[Results of surgical treatment of papillary thyroid cancer with lymph node metastasis - review of our data in a 5-year period]

A papillaris pajzsmirigyrák prognózisát a gyakori nyaki nyirokcsomóáttét-képzés befolyásolja. Sebészi kezelésük minősége a betegek túlélését és a recidíva előfordulási gyakoriságát is meghatározza. Az Országos Onkológiai Intézet Fej-Nyaki Daganatok Multidiszciplináris Központjában a fej-nyak sebész szerzők által 2013 és 2018 között operált, nyaki áttétet adó papillaris carcinomás betegek adatait vizsgáltuk. 130, nyaki áttétet adó papillaris pajzsmirgy-carcinomás beteg esetében az ATA (American Thyroid Association) 2015. évi irányelvei alapján teljes pajzsmirigy-eltávolítást és nyaki nyirokcsomó-dissectiót végeztünk. Az eltávolított anyagokat szövettani feldolgozásra küldtük, vizsgáltuk a nyirokcsomóáttét(ek) arányát az életkor, a nem, a tumor-multifokalitás, a kétoldaliság, a tokon kívüli terjedés, a nyirok-, érinvázió függvényében. Elemeztük a műtét után fellépő szövődményeket is. 43 betegnél thyreoidectomia, totális és centrális nyaki dissectio (VI. régió), 87 esetben centrális (VI. régió) és laterális (II–V. régió) nyaki dissectio történt. Átmeneti (6 hónapon belül normalizálódó) hypocalcaemia 30 betegnél (23%), permanens hypocalcaemia 4 betegnél (3%) fordult elő. Átmeneti nervus recurrens bénulás 12 esetben (9,2%), permanens bénulás 3 (2,3%) esetben történt. A szövettani értékeléskor érbetörés és tokinvázió 75 betegnél (57,7%), nyirokér-invázió 63 betegnél (48,5%), Hashimoto-thyreoiditis 51 betegnél (39,2%) igazolódott. Microcarcinoma (1 cm-nél kisebb daganat) 43 esetben fordult elő (33%). Az eltávolított nyirokcsomók átlagosan 48%-a volt áttétes. Ez csak a tumormérettel mutatott szignifikáns korrelációt, az életkorral nem találtunk összefüggést. Az oldaliság, a többgócúság, valamint a tok-, nyirokér- és érinvázió, a Hashimoto-status és a beteg neme nem mutatott összefüggést az áttétes nyirokcsomók számával. A túlélést befolyásolta a tok-, ér- és nyirokér-invázió, valamint a tumorméret is. A nyaki áttétet adó, differenciált pajzsmirigyrákos beteganyagunk kezelésében a kivizsgálási protokollt követően a teljes pajzsmirigy-eltávolítás és a megfelelő régiókat tartalmazó nyaki dissectio döntő fontosságú, a radiojód-terápiával kiegészítve az irányelveknek megfelelő kezelési modul. A pajzsmirigydaganat a leggyakoribb endokrin daganatos megbetegedés, melynek sebészi kezelése a multidiszciplináris terápia legfontosabb eleme. 5 év alatt operált, nyaki áttétet is adó, differenciált pajzsmirigyrákos beteganyagunkat feldolgozva ismertetjük eredményeinket az olvasóval. Orv Hetil. 2024; 165(3): 83–88.

Hormonal changes in the first 24 postoperative hours after cardiac surgical procedures

Background

Hormone level changes after heart surgeries are a widely observed phenomenon due to neurohormonal feedback mechanisms that may affect postoperative morbidity and mortality. The current study aimed to analyze the changes in thyroid and sex hormones in the first 24 postoperative hours after heart surgery.

Methods

This prospective, observational study (registered on ClinicalTrials.gov: NCT03736499; 09/11/2018) included 49 patients who underwent elective cardiac surgical procedures at a tertiary heart center between March 2019 and December 2019. Thyroid hormones, including thyroid-stimulating hormone (TSH), triiodothyronine (T3), and thyroxine (T4), and sex hormones, including prolactin (PRL) and total testosterone, were measured preoperatively and at 24 h postoperatively.

Results

Significant decreases in serum TSH (P < 0.001), T3 (P < 0.001) and total testosterone (P < 0.001) levels were noted, whereas T4 (P = 0.554) and PRL (P = 0.616) did not significantly change. Intensive care unit (ICU) hours (P < 0.001), mechanical ventilation (P < 0.001) and Vasoactive-Inotropic Score (VIS) (P = 0.006) were associated with postoperative T3 level. ICU hours were associated with postoperative T4 level (P = 0.028). Postoperative and delta testosterone levels were in connection with lengths of stay in ICU (P = 0.032, P = 0.010 respectively). Model for End-Stage Liver Disease (MELD) scores were associated with thyroid hormone levels and serum testosterone.

