal sinus CT revealed mucosal thickening in the left frontal sinus, left anterior-posterior ethmoidal cells, sphenoid sinus in the left compartment and in the left maxillary sinus, causing almost complete loss of ventilation. Mucosal thickening was observed in the left compartment of the sphenoid sinus and the ethmoidal cells on the left. Left frontal and left sphenoethmoidal recesses were obliterated. Left precentral fatty tissue and left pterygopalatine fossa, around the sphenopalatine foramen were dirty. Orbital CT was normal. Cranial MRI showed 22 × 10 mm flair hyperintensity accompanied by effacement in the sulcus in left frontal lobe, frontobasal-orbitofrontal level, cortical-subcortical located in the medial part. In this location, frontal bone integrity was not clearly differentiated, and signs of inflammation were observed in the adjacent frontal sinus. The patient was operated urgently. Histopathology confirmed the diagnosis of mucormycosis. Liposomal amphotericin-B treatment was started. The patient was discharged with intensive insulin treatment after five weeks.
Conclusion: Mucormycosis is an invasive and progressive disease which requires immediate diagnosis and treatment including surgical debridement. Although uncontrolled and long standing diabetes is a well-known important risk factor for this opportunistic infection, it is rare to see it in patients with newly diagnosed diabetes. Our case is important in terms of showing that this infection can also occur in newly diagnosed diabetes.
Background: We aimed to determine the awareness of obese, overweight and normal weight patients about the complications, causes and prevention of obesity. Methods: Patients who admitted to our clinic during a four months period were included. Demographical features, familial histories of obesity, smoking, alcohol use, chronic diseases, medications, medical nutrition therapy and exercise habits were determined. Answers of agree, not agree or no idea were obtained for 40 questions regarding the definition, consequences, risk factors and prevention of obesity. Patients were grouped as normal, overweight and obese according to the WHO criteria.
Results: Data of 352 patients (282 female and 70 male) were analyzed. There were 51(14.5%) normal weight, 72 (20.5%) overweight and 229 (65.0%) obese patients. Median ages were 49, 44 and 33 in obese, overweight and normal patients, respectively (P < 0.001). Education level was lower and familial history of obesity was higher in obese patients (P < 0.001). The rates of agreeing that obesity may cause insulin resistance, type 2 diabetes, cardiovascular disease, hypertension, dyslipidemia, fatty liver, sleep apnea, asthma, gastrointestinal problems, depression, mental problems, limitation of movement and mortality varied between 69.60% and 92.61%. Only 130 (36.93%), 138 (39.20%) and 191 (54.26%) patients agreed that obesity is associated with cholelithiasis, pancreatitis and cancer, respectively. The rate of patients who thought that obesity may cause death, sleep apnea and asthma were significantly higher in obese compared to normal weight patients. Approximately half of the patients agreed that obesity in family, eating too much, skipping meals, and engaging in other activities during eating are risk factors for obesity. Rates of agreement about risk factors for obesity were similar in three groups. More than 2/3 of patients agreed with how a healthy diet should be, and believed in the benefit of exercise. The rate of those who agreed that 4–6 meals/day and not to miss snacks are important for a healthy diet was highest in the obese group (72.92%, P = 0.043). There was no significant difference between groups in terms of other questions regarding a healthy diet.
Conclusion: While awareness about some of the obesity associated complications are high, awareness about others such as gall bladder disease, pancreatitis and cancer are low. Obese patients have higher awareness that obesity can cause death, sleep apnea and asthma. The knowledge about risk factors of obesity related with eating habits was relatively low. It is important to raise awareness of both obese and non-obese patients for the prevention and appropriate treatment of obesity.
Introduction: Lung transplantation was associated with a 32% prevalence of hypercholesterolemia and a 41% prevalence of hypertriglyceridemia. The prevalence of dyslipidemia in liver transplant recipients is 43% and 31% –51%. In this report, we present 2 cases who developed dyslipidemia after transplantation.
Case 1: The blood test of a 73-year-old male patient who had lung transplantation about 3 years ago revealed Triglyceride (TG) 475 mg/dl (<150), LDLCholesterol: 382 mg/dl (<100), HDL 53 mg/dl (>40), Total cholesterol 431 mg/dl (<200) and HbA1C: 8.3. Six months ago, he was diagnosed with diabetes mellitus by his primary physician. He was on everolimus, prednisolone, and mycophenalate sodium therapy, and was referred to us. There were no cutaneous findings related to hyperlipidemia. After the diet and blood sugar regulation, the tests were repeated; TG was 422 mg/dl and LDL was 366 mg/dl. He had elevated liver function test (LFT) levels, and hepatitis panel and liver auto antibodies were negative. Atorvastatin 1×10 mg was initiated on 14/02/2020. TG was 210 mg/dl (<150), and LDL cholesterol level was 123 mg/dl (<100).
Case 2: A 65-year-old female patient underwent liver transplantation from a cadaver on 12/09/2019 due to toxic hepatitis and on 25/09/2019 due to hepatic vein thrombosis after transplantation. Receiving tacrolimus and mycophenolic acid treatments after transplantation, she developed refractory dyslipidemia after the second transplant. Tests performed in February 2020 showed levels
of Triglyceride 474 mg/dl (<150), LDL-Cholesterol 512 mg/dl (<100), Total Cholesterol 815mg/dl (<200) and HDL cholesterol 11 mg/dl (>50). Pravastatin 1 × 40 mg was initiated in February 2020 and intermittent lipid apheresis was performed. In April 2020, ezetimibe 1 × 10 mg was added to her treatment. In May 2020, LDL level was determined 186 mg/dl.
Discussion: Maintaining or improving allograft function after transplantation and reducing cardiovascular risk are main objectives during follow-up. Interventions for dyslipidemia have the effect of reducing cardiac events in clinical studies specific to transplant population.
Objective: Primary hyperparathyroidism (PHPT) is the most common cause of hypercalcemia. A group of patients who were followed up with a diagnosis of PHPT had normal calcium levels with high parathyroid hormone (PTH) levels. For the diagnosis of normocalcemic PHPT, secondary causes of hyperparathyroidism such as vitamin D deficiency should be excluded. In this study, the data of 318 PHPT patients who were operated were retrospectively analyzed, and biochemical and clinical characteristics of hypercalcemic and normocalcemic patients were compared.
Methods: The data of patients who were admitted to our hospital’s endocrinology clinic between January 2012 and January 2019, diagnosed with PHPT and operated according to guidelines (all symptomatic patients and asymptomatic patients with at least one operation indication) were retrospectively evaluated. A total of 318 patients were divided into two groups as hypercalcemic and normocalcemic according to the corrected calcium level. The two groups were compared according to clinical and biochemical properties.
Results: Female gender was dominant in both groups (P = 0.07). The mean age was similar in both groups (P = 0.36), while it was 54.0 ± 10.3 in the hypercalcemia group, and 55.4 ± 12.8 in the normocalcemia group. As expected, serum corrected calcium (Ca), PTH levels and urinary Ca excretion were higher in the hypercalcemia group (P < 0.01). While phosphorus (P) level was lower in the hypercalcemia group (P < 0.01), urinary P excretion was similar between the two groups (P = 0.77). There was no difference between the two groups in alkaline phosphatase, creatinine, and vitamin D levels. Percentage of localization with preoperative ultrasonography and mean adenoma size were similar. Also, there was no difference in adenoma features (echogenicity, cystic appearance) and localization, thyroid nodules and thyroiditis prevalence on ultrasonography. The positive result obtained on neck MRI and MIBI scanning was similar. There was no difference between the two groups in terms of stone incidence and osteoporosis prevalance (P = 0.72 and P = 0.08, respectively).
Conclusion: In our cohort, corrected Ca and PTH levels and urinary Ca excretion were high in the hypercalcemic group, as expected. But, the phosphorus level was significantly lower in the hypercalcemia group. In the normocalcemic group, the PHPT phenotype was found to be similar to the hypercalcemic group. These findings suggest that the frequency of surgical indications is similar
in normocalcemic PHPT patients to that in hypercalcemic PHPT patients.
Introduction: Hypercholesterolemia may develop due to primary and secondary causes. Diabetes mellitus, hypothyroidism, nephrotic syndrome and liver diseases are among the most common causes of secondary hyperlipidemia. Here, we will present a case with severe hyperlipidemia due to primary sclerosing cholangitis(PSC).
Case: A 36-year-old male patient was admitted to our outpatient clinic due to severe hypercholesterolemia. It was learned in his history that he had increased liver enzymes for 3 years. He was diagnosed with PSC 4 months ago and liver transplantation was planned. The patient was using ursodeoxycholic acid 2x500 mg treatment. On physical examination, blood pressure was 120/70 mmHg, heart rate was 78 beats/minute and he had icteric appearance. Xanthoma, xanthelasma, arcus cornea was not observed. In laboratory tests, AST, ALT, ALP, GGT, total bilirubin, total cholesterol, LDL, triglyceride, VLDL, HDL were 111 U/l, 108 U/l, 1037 U/l, 301 U/l, 17 mg/dl, 574 mg/dl, 499 mg/dl, 348 mg/dl, 70 mg/dl, 5 mg/dl, respectively. The patient had no other comorbid diseases other than PSC. There was no history of early cardiovascular disease or sudden death in family members. It was learned that the patient’s LDL value was 102 mg/dl 5 years ago. The cause of hypercholesterolemia in the patient was considered depending on the PSC. Statin therapy was not considered due to impaired liver function tests. We planned to start cholestyramine 12 grams per day.
Conclusion: PSC is a liver disease with biliary obstruction. Lipid disorder due to biliary obstruction is associated with lipoprotein X (LpX). LpX is a abnormal low density lipoprotein. It is unable to exert negative feedback on the cholesterol synthesis rate limiting enzyme hydroxymethyglutaryl coenzyme A (HMGCoA) reductase. In contrast, the presence of LpX increases the activity of HMG-CoA reductase in the liver with increased hepatic cholesterol synthesis. Patients with biliary obstruction have increased LDL and decreased HDL. Hypercholesterolaemia improves with removal of obstruction or liver transplantation. LDL apheresis, statins and cholestyramine decrease
cholesterol levels in patients with PSC.
Background: Cardiovascular complications of Cushing’s syndrome (CS) include; hypertension, left ventricular hypertrophy, and myocardial ischaemia. Also, CS can cause structural and functional changes in the heart, leading to dilated cardiomyopathy in rare cases. Here, we present a case with dilated cardiomyopathy related to Cushing’s syndrome.
