Early Post-operative Stimulated Serum Thyroglobulin: Role in Preventing Unnecessary Radioactive Iodine Treatment in Low to Intermediate Risk Papillary Thyroid Cancer

AIM

The aims of the study are to evaluate the predictive value of early post-operative stimulated thyroglobulin (sTg) analysis on the recurrence risk, and to define a cut-off value that is related to recurrence risk in low to intermediate risk papillary thyroid cancer (PTC).

METHODS

This retrospective cohort study included individuals who were diagnosed with PTC aged 18 years or older and had been operated by experienced surgeons of a tertiary university hospital between the years 2011 and 2021. The American Thyroid Association thyroid cancer guidelines version 2015 was used as the risk stratification system. Early sTg measurement obtained at 3-4 weeks after surgery when TSH >30 µIU/mL. Data was collected from the hospital database. A total of 328 patients who had post-operative early sTg values with negative anti-Tg antibodies were included.

RESULTS

The median age was 44 years. Of the 328 patients, 223 (68%) were women. The median tumor diameter was 11 mm. One hundred ninety-one patients (58.2%) had low risk and 137 (41.8%) had intermediate risk for recurrent disease. Of the 328 patients, 4.0% had recurrent disease. In multivariate Cox regression, post-operative early sTg value [OR: 1.070 (1.038-1.116), P = .000], and the pre-operative malign cytology [OR: 1.483 (1.080-2.245), P = .042] were independent risk factors for recurrence. On the ROC curve analysis, the cut-off value of early sTg was 4.1 ng/mL for those with recurrent disease.

CONCLUSION

This study demonstrated that early sTg could predict recurrent disease in patients with low to intermediate risk PTC. A cut-off of 4.1 ng/mL was identified with a high negative predictive value.

Subacute THYROiditis Related to SARS-CoV-2 VAccine and Covid-19 (THYROVAC Study): A Multicenter Nationwide Study

CONTEXT

The aims of the study are to compare characteristics of subacute thyroiditis (SAT) related to different etiologies, and to identify predictors of recurrence of SAT and incident hypothyroidism.

METHODS

This nationwide, multicenter, retrospective cohort study included 53 endocrinology centers in Turkey. The study participants were divided into either COVID-19-related SAT (Cov-SAT), SARS-CoV-2 vaccine-related SAT (Vac-SAT), or control SAT (Cont-SAT) groups.

RESULTS

Of the 811 patients, 258 (31.8%) were included in the Vac-SAT group, 98 (12.1%) in the Cov-SAT group, and 455 (56.1%) in the Cont-SAT group. No difference was found between the groups with regard to laboratory and imaging findings. SAT etiology was not an independent predictor of recurrence or hypothyroidism. In the entire cohort, steroid therapy requirement and younger age were statistically significant predictors for SAT recurrence. C-reactive protein measured during SAT onset, female sex, absence of antithyroid peroxidase (TPO) positivity, and absence of steroid therapy were statistically significant predictors of incident (early) hypothyroidism, irrespective of SAT etiology. On the other hand, probable predictors of established hypothyroidism differed from that of incident hypothyroidism.

CONCLUSION

Since there is no difference in terms of follow-up parameters and outcomes, COVID-19- and SARS-CoV-2 vaccine-related SAT can be treated and followed up like classic SATs. Recurrence was determined by younger age and steroid therapy requirement. Steroid therapy independently predicts incident hypothyroidism that may sometimes be transient in overall SAT and is also associated with a lower risk of established hypothyroidism.

Previous, simultaneous, or subsequent occurrence of malignant tumours in patients with primary hyperparathyroidism: a closer look at the single-tertiary-centre cases

INTRODUCTION

Our aims were to explore the relationship between primary hyperparathyroidism (pHPT) and malignant tumour development, to determine the frequency and the time of occurrence of malignant tumours in patients with pHPT, and to evaluate the characteristics of pHPT in these patients.

MATERIAL AND METHODS

This retrospective cohort study included consecutive individuals who were diagnosed with pHPT aged 18 years or older in a university hospital during a 7-year period. A total of 198 patients with pHPT were reviewed retrospectively. Demographic, clinical, biochemical, radiologic findings, and histopathological diagnosis were collected from the electronic medical records of the hospital system.

RESULTS

The mean age of the study population was 58 ± 13 years and was predominantly female (female/male: 162/36). There were 42 (21.2%) patients with malignant tumours. Five (12%) out of 42 patients had metachronous double malignancies. The most common 2 concurrent malignancies were breast (36.1%) and thyroid (17.0%). Sixty-eight per cent of the malignant tumours occurred before the diagnosis of pHPT. A higher percentage (87.5%) of simultaneous tumours was seen in the thyroid gland. No statistically significant differences were observed between patients with and without malignant tumours in terms of demographic, clinical, biochemical, radiological, and histopathological features. The median follow-up duration was 24 months after parathyroid surgery.