Conclusions

T3 may represent a marker of nonthyroidal illness syndrome and testosterone may reflect hepatic dysfunction. In addition, PRL may act as a stress hormone in female patients.

The master role of polarized NIS expression in regulating iodine metabolism in the human body

Objective

The aim of this study was to investigate how polarized sodium iodide symporter (NIS) expression may regulate iodide metabolism in vivo.

Materials and methods

Polarized NIS expression was analyzed in tissues that accumulate iodide by the use of immunohistochemistry and polyclonal antibody against the C-terminal end of human NIS (hNIS).

Results

Iodide absorption in the human intestine occurs via NIS expressed in the apical membrane. Iodide is secreted into the lumen of the stomach and salivary glands via NIS expressed in the basolateral membrane and then circulates back from the small intestine to the bloodstream via NIS expressed in the apical membrane.

Conclusion

Polarized NIS expression in the human body regulates intestinal-bloodstream recirculation of iodide, perhaps prolonging the availability of iodide in the bloodstream. This leads to more efficient iodide trapping by the thyroid gland. Understanding the regulation and manipulating gastrointestinal iodide recirculation could increase radioiodine availability during theranostic NIS applications.

Hydrocortisone and purinergic signaling stimulate sodium/iodide symporter (NIS)-mediated iodide transport in breast cancer cells

The sodium/iodide symporter (NIS) mediates a remarkably effective targeted radioiodide therapy in thyroid cancer; this approach is an emerging candidate for treating other cancers that express NIS, whether endogenously or by exogenous gene transfer. Thus far, the only extrathyroidal malignancy known to express functional NIS endogenously is breast cancer. Therapeutic efficacy in thyroid cancer requires that radioiodide uptake be maximized in tumor cells by manipulating well-known regulatory factors of NIS expression in thyroid cells, such as TSH, which stimulates NIS expression via cAMP. Similarly, therapeutic efficacy in breast cancer will likely depend on manipulating NIS regulation in mammary cells, which differs from that in the thyroid. Human breast adenocarcinoma MCF-7 cells modestly express endogenous NIS when treated with all-trans-retinoic acid (tRa). We report here that hydrocortisone and ATP each markedly stimulates tRa-induced NIS protein expression and plasma membrane targeting in MCF-7 cells, leading to at least a 100% increase in iodide uptake. Surprisingly, the adenyl cyclase activator forskolin, which promotes NIS expression in thyroid cells, markedly decreases tRa-induced NIS protein expression in MCF-7 cells. Isobutylmethylxanthine increases tRa-induced NIS expression in MCF-7 cells, probably through a purinergic signaling system independent of isobutylmethylxanthine's action as a phosphodiesterase inhibitor. We also observed that neither iodide, which at high concentrations down-regulates NIS in the thyroid, nor cAMP has a significant effect on NIS expression in MCF-7 cells. Our findings may open new strategies for breast-selective pharmacological modulation of functional NIS expression, thus improving the feasibility of using radioiodide to effectively treat breast cancer.

Advances in Na(+)/I(-) symporter (NIS) research in the thyroid and beyond

The Na(+)/I(-) symporter (NIS) is a plasma membrane glycoprotein that mediates active iodide uptake in the thyroid-the essential first step in thyroid hormone biosynthesis-and in other tissues, such as salivary and lactating mammary glands. Thyroidal radioiodide uptake has been used for over 60 years in the diagnosis and effective treatment of thyroid cancer and other diseases. However, the NIS cDNA was only isolated in 1996 by expression cloning in Xenopus laevis oocytes, marking the beginning of the molecular characterization of NIS and the study of its regulation, both in the thyroid and other tissues. One of the most exciting current areas of NIS research-radioiodide treatment of extrathyroidal cancers-was launched by the discovery of functional expression of endogenous NIS in breast cancer and by the ectopic transfer of the NIS gene into otherwise non NIS-expressing cancers. This review summarizes the main findings in NIS research, emphasizing the most recent developments.