Case: A 31-year-old male patient applied to the cardiology department with shortness of breath that worsened with exertion for a year. Globally advanced hypokinetic and globally dilated heart was found in echocardiography with ejection fraction (EF) 20%. His medical treatment was arranged by cardiology department and referred to endocrinology clinic due to the 25 kg weight gain in one year, increased appetite and purple striae on the abdomen and shoulder. Laboratory tests revealed that; ACTH was <5 pg/ml, cortisol: 24.3 mg/dl, night cortisol: 24.7 mg/dl. After 1 mg dexamethasone suppression test (DST) and, 2 day 2 mg DST cortisol levels were found 18.9 mg/dl and 31.79 mg/ dl, respectively. Because these findings suggest the CS, abdominal MRI was performed and revealed that a mass lesion (adenoma?) with a smooth contour, 37 × 28 mm in size, showing heterogeneous signal loss in the outer phase in the left adrenal gland. No pathological finding was found in pituitary MRI. With these findings, the patient was diagnosed with adreanal Cushing Syndrome. Viral myocarditis, lupus or autoimmune myocarditis was ruled out by negative
viral respiratory panel, and negative autoimmune panel respectively. Absence of hilar adenopathy excluded sarcoidosis. Cardiac MRI conducted for cardiac exclusion of mixoma and revealed no findings that were consistent with the mixoma. After the exclusion of other reasons of cardiomyopathy the patient was diagnosed with dilated cardiomyopathy. In the control echocardiography 2 months after heart failure treatment, EF was found 40%. Metyrapone therapy was started gradually to lower the risk of surgery by lowering the patient’s preoperative cortisol load. The cortisol level was found to be 17.4 mg/dl, 2 hours after the first metyrapone treatment. 10 days after metyrapone treatment, when the cortisol level decreased by 14.8 mg/dl, left adrenal gland
excision was performed. Postoperative cortisol was found to be 1.8 mg/dl and 3.2 mg/dl. Pathology result was compatible with nodular diffuse hyperplasia.
Conclusion: Dilated cardiomyopathy and left ventricular failure are rare presentations of CS. Since cardiomyopathy can be reversed following successful treatment of Cushing’s syndrome it is important to consider this diagnosis in patients with both heart failure and signs of CS.
Background: Pheochromocytomas are rare tumors originating from chromaffin cells and characterized by excessive catecholamine synthesis. They are usually benign lesions. Hypertension(HT), tachycardia, sweating and headache are frequently observed. We aimed to present a high malignancy suspected pheochromocytoma case diagnosed in a young age female.
Case presentation: A 20-year-old female patient was admitted to the emergency department due
to high blood pressure, tinnitus and headache. The patient was hypertensive (220/110 mmHg) and had tachycardia (130/bpm). For the etiology of HT, renal doppler USG was performed. An extra-renal solid mass lesion (pheochromocytoma?) was reported. She was referred to our clinic. Surrenal MRI revealed a lesion in the left paraaortic area with 40 × 37 mm enhancement in the area corresponding to the adrenal region. 24-hour urinary normetanephrine and metanephrine levels were found 10 times higher than upper limit of the reference range. Laparoscopic partial adenomectomy was performed by the urologist. After surgery, blood pressure was return to normal range without any medication. In histopathology, Ki 67 proliferation index was reported as 20%. Periadrenal adipose tissue invasion, atypical mitosis, lymphovascular invasion and capsule invasion were found positive. Calculated PASS score was reported 6/21 and it was evaluated as high suspicion of malignancy. Genetic analysis (VHL, MEN, SDH) result was negative. The patient had an identical twin. Pheochromocytoma symptoms of the identical twin were not present. In the literature some cases of identical twins which have concominant pheochromocytoma were reported.
We performed pheochromositoma screening tests for identical twin and no pathology was found.
Conclusion: Although pheochromocytoma is most common in the 4th and 5th decades, it can be seen in all age ranges. The majority of patients are sporadic, there are also hereditary forms. Genetic background should be investigated in patients diagnosed with pheochromocytoma at the young age. Although our case was diagnosed with pheochromocytoma at a young age, her genetic tests was not
showed any mutation.
Objective: There is limited clinical data available on bilateral adrenal masses (BAM). Here we present a case with BAC and adrenal insufficiency. The patient’s lesions disappeared after steroids, re-grew in the follow-up, allowing a biopsy.
Case: A 60-year-old male patient presented with abdominal pain, nausea, and weakness to another hospital. Hyponatremia and hyperkalemia accompanied by hypotension were detected. Abdominal tomography revealed, “irregularly demarcated hyperdense mass lesions, 60 × 44 mm in the right and 75 × 26 mm in the left adrenal.” Upon referral to our hospital, we employed PET-CT, which demonstrated “mass lesions of 49 × 52 × 71 mm in the right and 56 × 57 × 75 mm in the left adrenal as well as pathological hypermetabolism in multiple foci in the skeletal system.” After diagnosing adrenal insufficiency, we initially gave the patients intravenous hydrocortisone, followed by oral maintenance. There were no pathological findings in tuberculosis tests, viral and autoimmune panel, and malignancy screening. Urine and plasma catecholamine and 17-hydroxy progesterone levels were normal. CT-guided biopsy of the adrenal mass revealed fat necrosis. After 45 days, we attempted a repeat biopsy without success due to almost wholly regressed adrenal masses. Also, bone lesions could not be visualized. Adrenal MRI showed “14 mm lesion on the right and, only diffuse thickening on the left adrenal.” A control PET-CT was obtained. “Evident decrease in the size of the adrenal lesions, in addition to the fairly reduced metabolic activity of adrenal masses and bone lesions.” We performed a biopsy from the most active bony lesion; however, it was inadequate. Two months after the initial presentation, he was admitted with abdominal pain. His lesions had progressed. In CT he had, 70 × 41 mm right adrenal mass invading liver and IVC, 56 × 38 mm left adrenal mass, and numerous metastasis in his liver and lungs. Adrenal biopsy, this instance was compatible with “CD20 + B cell lymphoma infiltration.” Patient died of cerebrovascular incident, whilst awaiting biopsy results.
Conclusion: Primary adrenal lymphoma is a rare etiological cause of BAM with only a handful of reported cases. Adrenal lesions vanishing after steroids should raise the suspicion of adrenal lymphoma. The shrinkage of tumors may lead to diagnostic difficulties such as our patient.
Background: Cytochrome P450 oxidoreductase (POR) deficiency is an autosomal recessive steroidogenesis disorder similar to combined deficiencies of 17α-hydroxylase, 17,20-lyase, 21-hydroxylase. POR deficiency (PORD) is a very rare type of congenital adrenal hyperplasia(CAH) characterized by sexual development disorders and skeletal anomalies. We present a case that was evaluated with a prediagnosis of nonclassical CAH and was found to have a heterozygous mutation in the POR gene.
Case report: A 23 years old male patient applied to our clinic with complaint of excessive hair. These symptom had started on her arms and legs at 6 years old, appeared on her back at 8 years old, then spread to all over the body. He has reached his final adult height at about 15 years old. He had no history of chronic illness, his 47 years old mother and 56 years old father were consanguineous. On physical examination, his blood pressure was 120/80mm/hg, height was 161cm, the length of the penis was 9.5cm and testicular volume was 20 ml. Laboratory tests were as follows; glucose 89 mg/dl (70−99), sodium 138 mEq/l (132−146), potassium 4.7 mEq/l (3.5−5.5), cortisol 20.3 mg/dl (5.2−22.4), ACTH 37.8 pg/ml (<46), TSH 1.6 mU/l (0.55−4.78), sex hormone binding globulin 7 nmol/l (10−57), FSH 3.2U/l (1.4−18.1), LH 6.9U/l (1.5-9.3), progesterone 1.26 mg/l (0.28−1.22), total testosterone 383 ng/dl (164−753), dehydroepiandrosteronesulfate 698.72 mg/dl (34.5−568.9), 17-alpha-hydroxyprogesterone (17-OHP) 1.22 ug/l, free testosterone 26.6 pg/ml (15−50), androstenedione 13.5 nmol/l (2.1−10.8). Maximum 17-OHP was 3.36 mg/l after ACTH-stimulation. Abdominal magnetic resonance imaging showed normal adrenal glands. Scrotal ultrasonography was normal. Bone age was 18 years. Genetic testing revealed that the patient was heterozygote for c.461A > T(p.Asp154Val) mutation in exon 5 of POR gene while CYP21A2, CYP17A1, CYP11B1, HSD3B2, STAR genes were normal. Subsequent genetic testing of parents showed that his mother also had POR(NM_000941.3):c.461A > T(exon5) heterozygote mutation, while there was no mutation in his father.
Conclusion: A great number of POR variants affecting more than 130 amino acids in the POR protein have been reported. There is clinical heterogeneity in patients with POR gene mutations, making the diagnosis difficult. Considering that the POR gene mutation shows ethnic differences, we think that the determination of variant cases in our society will clarify its importance in this case in the future
Aim: It is known that serum thyroglobulin (TG) can increase after fine-needle biopsy of thyroid nodules. We aimed to determine whether TG is increased after ultrasonography guided fine needle capillary biopsy (FNC) of suspicious cervical LNs in thyroidectomized patients and investigate the
possible association between change in TG and cytology results.
Material and methods: Data of 188 patients who underwent FNC of suspicious cervical LNs were
retrospectively evaluated. Demographical features, radioactive iodine (RAI) treatment status, thyroid-stimulating hormone (TSH), TG, anti-TG antibody and ultrasonography features of LNs were noted. TG levels before FNC (TGb-FNC), after FNC (TGa-FNC), TGa-FNC/TGb-FNC ratio and the number of patients with increased TG were determined. Patients were grouped as benign, nondiagnostic, suspicious for malignancy and malignant according to the cytological results.
Results: The age, gender, clinical diagnosis, history of RAI treatment and TSH levels were similar in different cytological groups. TGa-FNC, Tgb-FNC/Tga-FNC, and rate of patients with increased TG were significantly higher in malignant cytology group than other groups (P<0.001)(Table). The optimal cut-off level of TG increase that was predictive for malignancy was 7.6% with a sensitivity of 73.7% and specificity of 85.2%. TG increase was not associated with age, sex, TSH level, antiTG positivity and US features of LNs while signficantly lower in patients who received RAI treatment.