CONCLUSION

The results of this study revealed that pHPT was associated with various tumour types. The frequency of malignant tumours was 21.2%. Breast and thyroid cancers were the most common 2 cancers coexisting with pHPT. A large percentage of malignant tumours occurred before the diagnosis of pHPT. A higher percentage of simultaneous tumours was seen in the thyroid gland. pHPT patients with and without malignant tumours seemed to have similar characteristics.

Concomittant occurence of well-differentiated thyroid carcinoma metastasis and chronic lymphocytic leukemia in the same lymph node along with internal jugular vein thrombus: a case report

Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL) is the most common adult leukemia. The coexistence of CLL and papillary thyroid carcinoma (PTC) is extremely rare. PTC sometimes shows microscopic vascular invasion but rarely cause a tumor thrombus in the internal jugular vein (IJV). It is also rare to find both differentiated and poorly differentiated types of thyroid cancer in the same metastatic location. We report a case of 63-year-old Turkish man with history of CLL who had CLL/SLL involvement and PTC metastasis in the same lymph node. Additionally, there was macroscopic metastasis to the IJV with poorly differentiated areas in the removed tumor thrombus. Patient was treated with total thyroidectomy, left radical neck dissection, resection of the left IJV segment that contained the tumor thrombus and radioactive iodine (RAI) therapy. Furthermore, metastatic lesions were found in the brain, lung and bone. Radiotherapy and chemotherapy were performed. However, our patient died approximately 12 months after thyroidectomy. To our knowledge, our present report is the first description with its current features.

Effect of prophylactic central neck dissection on the surgical outcomes in papillary thyroid cancer: experience in a single center

PURPOSE

Morbidity due to papillary thyroid carcinoma (PTC) is increased mostly due to lymph node (LN) metastases, which lead to reoperations and complications associated with these operations. The aim is to compare the outcomes of PTC having total thyroidectomy and prophylactic central lymph node dissection (TT + PCND) with patients having total thyroidectomy (TT) alone.

METHODS

This study is a retrospective cohort analysis of 358 PTC patients that were operated by a single surgeon in a single center. Data about the patients were extracted from the medical records.

RESULTS

Of the patient cohort, 258 patients had TT + PCND (42.5 ± 11.3 years) and 100 patients (41.2 ± 11.9 years) had only TT. Total number of LN extracted in the TT + PCND group was 8.1 ± 6.9. The mean number of metastatic LN were 2.2 ± 1.9. Percentage of patients that had RAI were less in the TT + PCND group compared to the TT group. Seven patients (2.7%) in the TT + PCND group and 19 (19.0%) in TT group had recurrent disease (p < 0.0001). Of the complications, only transient hypoparathyroidism was increased in TT + PCND group compared to TT group (26.7% vs 10%, p < 0.0001).

CONCLUSION

TT + PCND performed by an experienced surgeon seems to decrease the number of LN recurrences, and the need for reoperations.

Association of Pro-apoptotic Bad Gene Expression Changes with Benign Thyroid Nodules

BACKGROUND/AIM

This study aimed to investigate the role of the mitochondrial apoptotic pathway in benign thyroid nodules.

MATERIALS AND METHODS

Paired samples of nodular and normal tissues were collected from 26 patients with nodular goiters undergoing thyroidectomy. Variable expression of Bcl-2, Bax and Bad genes were evaluated by quantitative PCR.

RESULTS

Expression level of Bad gene in nodules was found to be significantly decreased compared to normal tissues (p=0.049). A positive correlation was observed between nodule size and Bad expression levels (correlation coefficient=0.563, p=0.004); and this correlation was stronger in hot nodules (n=18, correlation coefficient=0.689, p=0.003). No significant difference was observed between nodular and normal tissue expressions of Bax and Bcl-2.

CONCLUSION

These results suggest that Bad expression correlates with the size of benign thyroid nodules and also its relatively lower expression in nodules, warrant further investigation.

Clinical impact of SPECT-CT in the diagnosis and surgical management of hyper-parathyroidism

Hyper-functioning parathyroid glands with autonomous overproduction of PTH is the most frequent cause of hypercalcemia in outpatient populations with primary hyper-parathyroidism. It is generally caused by a solitary adenoma in 80%-90% of patients. Despite the various methodologies that are available for preoperative localization of parathyroid lesions, there is still no certain preoperative imaging algorithm to guide a surgical approach prior to the management of primary hyper-parathyroidism (P-HPT). Minimally invasive surgery has replaced the traditional bilateral neck exploration (BNE) as the initial approach in parathyroidectomy at many referral hospitals worldwide. In our study, we investigated diagnostic contributions of SPECT-CT combined with conventional planar scintigraphy in the detection of hyper-functioning parathyroid gland localization, since planar imaging has limitations. We also evaluated the efficacy of preoperative USG in adding to initial diagnostic imaging algorithms to localize a parathyroid adenoma.