Immunohistochemical profile of the sodium/iodide symporter in thyroid, breast, and other carcinomas using high density tissue microarrays and conventional sections

Extrathyroidal cancers could potentially be targeted with (131)I, if the Na(+)/I(-) symporter (NIS) were functional. Using immunohistochemical methods we probed 1278 human samples with anti-NIS antibody, including 253 thyroid and 169 breast conventional whole tissue sections (CWTS). Four high density tissue microarrays containing a wide variety of breast lesions, normal tissues, and carcinoma cores were tested. The results of the normal microarray were corroborated in 50 CWTS. Nineteen of 34 normal tissues, including bladder, colon, endometrium, kidney, prostate, and pancreas, expressed NIS. Nineteen of 25 carcinomas demonstrated NIS immunopositivity; 55.7% of 479 carcinoma microarray cores expressed NIS, including prostate (74%), ovary (73%), lung (65%), colon (62.6%), and endometrium (56%). NIS protein was present in 75% benign thyroid lesions, 73% thyroid cancers, 30% normal-appearing, peritumoral breasts, 88% ductal carcinomas in situ, and 76% invasive breast carcinoma CWTS. Comparatively, breast microarray cores had lower immunoreactivity. Plasma membrane immunopositivity was confirmed in thyrocytes, salivary ductal, gastric mucosa, and lactating mammary cells. In other tissues, immunoreactivity was predominantly intracellular, particularly in malignant lesions. Thus, NIS is present in many normal epithelial tissues and is predominantly expressed intracellularly in many carcinomas. Elucidating the regulatory mechanisms that render NIS functional in extrathyroidal carcinomas may make (131)I therapy feasible.

The sodium/iodide Symporter (NIS): characterization, regulation, and medical significance

The Na(+)/I(-) symporter (NIS) is an integral plasma membrane glycoprotein that mediates active I(-) transport into the thyroid follicular cells, the first step in thyroid hormone biosynthesis. NIS-mediated thyroidal I(-) transport from the bloodstream to the colloid is a vectorial process made possible by the selective targeting of NIS to the basolateral membrane. NIS also mediates active I(-) transport in other tissues, including salivary glands, gastric mucosa, and lactating mammary gland, in which it translocates I(-) into the milk for thyroid hormone biosynthesis by the nursing newborn. NIS provides the basis for the effective diagnostic and therapeutic management of thyroid cancer and its metastases with radioiodide. NIS research has proceeded at an astounding pace after the 1996 isolation of the rat NIS cDNA, comprising the elucidation of NIS secondary structure and topology, biogenesis and posttranslational modifications, transcriptional and posttranscriptional regulation, electrophysiological analysis, isolation of the human NIS cDNA, and determination of the human NIS genomic organization. Clinically related topics include the analysis of congenital I(-) transport defect-causing NIS mutations and the role of NIS in thyroid cancer. NIS has been transduced into various kinds of cancer cells to render them susceptible to destruction with radioiodide. Most dramatically, the discovery of endogenous NIS expression in more than 80% of human breast cancer samples has raised the possibility that radioiodide may be a valuable novel tool in breast cancer diagnosis and treatment.

Na(+)/I(-) symporter activity requires a small and uncharged amino acid residue at position 395

Active iodide uptake in the thyroid is mediated by the Na(+)/I(-) symporter (NIS), a key plasma membrane glycoprotein. Several NIS mutations have been shown to cause I(-) transport defect, a condition that, if untreated, can lead to congenital hypothyroidism and, ultimately, cretinism. The study of I(-) transport defect-causing NIS mutations provides valuable insights into the structure-function and mechanistic properties of NIS. Here we report the thorough analysis of the G395R NIS mutation. We observed no I(-) uptake activity at saturating or even supersaturating external I(-) concentrations in COS-7 cells transiently transfected with G395R NIS cDNA, even though we demonstrated normal expression of G395R NIS and proper targeting to the plasma membrane. Several amino acid substitutions at position 395 showed that the presence of an uncharged amino acid residue with a small side chain at position 395 is required for NIS function, suggesting that glycine 395 is located in a tightly packed region of NIS. Substitutions of large amino acid residues at position 395 resulted in lower V(max) without affecting K(m) values for I(-) and Na(+), suggesting that these residues hamper the Na(+)/I(-) coupling reaction.

Journey of the iodide transporter NIS: from its molecular identification to its clinical role in cancer

The Na+/I- symporter (NIS) is an intrinsic plasma membrane protein that mediates the active transport of I- in the thyroid, lactating mammary gland, stomach and salivary glands. The presence of NIS in the thyroid is exploited in diagnostic scintigraphic imaging and radioiodide therapy in thyroid cancer. The continued rapid progress in NIS research (aimed at the elucidation of the Na+-dependent I- transport mechanism, the analysis of NIS structure-function relations and the study of the tissue-specific regulation of NIS at all levels), holds potentially far-reaching medical applications beyond thyroid disease, in breast cancer and malignancies in other tissues.