Among 31 patients with positive anti-TG, TGb-FNC/TGa-FNC, and rate of patients with increased TG were higher in malignant compared to benign and nondiagnostic cytology groups.
Conclusions: Serum TG increment and rate of patients with increased TG after FNC of suspicious cervical LNs were higher in patients with malignant cytology than with all other cytology results both in all study group and in subgroup of anti-TG positive patients. Increase in TG after FNC might be an additional tool for determining LN metastasis.
Table. Demographical, clinical and ultrasonography features and thyroglobulin levels in patients with respect to the cytological results of lymph nodes
Nondiagnostic (n=38, 20.2%)
Suspicious for malignancy
TGa-FNC / TGb-FNC
Quantitative and categorical variables are summarized by median (IQR: 25th -75th percentiles) and frequency (%), respectively.
1,2,3The same numbers indicates that the corresponding groups are significantly different from each other.
Objectives: Adherence to treatment is one of the most important parameters that affect the success of the treatment in hypothyroidism. We aimed to evaluate the use and adherence to treatment and determine the factors that are related to adherence in patients on levothyroxine therapy.
Materials and Methods: Patients older than 18 years old and using levothyroxine for hypothyroidism were recruited. Demographical, sociocultural and clinical statuses of patients were determined. The practices of using levothyroxine and compliance were evaluated through a questionnaire. Thyroid hormones and antibodies were obtained from medical records. Those who answered the frequency of not using/skipping the drug as never/rarely, sometimes and frequently/often were grouped as high, medium and low adherence, respectively. Data of high, medium and low adherence patients were compared.
Results: A total of 335 patients - 282 (84.18%) female and 53 (15.82%) - male were included. Mean age was 47.36±12.50. 330 (98.50%) patients were taking levothyroxine in the morning and 332 (99.10%) were taking fast. The period between the drug and meal was 15 min in 66 (19.88%), 30 min in 170 (51.20%), 45 min in 25 (7.53%), at least 1 h in 63 (18.98%) patients, while 8 (%2.41) patients were taking it just before or during the meal. Among 145 (45.03%) patients who use a medication that may interfere with the absorption of levothyroxine, 66.66% were using it in less than 2 h of levothyroxine. There were 218 (65.08%) high, 98 (29.25%) medium and19 (5.67%) low adherence patients. Drug adherence was not associated with sex, age, marrital and working status, smoking, alcohol use, the cause and duration of hypothyroidism, presence of comorbid disease and thyroid hormones. The rate of patients graduated from primary school was higher in low adherence and rate of patients graduated from university was higher in high adherence groups (P = 0.008). Familial history of thyroid disease was associated with high adherence (P = 0.013).
Conclusion: We showed that drug adherence is medium or low in 34.92% of hypothyroid patients, and education level and familial thyroid disease were related with high adherence. Although majority of patients take levothyroxine at fast, 22.29% eat less than 30 min after taking the drug. In addition, a considerable amount of patients using medications that inhibits the absorption of levothyroxine did not leave required time between two medications. For effective treatment of hypothyroidism, it is important to increase drug compliance and inform patients about hypothyroidism and levothyroxine.
Background: Diabetic ketoacidosis (DKA) is one of the most serious complications of diabetes. It is characterised by the triad of hyperglycemia (blood sugar >250 mg/dl), ketosis and metabolic acidosis (arterial pH <7.3 and serum bicarbonate <18 mEq/l). Rarely these patients can present with blood glucose (BG) levels of less than 200 mg/dl, which is defined as euglycemic DKA.
Case: A 22-year-old female patient applied to the primary care physician with tingling and numbness in the hands. Fasting blood glucose was 205 mg/dl with normal renal and liver function tests in the first laboratory evaluation and then suggested to apply to the endocrinology clinic. After learning about high blood sugar level, she avoided foods containing carbohydrates and followed a ketogenic diet. She is 160 cm tall and 45 kg heavy. The patient referred to the endocrinology clinic with nausea two weeks later. Her plasma glucose level was 86 mg/dl with an HbA1C of%10.3. HbA1C measurement was repeated and confirmed to be high. She was diagnosed with diabetes. Her laboratory assessments revealed an elevated anion gap of 20.9, increased urinary and plasma ketones, and metabolic acidosis. Low hCG values excluded pregnancy The diagnosis of euglycemic DKA was made, and treatment with intravenous fluids and insulin was initiated, then the patient improved.The C-peptide level was 0.42 mg/l (n:0.81-3.85 low normal). Anti-glutamic acid decarboxylase and anti-insulin antibodies were negative, while the anti-islet cell antibody was positive. There was no one with diabetes in her family. She was screened for liver diseases and glycogen storage diseases, and no pathological condition was detected.
Conclusion: We present a type 1 diabetic patient diagnosed with euglycemic DKA. The possible aetiology of euglycemic DKA includes decreased caloric intake, heavy alcohol consumption, the recent use of sodium-glucose cotransporter 2 inhibitors, chronic liver disease and glycogen storage disorders. DKA in pregnancy has also been reported to present with euglycemia. Our patient had euglycemic DKA triggered by the ketogenic diet. Euglycemic DKA can be missed or inadequately treated in patients presenting with euglycemia on initial presentation. Recognising this condition in newly diagnosed patients can also be a challenge for physicians.
Background: Immune checkpoint inhibitors, including anti-programmed cell death-1 (PD-1) antibodies, have become promising treatments for a variety of advanced malignancies. Nivolumab, an anti-PD-1 monoclonal Ab, is an effective treatment of unresectable metastatic melanoma, non-small cell lung cancer, renal cell carcinoma, head and neck cancer, Hodgkin lymphoma, and gastric cancer. These medicines can cause immune-related adverse events (irAEs), including endocrinopathies. Thyroid dysfunction (TD) is a common irAE induced by nivolumab. The TD includes hypothyroidism and thyrotoxicosis, which are generally mild to moderate. The most common endocrine adverse event with anti-PD-1 therapy is hypothyroidism (around 5.9% cases). Thyrotoxicosis is related to destructive thyroiditis in most of the cases. Patients with TgAbs or TPOAbs are prone to develop destructive thyroiditis after initiation of nivolumab treatment. The development of hyperthyroidism owing to Graves’ disease is virtually very rare, with only 4 cases reported so far. Here we aimed to present the 5th case of Graves’ disease after Nivolumab therapy.
Case presentation: A 75-year-old woman with primary malignant urethral melanoma received three courses of nivolumab at a dose of 240 mg every two weeks. Laboratory tests performed before the 4th course due to the patient’ palpitation. Thyroid- stimulating hormone (TSH), free triiodothyronine and free thyroxine level were < 0.015 (normal range [NR]: 0.55-4.78) mU/l, 7.44 (NR: 2.3-4.2) ng/l and 2.4 (NR: 0.89-1.76) ng/dl, respectively. Her thyroglobulin (Tg-Ab) and thyroid peroxidase antibody (TPO-Ab) were both positive, while TSH receptor antibody (TRAb) was negative. Thyroid ultrasonography showed enlargement of both thyroid lobes with low echogenicity and increased vascularity. Thyroid scintigram showed an increased and diffuse uptake. She had been diagnosed with Graves’ disease approximately eight years ago and treated medically. Tg-Ab and TPO-Ab were both positive, and TRAb was negative like now. After medical treatment was over, the patient was euthyroid in follow-up and even before PD-1 treatment.
Conclusion: While antibody positivity often causes destructive thyroiditis, differently caused Graves’ disease in this case. Also, this is the first case-reported that nivolumab therapy induced a relapse of Graves’ Disease.
Background: Although high levels of calcitonin suggest neoplastic proliferations such as medullary thyroid carcinoma, C cell hyperplasia and some neuroendocrine tumors, systemic diseases and drugs may also elevate calcitonin. Although calcitonin is not as effective as PTH, it has got a role in calcium hemoastasis. Supraphysiological calcitonin level can lead to hypocalcemia.
Case presentation: A 57-year-old male patient was diagnosed with epilepsy with complaints of contraction in the body at the age of 16. Phenytoin therapy was started. He had no epileptic seizures for 13 years. Basal ganglia calcification was detected in brain CT which had been taken when he had muscle contractions while he had been hospitalized for measles in 1992. Calcium: 6.9 mg/dl phosphorus: 5.3 mg/dl albumin: 4.7 g/dl, parathormone: 499 pmol/l (219-659) calcitonin: 145 (0-50) was measured and hypoparathyroidism was diagnosed. Calcitriol and calcium carbonate treatment had been started. In another medical center it was thought that he had pseudohipoparathyroidism, because calcium was normal, vitamin D and parathormone were high while he was not taking calcium replacement treatment. He came to outpatient clinic in 2018 while he was taking 2000 mg oral calcium carbonate treatment. Calcium: 8.9 mg/dl (8.7-10.4) phosphorus:3.5 mg/dl albumin:4.5 g/ dl, parathormone: 41 ng/l (18-80), 25-OH vitamin D: 41 ng/ml (25-80), 1,25OH vitamin D: 24.1 pg/ml (18-64) kalsitonin:117 ng/l (<8.4) was measured. Pseudohipoparathyroidism wasn’t considered with clinical findings. The control calcitonin value was 144, and the highest calcitonin value was 323. Thyroid USG and CEA levels were normal. He had no medullary thyroid carcinoma history in the family. CDKN1B, RET, menin gene analysis were normal. 24-h urinary calcium was 55 mg/day. The heterophile antibody examined by the PEG precipitation method and heterophile antibody-coated tube was negative. No pathological lesions were detected in GA-68 DOTA peptide imaging performed for possible neuroendocrine tumor.
Conclusion: In cases of hypercalcitoninemia, C cell neoplasms should be investigated primarily. In this case, medullary thyroid carcinoma was not considered with the current findings. Due to the coexistence of hypocalcemia and endogenous hypercalcitonemia, the possibility of autosomal dominant hypocalcemia was considered in which calcium sensing receptor activation is playing a role. However, hypocalcuria was interpreted against this possibility. In case of low/normal parathormone in the etiology of hypocalcemia, it is also suggested to measure the calcitonin level.
Background: Fine needle aspiration biopsy (FNAB) and Bethesda System for Reporting Thyroid Cytopathology (TBSRTC) have proven to be the most valuable diagnostic procedure for preoperative discrimination of benign and malignant thyroid nodules. Thyroid surgery may cause regional scarring and some degree of fibrotic process which may result in problems when collecting FNAB samples and evaluating the cellular abnormalities. In this study, we aimed to determine whether the Bethesda classification system in thyroid nodules is reliable in patients with a history of thyroid surgery.