METHODS

A total of 256 consecutive surgically naive patients with hyper-parathyroidism diagnosis were included in the following preoperative localization study. The study consisted of 256 consecutive patients with HPT, with a selected 154 patients who had neck surgery with definitive histology reports. All patients had 99mTc-methoxyisobutylisonitrile (99mTc-MIBI) double-phase scintigraphy. The SPECT-CT procedure, combined with standard 99mTc-MIBI planar parathyroid scintigraphy with a pinhole and parallel-hole collimator to evaluate whether the SPECT-CT procedure was able to provide additional information in the localization of the pathology, caused hyper-parathyroidism in both P-HPT and S-HPT.

RESULTS

In the 154 P-HPT patients, 168 lesions (142 adenomas including 2 intrathyroidal and 2 double adenoma, 2 carcinoma, and 22 hyperplastic glands (four patients had MEN I, each with four hyperplastic glands)), were found at surgery. SPECT-CT detected more lesions than planar imaging in P-HPT (97.8% vs. 87.6%). SPECT-CT detected all adenomas and increased sensitivity, particularly in small lesions. Regardless of their size, the number of detected hyperplastic glands by SPECT-CT was remarkably higher than planar imaging.

Prevalence of pituitary adenomas in macroprolactinemic patients may be higher than it is presumed

One form of prolactin (PRL) is macroprolactin with high molecular mass. Many macroprolactinemic patients have no pituitary adenomas and no clinical symptoms of hyperprolactinemia, it is controversial whether macroprolactinemia is a benign condition that does not need further investigation and treatment. In this study, we aimed to compare macroprolactinemic patients (group I) with the true hyperprolactinemic patients (group II) for the presence of pituitary adenoma. We investigated 161 patients with hyperprolactinemia, whose magnetic resonance imaging records of the pituitary were taken. All patients were questioned for irregular menses, infertility and examined for galactorrhea. Patients were screened for macroprolactinemia by polyethylene glycol precipitation, and a recovery of ≤40% and normal monomeric PRL level was taken as an indication of significant macroprolactinemia. Of 161 patients with hyperprolactinemia, 60 (37.26%) had macroprolactinemia. PRL levels of group II were lower than those of group I (P = 0.011), although monomeric PRL levels of group II were higher than those of group I (P = 0.0005). Of 60 macroprolactinemic patients, 16 (26.7%) had pituitary adenomas. The prevalence of pituitary adenomas was lower in group I, compared with group II (P = 0.0005). No significant differences were found between the prevalences of irregular menses and infertility of group I and II (P = 0.084, P = 0.361). Prevalence of galactorrhea in group I was lower than that in group II (P = 0.048). Prevalence of pituitary adenomas in macroprolactinemic patients is lower compared with the true hyperprolactinemic patients, but may be higher than that found in other recent studies and in the general population.

Investigation of early atherosclerotic changes in acromegalic patients

BACKGROUND

Functional and morphological changes of endothelium were risk factors for mortality attributed to atherosclerosis. Studies investigating early atherosclerotic alterations and the effect of the treatment of acromegaly on these alterations gave conflicting results.

OBJECTIVE

Surrogate markers of early atherosclerotic changes, i.e. brachial artery flow-mediated dilation (FMD) and carotid artery intima-media-thickness (IMT) in active and inactive acromegalic patients were compared with control subjects matched to patients for age, sex and cardiovascular risk factors to find out the direct effects of growth hormone (GH)/insulin-like growth factor-1 excess.

METHODS

In 14 active acromegalics and their 14 matched controls, 14 inactive acromegalics and their 14 matched controls, carotid artery IMT and FMD of brachial artery were measured. Inactive acromegalics were in remission for at least 1 year.

RESULTS

Active acromegalics had higher IMT than matched controls and inactive acromegalics (0.85 +/- 0.20 mm, 0.64 +/- 1.77 mm, 0.66 +/- 0.20 mm respectively; p < 0.005, p < 0.05) and IMT of inactive acromegalics was not different from their matched controls (0.61 +/- 0.12 mm). FMD was significantly lower in active acromegalics than in matched controls and inactive acromegalics (2.910 +/- 2.00 mm, 6.5 +/- 2.81 mm, 5.68 +/- 2.9 mm respectively; p < 0.005, p < 0.05). FMD of inactive acromegalics was not significantly different from their matched controls (7.96 +/- 3.12 mm). A significant inverse relationship was found between GH and FMD in active acromegalics (r = -0.659, p = 0.010).