Rapid communication: predominant intracellular overexpression of the Na(+)/I(-) symporter (NIS) in a large sampling of thyroid cancer cases

Here we report the analysis of the Na(+)/I(-) symporter (NIS) protein expression in 57 thyroid cancer samples by immunohistochemistry with high-affinity anti-NIS Abs. As many as 70% of these samples exhibited increased NIS expression with respect to the normal surrounding thyroid tissue. Most significantly, NIS was located in these samples either in both the plasma membrane and intracellular compartments simultaneously, or exclusively in intracellular compartments. This suggests that NIS is clearly expressed or even overexpressed in most thyroid cancer cells, but malignant transformation in some of these cells interferes either with the proper targeting of NIS to the plasma membrane, or with the mechanisms that retain NIS in the plasma membrane after it has been targeted. The results further indicate that, in addition to indicating NIS expression in cases where it is absent (approximately 30%), improvements in (131)I radioablation therapy might result from promoting targeting of NIS to the plasma membrane in the majority (approximately 70%) of thyroid cancers.

[Aspergillosis of the sphenoid sinus: presentation as a pituitary mass]

A rare manifestation of aspergillosis in the central nervous system is its invasion through the sphenoidal wall into the sella turcica representing itself as a pituitary mass. The symptoms may be headache, visual defect caused by compression of the chiasma, hypopituitarism and diabetes insipidus. In the majority of cases only the postoperative histology leads to the correct diagnosis. A case of invasive aspergillosis was reported here with the clinical picture of a pituitary tumor and without underlying immunodeficiency.

The blood spot thyrotropin method is not adequate to screen for hypothyroidism in the elderly living in abundant-iodine intake areas: comparison to sensitive thyrotropin measurements

We investigated whether the blood spot thyrotropin (TSH) method was adequate for screening elderly subjects with abundant iodine intake (median excretion 330 microg/g creatinine) for hypothyroidism. In 97 healthy adults (group A), 210 nursing home residents (group B) and 265 elderly subjects living at home (group C) serum (sensitivity < 0.02 mU/L, cost 1.2 U.S. dollars [USD]) and blood spot TSH (sensitivity < 1.0 mU/L, cost 0.4 USD) were measured, and the sensitivity and specificity of different blood spot TSH cutoff points to detect cases with elevated serum TSH were calculated. Elevated (> 3.5 mU/L) serum TSH levels (group A, 6.2%; group B, 16.2%; group C, 22.3%; B > A, p = 0.025; C > A, p < 0.001) were detected with the required sensitivity of greater than 0.9 only if the cutoff point of the blood spot TSH was set as low as 2.5 mU/L, but this led to a considerable loss of specificity. At cutoff point 2.5 mU/L, the rate of positivity was 39.3% and the cost of blood spot screening/person increased to 0.88 USD, considering that positive cases have to be rechecked by serum TSH to exclude false positivity. Cases with significantly elevated (> 10.0 mU/L) serum TSH (group A, 1.03%; group B, 2.85%; group C, 2.20%) were detected at blood spot cutoff points 10.0-4.0 mU/L with a sensitivity of 1.0 and without considerable loss of specificity. We conclude that while screening for hypothyroidism in the elderly population with abundant iodine intake is justified by the high prevalence of elevated ultrasensitive serum TSH values, the sensitivity of the blood spot method is insufficient to detect the subclinical hypothyroidism accurately and would, therefore, fail to detect most affected subjects.

The efficacy of long term thyrostatic treatment in elderly patients with toxic nodular goitre compared to radioiodine therapy with different doses