Methods: We retrospectively examined outcomes of 130 patients with 260 nodules who underwent a thyroidectomy for recurrent goiter (Group 1) and compared them with 2821 patients with 5890 thyroid nodules who underwent first thyroidectomy (Group 2) in our center between 2007 and 2014.
Result: Malignancy rate was significantly lower in group B (24 (18.5%) patients) compared to group A (911 (32.3%) patients) (P = 0.016). The most frequent operation indications in group A may explain the hight rate ofmalignancy in this group, that were giant nodule and suspicious cytology results in group B and group A respectively (P = 0.001). Hypothyroidism was significantly higher in group B and result by a hight ratio of gaint nodules (P = 0.001). Although a relationship between giant nodule and higher malignancy rate was reported in previous studies, we did not find a correlation between giant nodules and malignancy rate of patient in group B. Diagnostic value of Bethesda was determined in patients with primary and reoperative thyroid surgery. Benign cytology was considered negative and suspicious for malignancy and malignant cytologies were considered positive. Sensitivity, specifity, PPV, NPV and accuracy of Bethesda classification in patients with primary thyroid surgery were 74.50%, 98.18%, 83.38%, 96.92% and 95.60%, respectively. In patients with reoperative thyroid surgery, sensitivity was 62.50%, specifity was 98.91%, PPV was 71.43%, NPV was 93.38% and accuracy was 97.39%.
Table 1. Diagnostic value of Bethesda classification in patients who underwent primary and reoperative thyroid surgery.
a (n = 3710)
b (n = 3814)
a (n = 192)
b (n = 199)
Positive predictive value
Negative predictive value
Conclusion: FNAB is known to be the most accurate and cost-effective method that provides avoidance of unnecessary surgery in 25% of patients with benign thyroid disease. A lower frequency of malignancy was observed in patients/nodules with reoperative thyroid surgery compared to patients/nodules with primary thyroid surgery in this surgical series. Sensitivity and PPV of Bethesda were affected negatively by previous thyroid surgery. This might be considered in these patients while deciding for a recurrent surgery which has a higher risk of complications.
Background: Alstrom syndrome is a rare autosomal recessive genetic disorder characterised by vision loss, hearing loss, childhood obesity, insulin resistance and hyperinsulinemia, type 2 diabetes, hypertriglyceridemia, cardiomyopathy, and progressive pulmonary, hepatic, and renal dysfunction. Hyperinsulinemia develops early, and pancreatic islets show beta-cell proliferation, thus suggesting that both insulin resistance and increased insulin secretion might contribute to glucose intolerance. Increased triglyceride levels, steatosis in the liver and pancreas can also amplify the insulin resistance.
Case presentation: A 20-year-old male patient was diagnosed with congenital amaurosis at the age of 6, diabetes mellitus and hypothyroidism at the age of 8, and hearing loss at the age of 9. Then mutations in ALMS1 detected and Alstrom syndrome was diagnosed. No pathology was detected in bone marrow biopsy for pancytopenia in 2015, and follow-up planned. Chronic liver disease and esophageal varices were detected in 2017. He was admitted to our Endocrinology outpatient clinic with high blood sugar. The serum level of FPG, HbA1c, insulin (fasting), and c-peptide were 148 mg/dl, 10.5%, 63.1 mU/l (3-25) and 5.31 mg/l (0.81-3.85), respectively. Anti-GAD, anti-islet antibody and anti-insulin antibody were negative. He was hospitalised for blood glucose regulation. His height was 155 cm and body weight was 55 kg. On admission, he received 15 units/day insulin glargine and 25 units/day insulin aspart. The total daily insulin requirement increased to 216 units and blood glucose was in the range of 150-300 mg/dl. Due to cirrhosis, the recommendation of pediatric metabolic disease doctors was taken, and then metformin and pioglitazone treatment were started while sodium benzoate treatment was continuing. Liver decompensation did not develop at follow-up and insulin requirement gradually decreased to 160 units/day and blood glucose decreased to 90-190 mg/dl.
Conclusion: In diabetes mellitus types with insulin resistance such as Alstrom syndrome, drugs that increase insulin sensitivity such as metformin and glitazone come into prominence. Due to cirrhosis of our case, metformin and pioglitazone treatment was started cautiously. There was a significant decrease in insulin requirement and improvement in the brittle blood glucose profile without any side effects.
Objective: Primary hyperparathyroidism (PHPT) is a clinical condition characterized by hypercalcemia-specific symptoms and signs caused by excessive secretion of parathormone. After the evaluation of blood calcium measurements within routine tests, the frequency of hyperparathyroidism increased and there is a marked decrease in the frequency of classical symptoms and signs. Recently, most PHPT cases are detected in the asymptomatic period, and which of these asymptomatic patients will go to surgery, is individually evaluated. In this study, it was investigated whether there is any feature that can be taken into account in the diagnosis and follow-up by considering the calcium course in the period until the development of hypercalcemia.
Methods: The biochemical records of patients who were operated with the diagnosis of PHPT and whose histopathological diagnosis was parathyroid adenoma were reviewed from our database. We evaluated patients who had at least 2 consecutive albumin corrected calcium levels before the time of first hypercalcemia were detected, during the preoperative period. The date when the first hypercalcemia detected, first hypercalcemic value, normocalcemic values and dates, and the intervals between them were recorded. We determined delta change and percentage changes within the patients who had at least 1 year of periyod between normocalcemia values.
Results: In this study,18(94.7%) female and 1(5.3%) male,19 patients with PHPT were included and the mean age was 52.21 ± 10.9. The median time to develop hypercalcemia after the last normocalcemia time was 5 months (0.5-36 months). Median hypercalcemia level was 10.3 mg/dl (10.1-10.9),median for last normocalcemia was 9.8 mg/dl (9.3-10.0). It was found that the development time of hypercalcemia was decreasedas the normal calcium level increased (P = 0.044). A higher hypercalcemic value was found as the time between normocalcemia and hypercalcemia increased (P = 0.049). The course of increase in calcium levels over time was statistically significant (P = 0.0). For the course of changes in normocalcemic values determined in these 19 patients until hypercalcemia was detected, delta change and percentage changes of 12 patients with 2 normocalcemic values at least 1 year intervals before the development of hypercalcemia were calculated.
Conclusion: Recently, some patients with primary hyperparathyroidism who are asymptomatic at the time of admission are treated surgically and some of them are followed up. Individualized treatment is applied in this regard, according to the guidelines some of the patients recommended surgery are followed, some of those recommended for follow-up are also operated. More information about the natural course of untreated primary hyperparathyroidism can help resolve this imprecise situation.
Aim: While the histopathological diagnosis is parathyroid adenoma in majority of patients with primary hyperparathyroidism (PHPT),parathyroid hyperplasia, atypical parathyroid adenoma or parathyroid carcinoma can be seen in others. Although it is known that serum calcium (Ca) and parathyroid hormone (PTH) levels are higher in patients with parathyroid carcinoma, there are not any cut-off value for serum Ca, phosphorus (P) and PTH levels defined for different histopathological parathyroid lesions. In this study, we aimed to determine cutoff levels for serum Ca, P and PTH in different histopathological PHPT lesions.
Materials and Methods: The data of 392 patients operated for PHPT were evaluated retrospectively. Patients were grouped as parathyroid hyperplasia, parathyroid adenoma and atypical parathyroid adenoma according to histopathological results. Three way ROC analysis was used to evaluate the performance of serum Ca, P and PTH to determine the three groups. It was shown that Volume Under Surface (VUS) higher than 0.17 was giving information beyond chance. Cut-off levels and correct classification rates (CCR) were calculated when the VUS value was significantly higher than 0.17.
Results: There were 19 patients with parathyroid hyperplasia, 343 with parathyroid adenoma and 31 with atypical parathyrod adenoma. Serum Ca, P and PTH levels were significantly different between groups (P = 0.026, P = 0.003 and P ≤ 0.001, respectively). Serum Ca was significantly lower in parathyroid hyperplasia group compared to other two groups (P = 0.032 and P = 0.036, respectively). Serum Ca was similar in patients with parathyroid adenoma and atypical parathyroid adenoma (P = 0.999) (Table 1). The performance of serum P and PTH to determine groups were not sufficient significantly (P >0.05). In determining the groups, only the VUS value of serum Ca was statistically significantly higher than 0.17 (P = 0.005). The cut-off values for the variable
were determined as C1 = 10.73 mg/dl and C2 = 11.40 mg/dl, respectively.
Conclusion: In this study, we found that serum Ca levels can be predictive for the histopathological diagnosis in patients with PHPT. Serum Ca lower than 10.73 mg/dl, 10.73–11.40 mg/dl and >11.40 mg/dl were determined to predict parathyroid hyperplasia, parathyroidadenoma and atypical parathyroid adenoma, respectively.
Table 1. Serum calcium, phosphorus and parathyroid hormone in patients with primary hyperparathyroidism according to histopathological diagnosis
(n = 19)
(n = 342)
Atypical parathyroid adeoma
(n = 31)
10.98 ± 1.31
3.83 ± 2.08
2.62 ± 0.69
2.35 ± 0.59
Parathyroid hormone (pg/ml)
806.71 ± 923.07
229.82 ± 311.67
402.54 ± 383.46
Introduction: Primary hyperparathyroidism (PHPT) is a common endocrine disorder that is characterized by hypercalcemia and elevated or normal levels of parathyroid hormone (PTH). Most PHPT cases are incidentally discovered when routine laboratory analysis reveals hypercalcemia. PHPT should be considered in any person with elevated serum calcium (Ca) levels and no clear evidence of malignancy. Serum phosphorus (P) is low due to the phosphaturic effects of PTH and mostly in the lower half of the normal range. As serum Ca and P are inversely related in PHPT, we examined the diagnostic value of the serum Ca/P ratio in the diagnosis of PHPT.
Method: A total of 364 patients followed at our clinic with a diagnosis of PHPT were retrospectively analyzed. As a control group, we selected 98 patients who attended the clinic in the same time period, presenting serum PTH, Ca and P within the normal range. The main outcome measures were: serum Ca, P, albumin, PTH, 25-OH vitamin D and creatinine. Both patients with normocalcemic PHPT and hypercalcemic PHPT were included. The diagnostic accuracy of Ca/P was investigated using receiver operator characteristic (ROC) curve analysis. The resultant cut-off was verified using the independent set of data containing 100 patients and 50 control cases.