CONCLUSION

In active acromegalics, early atherosclerotic changes are not only attributed to the high prevalence of risk factors, but also to the abnormal GH secretion itself.

Fas ligand (FasL, Apo-1L/CD95L) expression and clinical outcome in papillary microcarcinoma and papillary thyroid carcinomas with diameter smaller than 1.5 centimeters

CONTEXT

The presence and the importance of FasL (FasL, APO-1L/CD95L) in papillary microcarcinoma lesions which are smaller than 1.5 cm of the thyroid is unclear.

OBJECTIVE

It was aimed to investigate FasL expression in papillary microcarcinoma (PMC) of the thyroid.

DESIGN

FasL immunoreactivity was evaluated in PMC lesions. Paraffin sections of thyroid specimens obtained from 59 papillary thyroid carcinoma consecutive patients were stained using antibody to FasL. Fas ligand expression and the relation and comparison with clinical and pathological findings in PMC were determined.

RESULTS

There were 39 females (66.1%) and 20 males (33.9%) aged 23-74 years (51.9±11.8 yrs), and 20 patients with tumor size ≤5 mm, 24 patients with 6-10 mm and 15 patients with 10-15 mm. The mean of the intensity and the percentage of FasL immunoreactivity were significantly higher in lesions of PMC than peripheral thyroid tissue (29.5±37.9% and 1.42±1.25 vs. 2.1±5.4% and 0.46±0.95, respectively; p<0.001). Fas ligand immunoreaction were not different according to tumor size, the presence of tumor capsule and tumor invasion, invasion of thyroid capsule, peripheral tissue and vascular structures and multicentricity (p>0.05). However, FasL positivity, staining and intensity were high in patients above 45 years, in oncocytic and tall cell variants, in TNM stage pT4A (p<0.05).

CONCLUSIONS

This study showed that FasL expression (positivity, staining and intensity) was high and increased in PMC of the thyroid tissue, and above 45 years, in tall cell and oncocytic variants, and in advanced tumor.

Polymorphisms at the ligand binding site of the vitamin D receptor gene and osteomalacia

Vitamin D receptor (VDR) gene polymorphisms have been suggested as possible determinants of bone mineral density (BMD) and calcium metabolism. In this study, our aim was to determine whether there is an association between VDR gene polymorphism and osteomalacia or not. We determined ApaI and TaqI polymorphisms in the vitamin D receptor gene in 24 patients with osteomalacia and 25 age-matched healthy controls. Serum calcium, phosphorus, ALP, PTH, 25OHD levels were also examined. We used PCR and RFLP methods to test for an association between osteomalacia and polymorphisms within, intron 8 and exon 9 of the VDR gene. When the control and patients were compared for their ApaI and TaqI genotypes there was no relationship between VDR gene allelic polymorphisms and osteomalacia. Whereas a nearly significant difference for A allele was found in the allellic distribution of the patients (p = 0.08). Also no association between biochemical data and VDR gene polymorphisms was observed.

The presence of erythropoietin receptor in parathyroid cells

CONTEXT

Effects of erythropoietin on parathyroid cell function has not been studied before.

OBJECTIVE

We aimed to demonstrate whether erythropoietin receptor present in parathyroid cells.

DESIGN

The specimens of normal parathyroid gland, parathyroid adenoma and hyperplasia were retrieved from our pathology archives. The sections were stained immunohistochemically. Quantitative gene expression study was performed for erythropoietin and erythropoietin receptor.

RESULTS

Erythropoietin receptors were detected by immunohistochemical staining and by its gene expression. Its density was higher in normal parathyroid, followed by parathyroid adenoma and hyperplasia.

CONCLUSION

Erythropoietin receptor is present in normal parathyroid, parathyroid adenoma, and hyperplasia.

Clodronic acid in the treatment of postmenopausal osteoporosis

BACKGROUND

Clodronic acid, a first-generation bisphosphonate, has been successfully used in the treatment of high bone turnover states, Paget's disease and osteolytic bone metastases. However, controversies remain over its optimal dosage and method of administration in the treatment of postmenopausal osteoporosis. In this study we aimed to evaluate the effect of clodronic acid treatment for 3 years on bone mineral density (BMD) in women with postmenopausal osteoporosis.

METHODS

This was a prospective, open-label, randomised, controlled study that was conducted in an outpatient clinic at the Bone Metabolism Unit of a tertiary referral centre university hospital. Thirty postmenopausal women (age range 48-73 years) with osteoporosis and a control group of 49 osteoporotic women (age range 47-74 years) received randomised therapy. The clodronic acid group of participants received oral doses of clodronic acid 800 mg plus elemental calcium 500 mg and 400 IU of vitamin D daily, while the control group was treated with calcium and vitamin D only. BMD was measured by dual energy x-ray absorptiometry at yearly intervals. Biochemical markers of bone turnover were also measured.