The objective of the study was to investigate the efficacy of long term thyrostatic versus radioiodine treatment of hyperthyroidism in old age. Our study is a retrospective analysis of the therapeutical outcome in 66 patients over 60 years of age with toxic nodular goitre. The patients were divided in two groups: Group A: 28 patients on methimazole treatment: starting dose 5-30, median (M) 10 mg, maintenance dose 2.5-15 (M = 5) mg, follow up 6 to 240 months (M = 23.5 months). Group B: 38 patients treated by either 100-300 MBq (N = 14, subgroup B1) or 325-1000 MBq (N = 24, subgroup B2) 131I, follow up: 18 to 156 months (M = 48 months). The efficacy of the different therapeutical approaches were compared by calculating the occurrence rate of persisting and relapsing thyroid dysfunctions and associated side effects. The 28 patients on methimazole treatment became euthyroid after 1-16 (M = 5) months but numerous relapses occurred in the follow up: hyperthyroidism, clinical: 5, subclinical 13, (relapse duration: M = 8 months; associated symptoms: hypertension in 4, cardiac arrhythmia in 3, cerebral embolism in 1, angina pectoris in 2, weight loss in 2 cases). Poor patient's compliance (9/28) or dose reduction by the physician (5/28) were the main causes of the relapses. Transient clinical (3 cases) or subclinical (6 cases) hypothyroidism also occurred (duration: 1-3 M = 2 months, no clinical symptoms). In 7 out of 14 (50%) patients receiving 100-300 MBq 131I (Group B1) hyperthyroidism persisted (versus 4/24 -16.7%- in Group B2 following 325-1000 MBq 131I; chi2(1) = 4.78 P = 0.028), methimazole treatment had to be continued in 9/14 patients (64.3%) (versus 5/24 -20.8%)- in Group B2., chi2(1) = 7.18 P = 0.0074) and in 5/14 (35.7%) the radiotherapy had to be repeated (versus 5/24 -020.8%- in Group B2, not sign.). Our conclusions are: 1) long term thyrostatic treatment is not safe in elderly patients with toxic nodular hyperthyroidism, mainly because of poor compliance or dose reduction by the physician; 2) radioiodine treatment as the first choice should be recommended for these patients and higher doses should be preferred.

[Ganglioneuroma of the adrenal gland]

149 patients with adrenal incidentalomas were examined. Sixty-eight cases were histologically confirmed, five of them had ganglioneuromas. On the basis of these patients history current knowledge of this benign tumour was summarized. Histological and pathological characteristics of one tumour suggest that ganglioneuromas may develop by maturing of malignant neuroblastic tumours. The clinical symptoms (abdominal pain, meteorism) were local. In 2 of 5 cases mildly elevated levels of urinary vanillylmandelic acid and catecholamine could be measured. One patient had persisting hypertension after surgery. In an other patient previous diarrhoea stopped after the removal of tumour. On the basis of ultrasound and computertomographic features, the size and origin of a tumour and its relation to the surrounding organs can be well characterized. One patient was inoperable because of an infiltratively spreading tumour, but during five years of follow-up no tumour progression could be observed with computertomography. After surgery we could follow only 2 of 4 patients. Until now no recurrence of tumour were detected.

[Multiple endocrine adenomatosis IIB]

The first Hungarian MEN IIB (multiplex endocrine neoplasia) syndrome is reported with the short summary of the literature about the pathogenesis and diagnosis of medullary thyroid carcinoma, presenting 80% in sporadic, 20% in hereditary form. The appearance of the patients alone (marfanoid stature, bulky lips, and ganglioneuromatosis of the tongue) may be almost enough for the presumption for the diagnosis of MEN IIB: For screening and preventing the clinical manifestation of the very aggressive medullary carcinoma in the relatives of the patient, the genetic screening is indispensable. The costs of the genetic screening and early treatment of the patients are much lower than the expenses of the traditional annual biochemical screening and the--delayed, often only supportive--treatment of the clinically manifested illness.

In old age the majority of thyroid peroxidase autoantibodies are directed to a single TPO domain irrespective of thyroid function and iodine intake

OBJECTIVE

We have examined (1) which epitopes on thyroid peroxidase (TPO) are recognized by TPO autoantibodies (TPO-Aab) in old age and to what extent? (2) Does the TPO-Aab pattern differ in euthyroid and hypothyroid elderly subjects or does it depend on their iodine intake?

DESIGN

TPO-Aab positive sera obtained from a screening study of nursing-home residents living in areas of varying iodine intake were tested by competition studies with monoclonal antibodies (mAbs) recognizing different epitopes on TPO.

SUBJECTS

The nursing-home residents with TPO-Aab positivity were from (A) an iodine abundant area (Eastern Hungary, median iodine excretion -MIE-: 0.462 mumol/mmol creatinine, N = 13); (B) an area of obligatory iodinated salt prophylaxis since the 1950s (Slovakia, MIE: 0.090 mumol/mmol creatinine, N = 11); (C) a moderately iodine-deficient area (Northern Hungary, MIE: 0.065 mumol/mmol creatinine, N = 13).