Results: There were 317 (87%) females and 47 (13%) males in patients group, and the mean age of the cohort was 53.9 ± 11.4 years (range: 20–82 ). Ca and PTH were significantly higher in PHPT than in controls (P < 0.0001). The Ca/P ratio was also significantly higher in PHPT than in controls (P < 0.0001). ROC curves analyses identified a cutoff value as 3.23 (mg/dl) for Ca/P ratio with a sensitivity and specificity of 94% and 93%, respectively (P < 0.0001). This cut-off value was confirmed by an independent group of cases (100 PHPT and 50 control cases) with 91% sensitivity and 80% specificity.
Conclusion: Ca/P is a precious predictor for the diagnosis of PHPT and it can be used instead of evaluating serum Ca and P levels solely. As Ca/P ratio is easily accessible and inexpensive, it will be useful for PHPT diagnosis and provide simplicity especially for the practitioners with limited resources.
Introduction: Primary hyperparathyroidism (PHPT) is a prevalent endocrinologic disease and the most common cause of hypercalcemia. PHPT usually affects the elderly. PHPT younger than 40 years of age is less frequent. In young patients especially for ones younger than 30 years of age, screening for familial syndromes such as MEN 1 and MEN 2A is recommended. However, in most of the cases genetic tests are negative and evidence for other endocrine components are absent. Herein this study we retrospectively evaluated the data of 322 patients with asymptomatic PHPT patients who were operated and compared the biochemical and clinical features of young patients (<40 years old) with older ones.
Method: This study had a retrospective design. We evaluated the data of the patients who admitted to our university hospital’s endocrinology clinics and diagnosed with PHPT between September 2015-may 2018. According to the clinical guidelines all symptomatic patients and asymptomatic ones who had
at least one indication for surgery were operated. There were 346 adenomas belonging to 322 patients in total. The patients were classified into 2 groups regarding age (<40 years or >40 years old as Group 1 and 2, respectively). Two group was compared according to clinical, biochemical and histopathologic features.
Results: There wasn’t any statistically significant difference between groups according to histopathology (adenoma, hyperplasia and carcinoma) (P = 0.065). In both groups there was female predominance, but number of male patients was significantly higher in Group 1 compared to Group 2 (P = 0.004). Serum Ca levels were similar whereas PTH level was higher in Group 1. According to ultrasonographic features, Group 2 had higher prevalence of accompanying thyroid nodules or thyroiditis (P <0.001).Interestingly T scores on femur and total vertebra and prevalence of osteoporosis were similar in between two groups. The percentage of preoperative localization with US and mean size of adenomas were similar. However positive result on MIBI scan was higher in Group 2. median Urinary Ca excretion was higher in Group 1 despite similar vitamin D levels (P = 0.0012).
Conclusion: The phenotype of PHPT in young adults is different from older patients. In our cohort number of male patients, serum PTH, urinary Ca excretion were higher in younger patients.
Introduction: Denosumab is a monoclonal antibody, which is used to prevent bone-related
outcomes in patients with solid tumor bone metastasis and reduces the transfer of calcium from
bone into the blood. It rarely causes severe hypocalcemia as a side effect. Here we present a case of
severe hypocalcemia lasting 8 months after administration of a single dose of denosumab given for
diffuse bone metastasis. The patient’s concomitant surgical hypoparathyroidism has also contributed
to the development of hypocalcemia.
Case: A 57-year-old female patient who underwent left mastectomy for breast cancer in 2002 and
received chemotherapy and radiotherapy was operated for multinodular goiter in 2013.
Histopathological diagnosis was multifocal papillary thyroid carcinoma and it was in complete
remission. In April 2018, she was diagnosed with postoperative hypoparathyroidism and her serum
calcium levels were in normal ranges with calcitriol 0.5 mcg/day and calcium carbonate 1000
mg/day. In December 2018, she was given denosumab 60 mg subcutaneously and capecitabine
treatment due to disseminated bone metastasis of breast cancer detected in 18F-FDG-PET
examination. Although her serum calcium was 9.3 mg/dL a few days before denosumab, four days
after injection her serum calcium was 6.9 mg/dL. Her calcitriol and oral calcium supplementation
doses were increased in course of time in another clinic. At the second month of denosumab, she
was consultated to our clinic due to weakness, tingling in the body and numbness and a serum
calcium was 6.2 mg/dl (8,7-10,4), phosphorus was 4.3 mg/dL (2,4-5,1), albumin was 36 g/L
(32-48) and parathyroid hormone was 28.0 pg/mL (18,5-88) despite treatment with calcitriol 2
mcg/day and oral calcium 5000 mg/day. She was hospitalized and intravenous calcium infusion was
given with oral active vitamin D and calcium supplementation. Since the patient had low calcium
values with calcitriol, treatment was replaced by alphacalcidol. During hospitalization, intravenous
calcium infusions were repeated and oral vitamin D and calcium supplementation doses were
increased. Her serum calcium could be maintained between 7.5-8 mg/dl with high doses of vitamin
D and calcium. She was on 3 mcg/day alphacalcidol, 8000 mg/day calcium carbonate and she had a
serum calcium of 7.6 mg/dl when she was discharged at the 25th of hospitalization. She was
followed weekly and then every 15 days in the outpatient clinic and vitamin D and calcium
supplementation doses were reduced, gradually. Finally at the 8th month of denosumab injection,
the treatment doses of alphacalcidol and calcium carbonate could be reduced to basal levels which
were 0.5 mcg/day and 1000 mg/day, respectively.
Conclusion: Hypocalcemia is a known side effect of denosumab, however it is usually mild. In the
case of coexisting hypoparathyroidism, severe and prolonged hypocalcemia that needs to be treated
with intravenous calcium and very high doses of vitamin D and oral calcium supplementation may
Background: It is known that 85-90% of the parathyroid adenomas (PA) are found in usual locations while
5-10% can be located ectopically in the thymic band or mediastineum. PAs are visualized as oval and
hypoechoic lesions generally parallel to the thyroid gland in two dimensional ultrasonography (US) images.
However, adenomas with atypical locations can be in different forms in the three dimentional plane. The
most common form is the bean grain type. In this report we present four cases of atypical PA with different
US features and locations.
Case-1: A 41-year old patient was referred to emergency service with hypercalcemia crisis. His calcium (Ca)
and intact parathyroid hormone (iPTH) levels were 14.24 mg/dl and 735 pg/ml respectively. His biochemical
parameters were shown in table. Since Ca level did not decrease with intravenous hydration and loop
diuretics, hemodialysis was performed and his Ca level decreased to 11 mg/dl. There was no lesion
compatible with PA in his first neck US. Technetium-99m-sestamibi was compatible with PA. No adenoma
was found in the second US evaluation also. But when the US probe was changed from 13-5 MHz to 10-5
MHz and the tissue penetration was also changed, a giant PA isoechoic with the thyroid gland was seen
inferior to the right thyroid lobe starting from the lower end extending to the cervical vertebrae. PA was
removed successfully with minimally invasive procedure (MIP) and the histopathological diagnosis was
Case 2: A 52-year old woman was referred to our clinic because of hypercalcemia. Her biochemical
parameters were shown in the table. US revealed a hypoechoic lesion (compatible with PA) with
macrocalcific areas, fibrous bands and partial cystic changes in the inferior posterior part of the right thyroid
gland. She underwent MIP and atypical PA was detected histopathologically.
Case-3: A 35-year old woman admitted to emergency clinic due to the hypercalcemia crisis (biochemical
parameters were shown in table). A giant PA lesion in the right thyroid gland starting from the middle part to
the inferior part was detected in neck US. It was iso-hypoechoic and had partial cystic areas. After the
removal of the PA, her Ca level was normalized and histopathologically atypical PA was observed.
Case-4: A 82-year old man was referred to our outpatient clinic due to hypercalcemia. His US finding was
consistent with PA located superior to the right thyroid gland. It was isoechoic and had partial cystic areas.
He underwent MIP and Ca levels decreased to normal levels. The histopathological diagnosis was atypical
Conclusion: The common US findings of these four atypical PAs were either the anteroposterior diameter
was longer than the transvers diameter (in all of the four cases) or the PA was larger than the longest
diameter of the thyroid gland (case 3 and 4). Our findings suggest that the location and the size of atypical
PAs may also be atypical.
Table. Biochemical features and Technetium-99m-sestamibi results of the patients and sizes of the
parathyroid adenomas and the longest diameter of the thyroid gland
Variables Case 1 Case 2 Case 3 Case 4
Calcium (mg/dl) 14.24 13.4 15.3 12.3
Albumin (gr/dl) 4.82 4.5 4.61 4
Phosphorus (mg/dl) 2 1.9 2.5 1.8
Creatinine (mg/dl) 1.35 0.8 0.75 1.2
66 159 290 132
735 270 998 387
25-hydroxy vitamin D
16.4 23.3 5.1 8.13
Parathyroid adenoma size
Anteroposterior 40 25.8 21 30
positive positive negative positive
Longest diameter of the
thyroid gland (mm)
40 45 45 35
Introduction: Chronic kidney disease-mineral and bone disorder (CKD-MBD) is frequently seen in
advanced stages of chronic kidney disease. These patients are at high risk of fracture. Denosumab,
an injectable human monoclonal antibody with affinity for nuclear factor-kappa ligand, is an
effective treatment for osteoporosis in postmenopausal women and men. In contrary to the
bisphosphonates, the pharmacokinetics and pharmacodynamics of denosumab are not influenced by
the renal function and are being increasingly used for patients having CKD-MBD with low bone
mineral density to reduce the risk of fragility fractures. Hypocalcemia is a known side effect of this
drug along with compensatory increase in parathyroid hormone (PTH). Here, we present a patient
with grade IV renal failure who developed severe symptomatic hypocalcemia and dramatic increase
in PTH following denosumab therapy.