RESULTS

In this clinical study of postmenopausal women with osteoporosis, 36 months of clodronic acid treatment significantly increased average femoral neck BMD by 3.2 +/- 2.9%, trochanter BMD by 2.2 +/- 2.9% and lumbar spine BMD by 3.1 +/- 3%. In the control group, femoral neck, trochanter and lumbar spine BMD decreased by -6 +/- 2.7%, -7.3 +/- 2.5% and -5.4 +/- 2%, respectively (p<0.01, p<0.05 and p<0.05 for clodronic acid vs control, respectively). There was a significant decrease in urinary hydroxyproline (-38.3%) over 3 years in the clodronic acid group compared with baseline (p<0.05), while no significant change occurred in the control group. Clodronic acid was well tolerated and compliance was good. There were no clinically meaningful differences in the incidence of individual adverse events between the groups.

CONCLUSION

These results indicate that daily oral administration of clodronic acid 800 mg provides benefits to skeletal bone density in osteoporotic postmenopausal women. Calcium and vitamin D supplementation alone did not prevent further bone loss.

Lack of association between vitamin D receptor gene polymorphism (BsmI) and osteomalacia

Vitamin D receptor (VDR) gene polymorphism has been reported to be a determinant of bone formation and intestinal calcium absorption. We carried out this study to assess the role of VDR gene polymorphism in the pathogenesis of osteomalacia. We investigated BsmI polymorphisms in the gene encoding the 1,25 dihydroxyvitamin D receptor in 38 patients with osteomalacia and 31 healthy controls, along with examination of serum calcium, phosphorus, alkaline phosphatase, parathyroid hormone, and 25 hydroxyvitamin D levels. VDR allelic variants were: BB, 31.6%; Bb, 44.7%; and bb, 23.7% in the osteomalacia patients and BB, 19.4%; Bb, 61.3%; and bb, 19.4% in the controls. Although heterozygotes (Bb) were more frequent than other genotypes in both groups, the BB genotype was found to be more prevalent in osteomalacia than in controls. There was no statistical relationship between VDR genotype and osteomalacia. It is concluded that, in this small group of patients, there was no relationship between VDR allelic polymorphisms and osteomalacia.

Clinical characteristics and genetic screening of an extended family with MEN2A

MEN-2A is characterized by medullary thyroid carcinoma (MTC) with pheochromocytoma and sometimes parathyroid adenoma. In affected members of the family, the risk of MTC is about 100%. Biochemical screening allows tumors to be detected early but even at this stage treatment is not always curative. Missense mutations in exon 10 and 11 of the RET proto-oncogene are associated with MEN-2A. Early detection of this mutation by DNA analysis allows the identification of the carriers of the gene. We performed genetic screening in 88 members of an extended family with MEN-2A and found 18 members positive for RET mutation (Cys634Gly). Only three of these 18 RET positive cases had a previous diagnosis of medullary cancer and/or pheochromocytoma. Up to now, 12 of the RET positive cases have undergone thyroidectomy. There was extended disease with cervical lymph node metastasis in 6 of them, bilateral medullary microcancer in 3 and c-cell hyperplasia in the remaining 3. Three of the 18 RET positive patients had also pheochromocytoma. Primary hyperparathyroidism was present in only one patient. The mean age of diagnosis of medullary cancer was between 25-50 yr and mean age of death was between 35-95 yr in affected members of the family. The family had many other affected members in other cities in Turkey and in other countries throughout the world from Australia to the Netherlands. So this family is perhaps one of the most extended families with MEN-2A.

Relationship of bone turnover parameters, endogenous hormones and vit D deficiency to hip fracture in elderly postmenopausal women

Hip fracture is one of the severest consequences of osteoporosis affecting elderly women, but abnormalities of bone turnover responsible for bone loss have not been clearly defined. This study evaluated the relationship of bone turnover parameters to hip fracture in postmenopausal elderly women. We also investigated the effects of endogenous hormones and vitamin D deficiency on osteoporotic hip fracture. The subjects were 21 osteoporotic patients with hip fracture (study group) and 20 healthy postmenopausal women (control group). We measured osteocalcin levels, total and bone alkaline phosphatase (T-ALP and B-ALP), calcitonin, intact parathyroid hormone (iPTH), serum 25 hydroxyvitamin D (25OHD), urinary free deoxypyridinoline (D-pyr) and cross-linked N-telopeptides of type 1 collagen (NTx) levels. Serum T-ALP and B-ALP levels in the study group were lower than those of the control group. The mean serum 25OHD levels in the study group were not significantly different from the control group, but in five cases the mean serum iPTH level was increased. The mean urinary NTx levels were significantly increased in the study group compared with the control group (p<0.05). There was no significant increase in urinary free D-pyr between the two groups. There was significant correlation between serum T-ALP levels and B-ALP levels and between serum iPTH levels and B-ALP levels. The mean serum SHBG level in the study group was higher than in the control group (p<0.05). These data suggest that postmenopausal hip fracture patients have biochemical evidence of decreased bone formation and increased bone resorption compared with postmenopausal healthy subjects. We suggest these abnormalities play a role in the decrease of bone mass and the consequent increase in bone fragility that characterises osteoporotic hip fracture.