MEASUREMENTS

Thirteen murine TPO antibodies generated against several epitopes of the four (A, B, C, D) antigenic domains on the TPO were co-incubated with the TPO-Aab positive sera on TPO coated microtitre plates. The amount of mAb bound was estimated after further incubation with goat anti-mouse antibodies, conjugated with horseradish peroxidase and tetramethylbenzidine as chromogen. The TPO-Aab positive sera were characterized by the pattern of percentage of inhibition of mAb binding caused by the TPO-Aabs.

RESULTS

TPO-Aabs inhibited only the binding of mAbs raised against the antigenic domains A (mAb9, mAb2, mAb60) and B (mAb64, mAb59, mAb18, mAb15). The extent of inhibition depended upon the TPO-Aab titre but in all cases the binding of mAb9 was inhibited to the highest degree. The percentage inhibition of mAb9 was (a) 34 +/- 17% (M +/- SD) caused by sera (N = 8) with TPO-Aab titre 1/100-1/200 (higher than that of all mAbs recognizing domain B, P < 0.01-P < 0.001), (b) 76 +/- 18% caused by sera (N = 14) with TPO-Aab titre 1/1000 (higher than that of all other mAbs -P < 0.01-P < 0.001, except mAb64), (c) 99 +/- 4% caused by sera (N = 15) with TPO-Aab titre 1/4000-1/16,000 (higher than that of all other mAbs, P < 0.01-P < 0.001). Thus, only mAb9 was inhibited completely by high titres of TPO-Aabs. The qualitative and quantitative distribution pattern of mAb inhibition was similar in the subgroups of elderly hypothyroid and euthyroid subjects with comparable TPO-Aab levels, as well as in the subgroups with varying iodine intake.

CONCLUSIONS

(1) In old age, there is a polyclonal TPO autoantibody response but the majority of the autoantibodies are directed to the TPO region mapped by or close to mAb9 (domain A); (2) the autoantibody response does not differ in elderly subjects with or without the clinical manifestations of autoimmune thyroid disease and does not depend on the iodine supply of the elderly subjects.

The effect of surgical treatment on secondary hyperaldosteronism and relative hyperinsulinemia in primary hyperparathyroidism

OBJECTIVE

To evaluate the renin-aldosterone system and insulin secretion in hyperparathyroidism and their effects on blood pressure regulation.

DESIGN

Studies were carried out on patients with primary hyperparathyroidism (PHPT) prior to and following removal of the parathyroid tumor.

METHODS

Sixteen normotensive and euglycemic patients with PHPT were studied. The following parameters were measured: basal and stimulated plasma renin activity (PRA) and aldosterone (ALD) secretion: parathormone (PTH) and serum electrolytes. Insulin and glucose levels were measured during an oral glucose tolerance test.

RESULTS

Systolic but not diastolic blood pressure showed a decrease following surgery, from 123.3+/-13.0/80+/-8.6 to 116.7+/-13.5/77.3+/-8.8 mmHg. The decrease in the systolic pressure was not clinically significant. After surgery, both the basal and stimulated PRA and ALD values decreased, and the preoperative pathological values returned to normal: PRA basal: 1.79 --> 0.70 ng/ml/h, P=0.0049; PRA stimulated: 7.76 --> 1.90 ng/ml/h, P=0.0031; ALD basal: 111.5 --> 73.0 pg/ml, P=0.0258; ALD stimulated: 392.5 --> 236.0 pg/ml, P=0.0157. The postoperative decrease in the PRA correlated with the changes in PTH levels (r=0.5442, P < 0.05, n=16) but did not correlate with the changes in serum calcium concentrations. Both the fasting and stimulated insulin levels decreased after surgery but remained within the normal range: insulin fasting: 10.2 --> 5.0 mIU/l, P=0.0218; insulin area under the curve: 5555 --> 3296 mIU/l*min, P=0.0218. There was no correlation between the changes in insulin levels and PTH or ion levels. Sodium, potassium and blood glucose levels remained unaffected by parathyroid surgery.

CONCLUSIONS

In a population of normotensive hyperparathyroid patients an increased activity of the renin-aldosterone system related to PTH was found and surgery resulted in a small and insignificant decrease in blood pressure. This change was accompanied by a significant decrease in the activity of the renin-aldosterone system indicating the role of the renin-aldosterone system in the regulation of blood pressure in PHPT. Both fasting and stimulated insulin values decreased following removal of the parathyroid tumor, but with no individual correlation with PTH and calcium levels.