Case: A 84 years old female patient with coronary heart disease, essential thrombocytosis,
hypothyroidism and chronic renal disease was consultated to our clinic for osteoporosis. She had
stage IV chronic renal disease for 7 years. Her serum creatinine, urea, glomerular filtration rate
(GFR), calcium, phosphorus, albumin and PTH were 1,8 mg/dl, 58 mg/dl, 25 ml/min/1.73 m 2 , 9.3
mg/dl, 4.7 mg/dl, 3.4 mg/dl, and 65 pg/ml, respectively. Dual energy X-ray absorptiometry revealed
a femoral neck t score of -3.7 and lumbal vertebra t-score of -3.3. She was given vitamin D 7500
IU/day for 8 days and then denosumab 60 mg subcutaneously. Ten days after injection, her serum
calcium was 6 mg/dl, albumin was 3.6 mg/dl, phosphorus was 2.5 mg/dl and PTH was 669 pg/ml.
She had mild numbness and tingling in her fingers but no other symptoms of hypocalcemia,
however Chvostek and Trousseou signs were positive. She was initially managed with intravenous
calcium and then oral calcium supplementation and calcitriol. One week after therapy serum
calcium was 8 mg/dl, albumin was 3.8 mg/dl and PTH was 569 pg/ml. She was managed as an out-
patient with close monitoring of calcium homeostasis. Three weeks after therapy serum calcium
was 8,4 mg, albumin was 3,8 g/dl, phosphorus was 3,3 mg/dl, and PTH was 380 pg/ml.
Conclusion: Denosumab is increasingly used to prevent skeletal-related events related with
osteoporosis and metastatic bone disease. Hypocalcemia is a known side effect of denosumab but it
is generally mild and can be avoided by simultaneous vitamin D and calcium supplementation.
Patients with a low baseline GFR are at significantly increased risk for developing hypocalcemia.
Clinicians should ensure special attention in recognizing patients at risk of developing this serious
adverse effect, so that prompt treatment and preventive strategies can be implemented.
Introduction: Poorly differentiated thyroid carcinomas (PDTC) are a rare subtype of thyroid
carcinomas that are biologically situated between well-differentiated thyroid carcinomas (WDTC)
and anaplastic thyroid carcinomas. Even a minor poorly differentiated component of only 10% of a
given carcinoma significantly affects patient prognosis. Here we present a 63-year-old female
patient who presented with diffuse bone pain and thyrotoxicosis, and diagnosed with PDTC and
diffuse bone metastasis.
Clinical course: A 63 years old female patient with nodular goitre was suggested thyroidectomy 20
years ago, but she has declined the operation. She presented with back and hip pain which
intensified in the last two months and could not be relieved with nonsteroidal anti-inflammatory
drugs. In laboratory examination she had thyrotoxicosis and methimazole was started. Technetium-
99m scintigraphy revealed a hypoactive nodule in the right thyroid lobe. The sacroiliac magnetic
resonance imaging showed a 45x36 mm lesion in the right half of the sacrum. In 18F-FDG PET
scan, a 65x60 mm lesion with calcifications and necrotic areas filling the right thyroid lobe and
isthmus of the neck, extending into the upper mediastinum at the inferior, narrowing the trachea at
this level, with borders that cannot be clearly distinguished from neighbouring anatomical structures
was observed. Additionally, there were mediastinal lymph nodes and metastatic foci in the right
lung, left scapula, T5 vertebrate, right sacrum, left ischium and right femur. Bone biopsy from the
left scapula resulted in WDTC metastasis. Since her thyroid functions were not normalized despite
60 mg/day methimazole treatment, total thyroidectomy and lymph node dissection were performed
after 3 days of plasmapheresis. Histopathologically, a 60 mm tumoral tissue in the right thyroid lobe
was detected. Approximately 20% of the tumor was composed of poorly differentiated cancer cells
including trabecular, solid and insular pattern. The remaining areas were morphologically WDTC.
There were also capsular and lymphovascular invasion. An additional follicular variant papillary
carcinoma of 3 mm was observed in the same lobe. Four central lymph nodes were excised and all
were reactive. At the 6th day of surgery, her serum TSH was <0.008 uıU/ml (0.55-4.78), free
thyroxine was 0.60 ng/dl (0.89-1.76) and free triiodothyronine was 2.47 pg/ml (2.3-4.2) and
methimazole treatment was stopped. The patient was discharged with radioactive iodine treatment
Conclusion: PDTC patients have worse outcomes than patients with WDTC. There is no difference
in the outcomes of PDTC and WDTC with poorly differentiated component. In our case;
approximately 20% of the tumor was composed of poorly differentiated cancer cells and at the time
of diagnose patient had bone metastasis without cervical LAP metastasis.
Introduction: In our country, some health institutions are allowed to constitute additional service
buildings/centers in order to increase the accessibility to outpatient services and decrease the
crowdiness in hospitals. We aimed to investigate the satisfaction of the patients evaluated in our
endocrinology and metabolism diseases center-ENDOOTEM (Endocrinology-Nuclear Medicine-
Diabetes-Obesity-Osteoporosis-Thyroid Diagnosis and TreatmentCenter)- which serves as a part of
our university hospital since 2007.
Methods: Patients who were examined in our center between September 2018-January 2019 were
asked to participate in satisfaction survey. ‘Satisfaction surveys application guide’ published by
Ministry of Health of our country, satisfaction survey recommended by ‘American Association of
Family Physicians-AAFP’ and PQ8-18 survey developed in 1994 were modified to create our own
Results: 1387(58.6%) female and 979 (41.4%) male patients completed the questionnaire. The
question of ‘Are you satisfied with our center in general?’ was answered as yes by 1374 (58.1%),
partially by 625 (26.6%) and no by 353 (14.9%) patients. There were 1526 (64.5%) patients who
thought that the doctor spent enough time for his/her illness and 368 (15.6%) patients who thought
he/she partially spent enough time. Whether the doctor was polite and respectful was answered as
yes by 1800 (76.7%), partially by 335 (14.3%) and no by 213 (9.1%) patients. There were 1930
(82.0%) patients who were completely or partially pleased with the attitude of the staff and 1988
(84.5%) patients who stated that his/her personal privacy was taken care of. Waiting rooms were not
enough according to 1406 (59.4%) and not comfortable according to 1140 (48.2%) patients. The
main problems were defined as difficulty of making appointment by 990 (41.8%), waiting for a
long time for evaluation of results by 1056 (44.6%), waiting for a long time for examination dates
by 734 (31.0%), difficulty in transportation and car parking by 573 (24.2%) and not being able to
make appointment for the same doctor by 472 (19.9%) patients. 1695 (72.2%) patients declared that
they wanted to continue the follow-up in our center.
Conclusion: Majority of patients were satisfied with the services, the physicians and the staff
working in our center. However, the difficulty in making appointments and physical conditions
seem to be the most important problems. These results suggest that specialized centers may increase
the quality of health services and the number of such centers should be increased. Nevertheless, it is
important to provide the proper physical conditions before opening a specialized health center.
Introduction: Familial Mediterranean Fever (FMF) is an autosomal recessive hereditary disease
characterized by fever and inflammation of serous membranes. The most important complication of
FMF is amyloidosis which has significant role in the prognosis. It is unclear how endocrine system
hormones are affected in FMF. We present adrenal insufficiency in a an FMF patient without
Case: A 39 years old male patient who had been diagnosed with FMF at the age of 14 years
admitted to the emergency department with the weeklong complaints of cough, fatigue, fainting and
abdominal pain. He had started colchicine treatment at the diagnosis but was not using it regularly.
He had a personal history of hospitalization in the intensive care unit with the diagnosis of
pericardial effusion and FMF attack 6 years ago. His blood pressure was 80/50 mm/hg, body
temperature was 36.88? ?C. In laboratory examination, his blood glucose was 40 mg/dl, sodium was
133 mmol/l, potassium was 6.1 mmol/l, calcium was 8.2 mg/dl, phosphorus was 3.0 mg/dl and
albumin was 4.0 g/dl. Cortisol and adrenocorticotrophic hormone were 0.326 ug/dl and 324.4
He was hospitalized with the diagnosis of adrenal insufficiency and glucocorticoid and
mineralocorticoid therapies were started. 24 hour urine protein excretion was 265.1 mg/day which
was suggestive for lack of renal amyloidosis. The size of the kidneys was normal in the abdominal
ultrasonography. Abdominal magnetic resonance imaging showed aplastic/hypoplastic right adrenal
gland that could not be distinguished and a small left adrenal gland. His complaints regressed with
hydrocortisone, fludrocortisone and colchicine treatments.
Conclusion: The most common cause of adrenal insufficiency in developing countries is
tuberculosis while its most common cause in developed countries is autoimmune adrenalitis. Lack
of proteinuria and presence of hypoplastic adrenal glands were suggestive for the absence of
amyloidosis in our patient. Coexistent FMF and Addison’s disease in a patient might be associated
with the immunopathogenic mechanisms or just a coincidence rather than amyloid involvement of
Aim: Radioactive iodine (RAI) is one of the treatment approaches in Graves and toxic nodular or
multinodular goiter (TNG/TMNG) with low cost and high efficacy. In this study, we aimed to
evaluate ultrasonographical and cytological features of thyroid nodules in patients who were treated
with radioactive iodine for hyperthyroidism years ago.
Methods: Patients who had a history of RAI treatment for hyperthyroidism and had thyroid nodules
that were evaluated with fine needle aspiration biopsy (FNAB) were included in the study.
Ultrasonographical features, and cytological and histopathological results of nodules were obtained
from the records.
Results: There were 27 patients (22 female and 5 male) with a mean age of 59.3±13.5. The
indication for RAI treatment was Graves in 5 (18.6%), TNG/TMNG in 16 (69.2%) and unknown in
6 (22.2%) patients. A total of 48 thyroid nodules were evaluated with FNAB and cytological
diagnosis were benign in 24 (50.0%), nondiagnostic in 15 (31.2%), atypia of undetermined
significance in 5 (10.4%), suspicous for malignancy in 2 (4.2%) and malignant in 2 (4.2%) nodules.
Mean duration between RAI treatment and FNAB was 76.4±63.1 months. Thyroidectomy was
performed in 10 patients and 5 were benign (50.0%) and 5 (50.0%) were malignant
histopathologically. FNAB result was benign in 1 (20.0%), atypia of undetermined significance in 1
(20.0%), suspicious for malignancy in 1 (20.0%) and malignnt in 2 (40.0%) nodules with malignant
histopathology. Ultrasonography features of 31 cytologically/histopathologically benign and 5
cytologically/histopathologically malignant nodules were compared. Rates of nodules with
anteroposterior/transverse diameter ratio higher than 1, solid structure, presence of peripheral halo,
marginal irregularity and microcalcification were similar in benign and malignant nodules
(P=0.303,P=0.684, P=0.829, P=0.973 and P=0.621, respectively). There were 1 (20.0%) isoechoic,
1 (20.0%) hypoechoic and 3 (60.0%) iso-hypoechoic nodules among malignant nodules, while 24
(77.4%) of benign nodules were isoechoic, 3 (9.7%) were hypechoic and 4 (12.9%) were
isohypoechoic (P=0.025). Macrocalcification was observed in 4 (80.0%) of malignant and 10
(32.3%) of benign nodules (P=0.042).