Association of Fallot Tetralogy with Carney's complex

The Carney complex is an inherited, autosomal disease of multicentric tumors in many organs. Some components of Carney's complex are cardiac myxoma, spotty pigmentation, and endocrine overactivity. Primary pigmented nodular adrenocortical dysplasia (PPNAD) is an exceedingly rare cause of Cushing's syndrome in infants, children, and young adults. PPNAD occurs sporadically or as part of a familial syndrome called Carney's complex. Up to our knowledge, the association of Fallot Tetralogy with Carney's complex has not been previously reported. We presented, a 20-year-old woman, who had been operated for Fallot Tetralogy at the age of 3 years, had Carney's complex, i.e. left atrial myxoma, two facial spotty pigmented areas, and PPNAD.

Prolactin response to TRH in patients with panic disorder

The effects of TRH administration (400 microg, i.v.) on the release of prolactin were examined in 15 patients who met DSM-III-R criteria for panic disorder and 15 normal control subjects. Four hundred micrograms TRH was given via IV route. Blood samples were taken before TRH administration (baseline values) and at 15, 30 and 60 min. The results demonstrate that prolactin responses to TRH did not differ between panic disorder patients and normal control subjects. When only women were evaluated, the findings indicate that women with PD tend to show excessive prolactin responses to TRH. The findings are discussed in view of findings from earlier reports.

Sunlight exposure and vitamin D deficiency in Turkish women

Vitamin D is an essential steroid involved in bone metabolism, cell growth, differentiation, and regulation of the minerals in the body. The main sources of this vital vitamin are adequate diet and photosynthesis in the skin. The aim of this study was to investigate the efficiency of vitamin D synthesis in 48 premenopausal women (14-44 years) in relation to three different types of dressing in summer. Women in the first group (Group I) dressed in a style which exposed the usual areas of the skin to sunlight; women in the second group (Group II wore traditional clothing with the skin of the hands and face uncovered, while the third group (Group III) dressed in traditional Islamic style, covering the whole body including hands and face. Serum 25OHD levels of Group I, Group II, and Group III were 56+/-41.3 nmol/l, 31.9+/-24.4 nmol/l, 9+/-5.7 nmol/l, respectively (Group I vs Group III, p<0.001; Group II vs Group III, p<0,03; Group I vs Group II, p>0.05). Vitamin D levels were low in 44 percent of the Group I and 60% of the Group II, which suggested that sun exposure of skin areas of hands and face may partially provide vitamin D synthesis, but may not be enough to eliminate vitamin D deficiency. All the patients in group III had vitamin D levels below normal. This study emphasizes the necessity of vitamin D fortification of food even in a sunny country where some people may not be exposed to sunlight because of inappropriate clothing or an indoor-life.

Anaplastic thyroid cancer with transient thyrotoxicosis: case report and literature review

A 55-year-old woman with anaplastic thyroid carcinoma presented with hyperthyroidism and neck swelling, hoarseness, and cervical lymphadenopathy. On physical examination, she was found to be clinically hyperthyroid with an enlarged, nontender multinodular goitre. Her serum thyroid hormone levels confirmed hyperthyroidism and technetium-99m pertechnetate scan failed to visualize the thyroid gland. Open biopsy showed an invasion of the thyroid gland by anaplastic thyroid carcinoma. The thyrotoxic phase lasted 60 days with predominantly increased thyroxine level and triiodothyronine/thyroxine (T3/T4) ratio decreased below 15. The thyrotoxic period was followed by subclinical hyperthyroidism and hypothyroidism which continued until she died of lung metastasis.

Disappointing results with Tc-99m tetrofosmin for detecting medullary thyroid carcinoma metastases comparison with Tc-99m VDMSA and TI-201

PURPOSE

This prospective study assessed the detectability of metastatic lesions by Tc-99m tetrofosmin in medullary thyroid carcinoma and to compare the results with Tc-99m penta dimercapto succinic acid (VDMSA) and TI-201.