[Glycoprotein hormone alpha-subunit secretion in non-functioning pituitary adenomas]

The aim of the present study was to investigate the prevalence of elevated free glycoprotein hormone alpha-subunit in different pituitary adenomas, to establish the diagnostic value of the basal and stimulated free alpha-subunit secretion in non-functioning adenomas. Serum basal levels of alpha-subunit were increased in 1 of 22 untreated, in 1 of 16 operated patients with non-functioning adenoma, in 6 of 28 untreated, in 1 of 7 operated patients with acromegaly, in 0 of 5 untreated prolactinomas and in 0 of 1 untreated gonadotrop adenoma. Overall free alpha-subunit levels were increased in 9 of 79 cases (11.4%). In 6 of 9 patients with untreated non-functioning adenoma thyrotrop hormone releasing hormone caused an abnormal--paradox--elevation of serum alpha-subunit. These data indicate that measurement of basal and stimulated alpha-subunit is of relatively poor value in the diagnosis of non-functioning pituitary adenomas. The transsphenoidal surgery did not resulted in a change of alpha-subunit secretion neither in patients with non-functioning adenoma nor with acromegaly. The present data confirm the view that non-functioning pituitary adenomas are not homogeneous since this subset of tumors includes adenomas that either do not secrete measurable amounts of free alpha-subunit or produce normal or supranormal amounts of subunits as consequence of still undefined biosynthetic abnormalities.

Diagnosis from thyroid aspirates. Is the cytopathologist handicapped if not fully informed about the patient?

OBJECTIVE

When fine needle aspiration cytology (FNA) of the thyroid is performed as a first-line test, the cytopathologist cannot be fully informed about the patient's data. The authors investigated whether this decreases the accuracy of FNA and results in consequences for the patient.

STUDY DESIGN

FNA smears of 202 patients, 190 with benign and 12 with malignant thyroid disease, were reevaluated, supplying the cytopathologist first with only information from the case history known already at the initial admission, and subsequently with full data.

RESULTS

The FNA diagnoses were corrected in 13 cases; in 8/13 they showed a more serious finding. The therapeutic modality was changed in only one case. No corrections were made in the ultimately malignant cases.

CONCLUSION

In several cases the cytopathologist may be handicapped by receiving only partial information about the patient, but in our patients this had no demonstrable adverse consequences. Thus, FNA can be performed upon patient's admission.

Apoplexy of a pituitary macroadenoma as a severe complication of preoperative thyrotropin-releasing hormone (TRH) testing

The case history of a 54-year-old male suffering from pituitary macroadenoma with suprasellar extension is reported. A TRH-test with 200 micrograms i.v. was followed by severe headache and vomiting after 60', and by development of ophthalmoplegia on the following day. Hyperdens patches on the CT scan showed haemorrhage into the tumor. A chromophobic adenoma with macroscopic and histological signs of haemorrhage was removed via the transsphenoidal route. In the postoperative period the ophthalmoplegia gradually disappeared but central hypoadrenia and hypothyroidism occurred. This is the second case in the literature showing that TRH alone and in a low dose may cause pituitary tumor apoplexy. It is concluded that TRH-testing is a risk for the patient with pituitary apoplexy. If, due to the size of the tumor the patients have to be operated on in any case, and the test is not of essential diagnostic value, the TRH-test should be done only in selected cases. Its use in the postoperative evaluation however is without risk for the patients.

Low dehydroepiandrosterone sulfate (DHEA-S) level is not a good predictor of hormonal activity in nonselected patients with incidentally detected adrenal tumors

To assess its differential diagnostic value, dehydroepiandrosterone sulfate (DHEA-S) was measured in a nonselected cohort of 84 patients with incidentally detected adrenal tumors (incidentaloma). Of the 38 histologically confirmed cases, 6 of 12 patients with primary or metastatic malignant tumor of the adrenals and 7 of 14 patients with benign cortical adenoma had low DHEA-S levels. Thus, the sensitivity, specificity, and predictive value of a low DHEA-S level to indicate a benign adrenal tumor were 0.35, 0.50, and 0.60, and the values to indicate a cortical adenoma were 0.50, 0.67, and 0.47, respectively. Of the 14 cases of histologically confirmed benign cortical adenoma, 10 had signs of hormonal activity, but DHEA-S was suppressed in only 7 cases. Thus, the sensitivity, specificity, and predictive value of a low DHEA-S level to indicate clinically significant hormonal activity of a benign cortical adenoma were 0.60, 0.75, and 0.86, respectively. For comparison, 5 of 5 males and 2 of 5 females with metastatic carcinomatosis, but without involvement of the adrenals, also had low DHEA-S levels. The data clearly show that in nonselected cases of incidentaloma a suppressed DHEA-S level is not a good predictor of hormonal activity and that DHEA-S measurement may be valuable only after having ascertained the cortical origin and benign feature of the tumor.