Conclusion: In patients treated with RAI due to hyperthyroidism, thyroid nodules with suspicious
ultrasonography features, particulary hypoechoic appearence and presence of macrocalcification,
should be evaluated with FNAB irrespective of the period after RAI treatment. Atypia related with
previous RAI treatment might cause diagnostic problems in cytological evaluation.
Aim: Although nonsecretory parathyroid carcinoma is relatively more frequent, nonsecretory
parathyroid adenoma was also reported. It is thought to precede functioning parathyroid adenoma.
Case report: An iso-hypoechoic 6.5x9.5x16.1 mm thyroid nodule with irregular borders in the
superior-posterior part of right thyroid lobe was observed in ultrasonography in a 44-year-old
female euthyroid patient. Fine-needle aspiration (FNAB) biopsy resulted with non-diagnostic
cytology (degeneration of follicular epithelial cells, colloidal material). A second FNAB was
recommended but she admitted five years later. There was subclinical hypothyroidism with positive
thyroid autoantibodies and normocalcemia in laboratory examination. The nodule in the superior-
posterior part of right thyroid lobe was well circumscribed and hypoechoic with diameters of
5.4x13.2x18.1 mm. The ultrasonographical apperarence was found to be suspicous for an
intrathyroidal parathyroid adenoma. Serum calcium was 8.99 mg/dL, albumin was 4.6 g/dL,
parathyroid hormone was 70.22 pg/mL and 25-OH Vitamin D3 was: 6.52 ng/mL. Parathyroid
hormone decreased to 37.94 pg/mL after replacement of vitamin D. The lesion was evaluated with
FNAB and the cytological result was again nondiagnostic (small amount of colloidal material, a few
epithelial cells). Parathyroid hormone washout was >5000 pg/mL in fine-needle aspiration fluid.
24-hours urinary calcium excretion was 210 mg. In Tc99m-sestamibi SPECT/CT revealed persistent
activity at superior-posterior part of upper pole of the right thyroid lobe. There was increased
echogenity compatible with crystalloid in urinary system ultrasonography. Z score was within the
expected range for age in bone mineral density. Surgical excision of the lesion was performed and a
parathyroid adenoma was confirmed histopathologically.
Conclusion: Parathyroid hormone washout should be considered in a lesion with suspicion of
intrathyroidal parathyroid adenoma even when primary hyperparathyroidism can not be shown
biochemically. If surgery is not performed, patients should be followed for possible development of
Introduction: 80-90% of insulinomas are smaller than 2 cm, equally located in the head, body and
tail of pancreas. Computer tomography (CT) is 75%, magnetic resonance imaging (MRI) is 55-
90%, endoscopic ultrasonography (EUS) is 85-95% and selective arterial calcium stimulation test
(SACST) is 95-100% sensitive in the diagnosis of insulinomas. Here, we presented two cases of
insulinoma which could not be located by conventional methods and evaluated with SACST.
Case 1: A 29-year-old male who described hypoglycemic symptoms especially after exercise in the
last 4 months was admitted to the hospital for a prolonged fasting test. At the 8th hour of the test,
laboratory results were as follows; blood glucose 36mg/dl, insülin 21 uIU/dl, c-peptide 4 ng/dl,
proinsulin 22 pmol/l and cortisol 18 ug/dl. Blood ketone and anti-insulin antibody were negative.
No pathology was observed in the abdominal CT and EUS. Abdominal MRI revealed a 10 mm
diameter nodular lesion in the posterior medial of the stomach which was suspicious for insulinoma.
It was seen only in T2A sequence in the venous phase in contrast-enhanced examination. Galium-
68 Dotatate scintigraphy showed no involvement in the pancreas. SACST was performed. A ten-
fold increase in insulin levels was observed in the splenic artery and distal pancreatectomy was
Case 2: A 41-year-old woman who had episodes of hypoglycemia for 3-4 months was referred with
a pre-diagnosis of insulinoma. The patient underwent a prolonged fasting test. At the time of
hypoglycemia (blood glucose 45 mg/dl), serum insülin was 7.8 uIU/dl, c-peptide was 2.2 ng/dl,
proinsulin was 8 pmol/l and, serum ketone and anti-insulin antibody were negative. There was no
contrast enhancement in the pancreas in the abdominal MRI, but a suspicious hyperintense area of
10 mm diameter was seen in T2A sequence. There was no pathology in abdominal CT and EUS. In
SACST, a five-fold increase in insulin levels was detected in the mesenteric artery which was
suggestive for an insulinoma lesion in the head of pancreas. Surgical excision was recommended
but the patient refused.
Conclusion: Although the biochemical diagnosis of insulinomas are usually not complicated, the
localization might be problematic. Because of the low sensitivity of non-invasive methods in tumors
smaller than 2 cm, invasive methods can be used for the localization like in our cases.
Table 1: 29 year-old man patient’s(case 1) selective arterial calcium stimulation test results
Splenic artery Gastric artery
0.second 22,51 uIU/ml 3,31 uIU/ml 2,014 uIU/ml 31,83 uIU/ml
20.second 25,58 uIU/ml 3,88 uIU/ml 19,8 uIU/ml 17,18 uIU/ml
40.second 28,22 uIU/ml 4,42 uIU/ml 33,42 uIU/ml 23,34 uIU/ml
60.second 19,23 uIU/ml 6,24 uIU/ml 23,53 uIU/ml 23,7 uIU/ml
Table 2: 41 year-old woman patient’s(case 2) selective arterial calcium stimulation test results
SMA Proximal splenic
0.second 17,54 uIU/ml 21,54 uIU/ml 19,8 uIU/ml 20,69 uIU/ml
20.second 18,49 uIU/ml 30,37 uIU/ml 20,01 uIU/ml 15,5 uIU/ml
40.second 84,93 uIU/ml 21,22 uIU/ml 20,52 uIU/ml 16,83 uIU/ml
60.second 110,3 uIU/ml 24,03 uIU/ml 22,36 uIU/ml 20,24 uIU/ml
Aim: Contradictory results in limited number of studies were reported about the effects of Ramadan
fasting on thyroid hormones. We aimed to evaluate the thyroid functions in Ramadan, and compare
late evening or pre-sahour use of levothyroxine in patients being treated for hypothyroidism.
Methods: Patients taking levothyroxine for hypothyroidism who were seen in the last one week
before Ramadan (8-15 May 2018) and had normal thyroid functions were recruited. Patients were
offered to take levothyroxine at 22.30-23.00 pm before sleep (Group-1) or between 01:30 and
03:00 am at least 30 min before sahour (Group-2).
Results: Basal thyrotophin (TSH) was 2.01? ?1.05 mIU/ml and significantly increased at the end of
Ramadan (3.09? ?3.38 mIU/ml, P=0.008). Free-triiodothyronine (FT3) decreased while free-
thyroxine (fT4) increased (P<0.001, P=0.028). Eighteen patients were in Group-1 and 44 were in
Group-2. There was unsignificant increase in TSH and FT4 in Group-1 (P=0.160, P=0.425), while
both increased significantly in Group-2 (P=0.022, P=0.008). FT3 decreased in Group-1 and 2
(P=0.016, P<0.001). At the end of Ramadan, TSH increased in 39(%63.9), decreased in 22
(%36.1) and did not change in 1 patient. Anti-thyroid peroxidase antibody was positive in 65.5% of
patients with increased TSH and in 35.3% of patients with decreased TSH (P=0.047).
Conclusion: Although mean TSH increased significantly,about one third of patients had lower TSH
indicating for the need to evaluate every patient individually and follow closely during this month.
Use of levothyroxine in late evening seems to maintain more stable thyroid hormones compared to
pre-sahour. Clinical studies with larger sample sizes will be helpful to determine the optimal time
for levothyroxine use during Ramadan.
Introduction: Subacute thyroiditis is an iflammatory disease of the thyroid gland characterized by
pain, tenderness and swelling in the neck. Less frequently, it may present with painless or silent
thyroiditis that occurs spontaneously or in the postpartum period. In a few studies in the literature,
urinary iodine was reported to be high in patients with postpartum thyroiditis, but it was not
evaluated in patients with subacute thyroiditis. We aimed to evaluate urinary iodine in patients with
subacute thyroiditis and determine whether it might have any role in the differential diagnosis.
Materials and methods: Patients diagnosed with subacute thyroiditis between April 2018 and
January 2019 were included in the study. Patients younger than 18 years old, with a history of
exposure to iodinated contrast media and pregnant or lactating women and patients with postpartum
thyroiditis were excluded. Demographic features, thyroid functions, thyroid autoantibodies, serum
thyroglobulin, erhytrocyte sedimentation rate (ESR), C-reactive protein (CRP), urinary iodine,
thyroid ultrasonography and Tc99m pertechnatate scintigraphy results were evaluated.
Results: There were 23 patients (16 female and 7 female) with a mean age of 38.65? ?7.99. At the
time of diagnosis, median serum thyrotrophin was 0.140 mIU/mL (minmax: 0.001-0.25) (normal
levels: 0.27-4.2 mIU/mL), mean serum free triiodothyroxine and free thyroxine were 8.29? ?3.53
pg/mL (normal levels: 1.8-4.6 pg/mL) and 3.56? ?1.34 ng/dL (normal levels: 0.9-1.7 ng/dL),
respectively. There was 1 (4.3%) patient with positive antithyroid peroxidase and 6 (26.1%) patients
with positive antithyroglobulin. Median serum thyroglobulin was 116 ng/mL (min-max: 2.7-500)
(normal levels: 0-78 ng/mL), mean ESR was 52.24? ?25.47 mm and median CRP was 63 mg/L (min-
max: 4.2-188) (normal levels: 0-5 mg/L). Ultrasonographically, thyroiditis was observed in 22
(96.7%) patients and 5 (21.7%) patients had thyroid nodules. Median urinary iodinewas 441 mcg/L
(min-max: 255-1843) and it was higher than 250 mcg/L in all patients. Thyroiditis was controlled
with nonsteroidal antiinflammatory drugs and beta blockers in 13 (54.5%) patients, while additional
corticosteroid treartment was required in 10 (45.5%) patients.