METHODS

A prospective study was performed on 24 patients (10 men, 14 women; ages 23 to 76 years) with medullary thyroid carcinoma after total thyroidectomy. Five cases were sporadic and 19 were familial. After the injection of 740 MBq (20 mCi) tetrofosmin, 740 MBq (20 mCi) VDMSA and 74 MBq (20 mCi) TI-201, whole-body scans and 5-minute static images of the head, neck, chest, abdomen and pelvis were obtained. All scintigraphic studies were compared with calcitonin levels, radiologic findings, histopathologic results, and clinical follow-up.

RESULTS

Thirty-four metastatic sites were detected in 12 patients on the basis clinical, radiologic, and histopathologic findings. Patients were divided into three groups according to the calcitonin levels and scintigraphic findings. Group 1 consisted of patients with elevated calcitonin levels and positive scintigraphic findings. Among 34 metastatic sites, 30 could be detected with VDMSA. Only 21 and 20 metastatic sites could be visualized with TI-201 and tetrofosmin, respectively. All 30 lesions showed intense VDMSA uptake but only faint or no uptake with TI-201 and tetrofosmin. Patients in group 2 were accepted to have micrometastases. In this group, calcitonin was minimally elevated, and the results of all three scintigraphs were negative. Group 3 included patients with true-negative results. All patients had normal calcitonin levels and negative results of scintigraphic studies.

CONCLUSIONS

Tetrofosmin has no role in the detection of medullary thyroid carcinoma metastases. These results show that VDMSA is clearly superior to TI-201 and tetrofosmin in the follow-up of patients with medullary thyroid carcinoma.

Determination of medullary thyroid carcinoma metastases by 201Tl, 99Tcm(V)DMSA, 99Tcm-MIBI and 99Tcm-tetrofosmin

Medullary carcinoma of the thyroid (MCT) is malignancy derived from the parafollicular cells (or C-cells) of the thyroid. It is usually sporadic, although it is familial in some cases. Several scintigraphic procedures can provide information regarding the primary and metastatic foci of the tumour. We performed whole-body scanning to establish the pathology of MCT using 201Tl, 99Tcm(V)DMSA and 99Tcm-MIBI in 14 patients, and found average sensitivities of 73%, 82% and 81%, respectively. Moreover, we also scanned three patients with 99Tcm-tetrofosmin and identified two of four pathological foci as well as residual thyroid tissue. The sensitivities of 201Tl, 99Tcm(V)DMSA and 99Tcm-MIBI were 100%, 100% and 85% in identifying lymphadenopathies; 40%, 50% and 71% for soft tissue foci; 100% and 100% for foci in pulmonary parenchyma; and 100%, 66% and 100% for recurrences in thyroid gland. Although 99Tcm(V)DMSA identified all bony metastases in three patients (100%), 99Tcm-MIBI detected only two of three foci (66%) and 201Tl none. 201Tl, 99Tcm-MIBI and 99Tcm-tetrofosmin accumulated in residual thyroid tissue, but 99Tcm(V)DMSA did not, as expected. We conclude that these agents were complementary, since they had different sensitivities in different tissues. The tumour-seeking properties of tetrofosmin are to be evaluated in a larger series.

Thyrotropin stimulating hormone response to thyrotropin releasing hormone in patients with panic disorder

OBJECTIVE

The aim of this study is to assess thyrotropin stimulating hormone (TSH) response to thyrotropin releasing hormone (TRH) in patients with panic disorder (PD).

METHOD

The effects of TRH administration on the release of TSH were examined in 15 patients who met DSM-III-R criteria for PD and compared their test results with those of 15 normal control subjects. Blood samples were taken before TRH administration (baseline values) and at 15, 30 and 60 min.

RESULTS

delta max TSH values were lower in the panic disorder patients than in the control subjects. Using the criterion of delta max TSH < or = 7 mlU/l, nine of the 15 panic disorder patients and four of the 15 control subjects had a blunted TSH response to TRH.

CONCLUSIONS

These results confirm the findings from earlier reports that patients with PD show blunted TSH response to TRH which is similar to that seen in depressed patients.

Thallium-201, technetium-99m-tetrofosmin and iodine-131 in detecting differentiated thyroid carcinoma metastases

The purpose of this study was to asses the detectability of differentiated thyroid carcinoma (DTC) metastases by 99mTc-tetrofosmin and to compare the results of 99mTc-tetrofosmin with 131I and 201Tl. The reliability of 201Tl and 99mTc-tetrofosmin scanning during suppression therapy also has been studied.