Prevalence of thyroid dysfunction in different geriatric subpopulations from a moderately iodine-deficient Hungarian region. Comparative clinical and hormonal screening

The aim of this study was to investigate the prevalence of thyroid dysfunction in different geriatric subpopulations from a moderately iodine-deficient Hungarian region and to compare the efficacy of clinical versus hormonal screening. A screening study was done on 279 chronically ill geriatric patients (Group I) and 256 consecutive hospital admissions over 60 years of age (Group II). The method of clinical screening was different from those used so far: the object was not to search for symptoms of hypo- or hyperthyroidism but to find any sign justifying a further thyrotrophin-based biochemical evaluation, i.e. history of thyroid disease or goitre or any clinical sign of hormonal dysfunction. The rates of overt hypothyroidism, overt hyperthyroidism, subclinical hypothyroidism and subclinical hyperthyroidism discovered by the hormonal screening were 2.9, 1.1, 3.6 and 5.7% in Group I and 3.5, 2.3, 3.9 and 2.0% in Group II. The sensitivities of the clinical screening to suspect overt or overt+subclinical dysfunctions were, respectively, 0.82 and 0.64 in Group I and 1.0 and 0.7 in Group II (or 0.67 and 0.4 if the clinical investigation was done not by an endocrinologist but by the medical attendants). A primarily clinical investigation-based screening would have spared 171/279 thyrotrophin estimation in Group I and 161/256 in Group II, but would have missed 2/11 overt and 11/26 subclinical dysfunctions in Group I. In Group II, no overt but 9/15 subclinical dysfunctions would have been lost in this way. Our approach of a clinical investigation-based screening was rather efficient in suspicion of overt thyroid dysfunction but failed to detect many cases with subclinical dysfunction.(ABSTRACT TRUNCATED AT 250 WORDS)

Incidentally detected adrenal tumours (incidentalomas): histological heterogeneity and differentiated therapeutic approach

OBJECTIVES

To find a differentiated therapeutical approach to incidentalomas.

DESIGN

Prospective study of incidentalomas: their histology, hormonal activity, and growth if primarily non-operated.

SETTING

Admissions to an academic tertiary care centre because of incidentaloma.

PATIENTS

Thirty-eight female, 25 male, 27-85 years old.

INTERVENTIONS

Ultrasound, computed tomography and adrenal scintigraphy when appropriate; investigations to exclude malignancy giving metastasis into the adrenal gland; ACTH, cortisol, aldosterone, renin activity, androgene, catecholamine measurements; surgery or follow-up.

MAIN OUTCOME MEASURES

Rate of malignancy; linkage of tumour size to probability of malignancy; prevalence of tumours with subtle hormone excess.

RESULTS

Cortical adenomas occurred in 13/31, metastases in 7/31 of the histologically confirmed cases. In 10/31 cases, the computed tomography indicated a size that was smaller than the pathological size (mean = 20 mm). 20.6% of all incidentalomas and 61.5% of the 13 operated corticol adenomas showed subtle hormonal activity. Twenty-seven incidentalomas < 30 mm were followed-up (3-41 months; mean 18 months) and showed growth in only one case. Sensitivity, specificity, and predictive value (PV) of a tumour > or = 30 mm to indicate malignancy were: 1.0, 0.56 and 0.27, respectively. The PV of a < 30 mm tumour to exclude malignancy was 1.0.

CONCLUSIONS

Oncological screening tests are necessary in all incidentalomas. Tumours > or = 30 mm should be operated but smaller ones can be followed-up, because they are usually benign and rarely show progressive growth. Cortical adenomas with subtle hormonal overproduction and hypertension, diabetes or osteoporosis should be operated, irrespective of their size, but in the absence of relevant clinical symptoms they can be followed-up.

[The place of insulin-like growth factor I in the diagnosis of acromegaly]

Insulin-like growth factor-I (IGF-I) and basal growth hormone (GH) (average of GH values measured at -20 an 0 minutes) levels were measured in 32 (29 treated, 3 untreated) patients with acromegaly. In 15 patients IGF-I and basal GH values were normal. In 12 patients both GH and IGF-I were elevated. In 5 cases normal basal GH and elevated IGF-I levels were found. We assume that elevated serum level of IGF-I is a reliable sign of acromegalic activity. Compared to this, the basal GH level proved to be a much less reliable indicator to predict or exclude active acromegaly (sensitivity: 0.7, specificity: 1, positive predictive value: 1, negative predictive value: 0.75).