Conclusion: In patients with subacute thyroditis, urinary iodine was very well above normal limits.
This might be helpful in the differential diagnosis and follow up of the disease. While, high iodine
levels may be a consequence of thyroid follicle epithelial cell damage, the possibility of being an
etiological factor should not be ignored. Large-scale prospective studies are required to determine
the role of iodine in subacute thyroiditis
Introduction: The aldosterone-to-renin ratio (A/R) is the most frequently used screening test for
primary hyperaldosteronism (PH) and a confirmation test is recommended when it is high.We
aimed to determine the frequency of PH in patients with high A/R and investigated possible clinical
features that might help to prevent unnecesary confirmation tests.
Method: Patients who underwent saline infusion test because of high A/R (>3.8) were
retrospectively reviewed. PH was diagnosed in patients with plasma aldosteron >10 ng/dl after 4
hours of saline infusion. Patients with postinfusion aldosteron level between 5-10 ng/dl and with <5
ng/dl were defined as indeterminate and not to have PH, respectively. Patients with and without PH
Results: There were 38 patients (27 female and 11 male) with a mean age of 55.18? ?10.13. Mean
serum potassium (K) was 4.01? ?0.69 mmol/l and aldosteron was 30.24? ?14.61 ng/dl. Median renin
and A/R were 2.015 ng/l and 12.913, respectively. After saline infusion test, the diagnosis of PH
was confirmed in 17 (43.6%) and excluded in 11 (28.2%) patients. Indeterminate results were
obtained in 10 (25.6%) patients. There were 9 female and 8 male patients with PH, while all 11
patients without PH were female (P=0.007). 16 (94.1%) patients with PH and 7 (63.6%) without PH
were hypertensive (P=0.040). The age, presentation, adrenal imaging findings, sodium and renin
were similar in patients with and without PH. Mean serum K were 3.57? ?0.65 mmol/l and 4.31? ?051
mmol/l in patients with and without PH, respectively (PZ0.003). Mean aldosteron and median A/R
were higher in patients with PH, however the differences were not statistically significant [For
aldosteron; 36.67? ?15.38 ng/dl vs 25.14? ?13.02 ng/dl, P=0.050, for A/R 16.27 (4.90-264.50) and
7.36 (3.97-53.84), P=0.051]. Median aldosteron after saline infusion was 19.40 ng/dl (10.26-64.35)
in patients with PH and 3.70 ng/dl (1.50-4.83) in patients without PH (P<0.001).
Conclusion: Confirmation of PH in less than half of patients with high A/R is suggestive for high
false positivity of this screening method. It may be rational to repeat measurements before
confirmation tests in women, patients without HT and without hypokalemia. However, male sex,
presence of HT and hypokalemia seem to be stronger clinical findings that requires confirmation
tests in patients with
Aim: Familial hypercholesterolemia (FH) is an autosomal dominant genetic disease characterized
by increased levels of low density lipoprotein cholesterol (LDLchol). Despite relatively high
prevalance and significant association with increased mortality, the awareness of physicians and
patients is low and it is an underdiagnosed and undertreated disease. We aimed to detect patients
with FH and determine treatment status and compliance.
Materials and methods: Patients >18 years old and have a serum LDL-chol? ?250 mg/dL between
January 2010-December 2016 were identified from the database of our hospital. A survey was
performed by reaching patients via phone. Demographic features, smoking status, use of alcohol,
exercise, presence of cardiovascular disease (CVD), use of medication for dyslipidemia, CVD and
high cholesterol levels in the family were questioned. Patients with a serum
thyrotrophin10? ?mIU/mL, patients with glomerulonephritis and nephrotic syndrome, patients with
high liver enzymes and patients with serum triglyceride >400 mg/dL were excluded. DUTCH lipid
diagnostic criteria was used to classify patients.
Results: LDL-chol was ? ?250 mg/dL in 1918 measurements. When repeated measurements were
excluded, 1365 patients were identified. Patients that could not be reached by phone and who
refused to interview were excluded and data of 367 patients were analyzed. There were 248 (67.6%)
female and 119 (32.4%) male patients and mean age was 50.5? ?11.66. LDL-chol was ? ?330 mg/dL in
50 (13.6%) and 250-329 mg/dL in 317 (86.4%) patients. Mean DUTCH score was 6.36? ?1.63. 40
(10.9%) patients were classified as definite, 181 (49.3%) as probable and 146 (39.8%) as possible
FH. Among patients with definite or probable FH, 84 (38.0%) had CVD. DUTCH scores were
8.09? ?1.54 and 6.74? ?1.31 in patients with and without CVD, respectively. Considering all patients,
42% were taking medication for dyslipidemia. Among 213 patients that were not on antilipidemic
treatment, 162 (76.1%) stated that medication was never recommended previously, 30 (14.1%) had
stopped medication him/herself and 21 (9.8%) had stopped medication with the advice of the
physician. 49 (58.3%) definite or probable FH patients with CVD was taking antilipidemic
Conclusion: A significant proportion of patients with LDL-chol? ?250 mg/dL were not taking
antilipidemic drugs and other cardiovascular risk factors were not under control. Similar with many
other countries, diagnosis and treatment rates of FH patients were very low in our country. Further
national studies are required to increase awareness of the disease in both physicians and patients
Aim: It has been reported that thyrotrophin receptor antibody (TRAb) is associated with frequency
and aggressiveness of thyroid cancer in patients with Graves disease (GD). However, there is not
any data regarding the effects of TRAb on cytology and histopathology results of patients with
nodular GD. Thus, the aim of the present study is to evaluate the effects of TRAb on cytology and
histopathology results in patients with nodular or multinodular thyroid disease on the basis of GD.
Materials and Methods: Clinical data of patients with GD who had thyroidectomy and
preoperative TRAb levels were reviewed retrospectively. The cytology and histopathology results
of 548 nodules from 598 patients with GD were evaluated for the present study.
Results: Of 598 patients, 189 (31.6%) were men and 409 (68.4%) were women. However 352
patients did not have nodular disease on preoperative thyroid ultrasound, 74 had only one nodule
and 172 had ≥2 nodules. 517 (86.5%) patients had benign and 81 (13.5%) had malignant final
histopathology. In malignant group, 77 (95.1%) patients had papillary throid carcinoma, 2 (2.5%)
had follicular thyroid carcinoma, 1 (1.2%) had thyroid tumor of uncertain malignant potential, and
1 (1.2%) had hurthle cell thyroid carcinoma. However, TRAb was detected as positive in 359 (60%)
patients, it was found as negative in 239 (40%) patients. There were 185 nodules in TRAb positive
group and 363 nodules in TRAb negative group, and there was no significant difference in cytology
results between groups (p=0.181) (Table 1). Malignancy was detected in 48 (13.4%) and 33
(13.8%) patients with TRAb positive and negative patients, respectively (p=0.878), and there was
not any difference in histopathology results between groups (p=0.161) (Table 1). Furthermore, there
was no difference in features of carcinoma such as capsular, vascular, and lymphatic invasions
between TRAb positive and negative groups (p>0.05).
Conclusion: In the present study, it was found that malignancy rate was similar in TRAb positive
and negative patients. Contrary to literature, TRAb positivity was not associated with increased
malignancy rate and also had no effect on cytology and histopathology results in patients with GD.
Table 1. Comparison of the cytology and histopathology results of Thyrotrophin receptor antibody
positive and negative patients with Graves Disease
TRAb Positive TRAb Negative p
Cytology (n,%) n=185 n=363
Nondiagnostic 52 (28,1) 81 (22,3) 0,181
Benign 113 (61,1) 258 (71,1)
Atypia of undetermined
lesion of undetermined
13 (7,0) 19 (5,2)
Suspicious for follicular
1 (0,5) 1 (0,3)
Suspicious for malignancy 4 (2,2) 3 (0,8)
Malignant 2 (1,1) 1 (0,3)
Histopathology (n,%) n=48 n=33
Papillary thyroid carcinoma 47 (97,9) 30 (90,9) 0,161
Follicular thyroid carcinoma 0 2 (6,1)
Thyroid tumor of unceratin
0 1 (3,0)
Hurthle cell thyroid
1 (2,1) 0
Aim: Although thyroid nodules located in isthmus were less frequent, papillary thyroid cancer in
this location was reported to be more aggressive in some studies. Our aim was to evaluate
hormonal, ultrasonographic, and cytopathologic features of nodules located in isthmus (isthmic
Material and methods: Data of patients who underwent thyroidectomy between 2006-2014 were
reviewed retrospectively. Hormonal, ultrasonographic, and cytopathologic features of patients with
isthmic and with lober (non-isthmic) nodules were compared.
Results: Patients with isthmic nodules (Group-1) and non-isthmic nodules (Group-2) consisted of
260 and 2171 patients, respectively. Age and gender distributions were similar. AntiTg positivity
was higher in Group-1 (28.6% vs 21.2%; P=0.018). Subsequently, 268 isthmic (10.7%) and 5347
non-isthmic (89.3%) nodules were compared. Although ultrasonographical features such as
presence of microcalcification and halo, nodule diameters, echogenicity, texture, margin, and
vascularity were similar between groups, macrocalcification rate was lower in isthmic nodules
(19% vs 27%; P=0.004). Furthermore, cytologic results were also similar. However, malignancy
rate was lower in isthmic nodules (6.0% vs 11.4%; P=0.006), type of thyroid cancer was similar in
isthmic and non-isthmic nodules. When malign isthmic (n=16, 2.6%) and malign non-isthmic
nodules (n=605, 97.4%) were compared, diameter and type of tumor, lymphovascular and capsular
invasion, extrathyroidal extension and multifocality rates were statistically insignificant. Malign
isthmic nodules (n=16, 6%) had smaller size [10.05(4.00-34.50) mm vs 20.05(8.40-74.10)mm;
P=0.002], higher hypoechogenity (31.2% vs 5.6%, P<0.001) and exophyticity rates (28.6% vs
4.9%; P=0.007) compared to benign isthmic nodules (n=251, 94%).
Conclusion: Although isthmic nodules had lower malignancy rate compared to non-isthmic ones,
histopathologic features were similar in isthmic and non-isthmic nodules. Relatively small,
hypoechoic, and exophytic nodules located in isthmus should be evaluated immediately for
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