METHODS

A prospective study was performed on 41 patients (30 females, 11 males) with DTC (30 papillary, 11 follicular) who had undergone total thyroidectomy and received an average dose of 117 mCi (4329 MBq) of radioiodine for ablation of postsurgical residual thyroid tissue. All patients (n = 41) had 201Tl, 99mTc-tetrofosmin or 131I whole-body imaging after discontinuation of thyroid hormone replacement (thyroxine-off group). Eight of 14 patients with distant metastases also were imaged when they were on thyroxine therapy both with 201Tl and 99mTc-tetrofosmin (thyroxine on-and-off group). Radiologic studies (chest radiography, CT and MRI), serum thyroglobulin assays and histopathologic examinations were performed to clarify the presence of metastases with positive uptake on any of three radionuclide studies.

RESULTS

In 26 of 41 patients all three scans were negative. These patients also clinically didn't show any evidence of metastases. Fourteen patients were considered to have distant metastases on the basis of clinical, radiologic and histopathologic findings. The sensitivities of 201Tl, 99mTc-tetrofosmin and 131I in diagnosing distant metastases were comparable (0.85, 0.85 and 0.78, respectively). Iodine-131 was much more sensitive than 201Tl and 99mTc-tetrofosmin for demonstrating residual thyroid tissue after surgery (1.00, 0.33 and 0.33, respectively). The only false-positive case involved radioiodine uptake in a tuberculoma. Thyroxine-on images of 8 patients with distant metastases showed no difference from their thyroxine-off images regarding the site, number and uptake of metastases.

CONCLUSION

Technetium-99m-tetrofosmin and 201Tl imaging are highly sensitive for detecting differentiated thyroid carcinoma metastases and do not require prior withdrawal of thyroid hormone suppressive therapy.

Propylthiouracil-induced cutaneous vasculitis

Cutaneous reactions to propylthiouracil and methimazole occur in 3%-5% of adults. Generalized maculopapular and papular purpuric eruptions are perhaps the most common thionamide-induced reactions. We report 3 patients who developed cutaneous vasculitis which is a rare and serious side-effect during antithyroid drug therapy. The observation of cutaneous vasculitis during administration of propylthiouracil suggested that clinical awareness of this complication should be of considerable importance.

Steroid cell tumor of the ovary as a rare cause of virilization

BACKGROUND

Virilization is associated with either ovarian causes, including polycystic ovary syndrome, hyperthecosis, and ovarian tumor, or with adrenal causes, including tumors and congenital adrenal hyperplasia. In establishing the diagnosis, levels of dehydroepiandresterone sulfate, testosterone, and 17 alpha-hydroxyprogesterone (17-OHP), with their response to dexamethasone treatment, should be assessed; and, where indicated, computerized tomography, ultrasound, and selective venous catheterization should be undertaken.

CASE REPORT AND RESULTS

A 21-year-old woman presented with a 17-year history of early accelerated linear growth and virilization. During this time, a putative diagnosis of nonclassic congenital adrenal hyperplasia had been made, and she had been treated with glucocorticoids, with no regression in virilization, for 8 years. On presentation to our group, the failure of low- and high-dose dexamethasone suppression tests to decrease blood levels of testosterone and 17-OHP, combined with a relatively low blood level of corticotropin, led us to investigate an androgen-secreting tumor of ovarian origin. When ultrasonography and computerized tomography of the ovaries and adrenal glands displayed no abnormality, selective venous catheterization was performed, revealing an abnormal ovarian-peripheral gradient for testosterone, 17-OHP, estradiol, and androstenedione in the right ovarian vein. On exploratory laparotomy, a neoplasm adjacent to the right ovary was resected and was found to be a steroid cell tumor of the ovary not otherwise specified, one of the rarest tumors causing virilization in children. Symptomatic resolution followed tumor removal.

CONCLUSION

Selective ovarian and adrenal venous catheterization for hormone assays is an efficient method of identification and localization of an androgen source in virilizing syndromes when noninvasive methods fail.

Cyproheptadine treatment in Cushing's disease

Cyproheptadine, a nonselective 5-hydroxytryptamine receptor blocking agent, reduces ACTH and beta-endorphin secretion from the ACTH-producing tumors. A 35-year-old female suffering from Cushing's disease due to microadenoma of the pituitary gland has been followed since the age of 15. Subtotal adrenalectomy followed by total adrenalectomy, pituitary irradiation, and transsphenoidal hypophysectomy, combined with second radiotherapy of the pituitary, were unsuccessful in achieving remission of the disease. Remission was achieved with cyproheptadine up to a dosage of 24 mg/day. Every attempt to discontinue cyproheptadine treatment was accompanied by recurrence of the disease. This is the first case of Cushing's disease in which cyproheptadine treatment has been the only efficacious therapy for a period of 11 yr. Cyproheptadine may be an alternative long-term therapy for Cushing's disease when other methods of treatment fail.