Thyroid hormone resistance in two patients with papillary thyroid microcarcinoma and their BRAFV600E mutation status

Resistance to thyroid hormone (RTH) is a rare autosomal dominant hereditary disorder. Here in, we report two patients with RTH in whom differentiated thyroid cancer was diagnosed. Two patients were admitted to our clinic and their laboratory results were elevated thyroid hormone levels with unsuppressed TSH. We considered this situation thyroid hormone resistance in the light of laboratory and clinical datas. Thyroid nodule was palpated on physical examination. Thyroid ultrasonography showed multiple nodules in both lobes. Total thyroidectomy was performed. The pathological findings were consistent with papillary thyroid microcarcinoma. BRAFV600E mutation analysis results were negative. RTH is very rare and might be overlooked. There is no consensus on how to overcome the persistently high TSH in patients with RTH and differentiated thyroid cancer (DTC). Further studies are needed to explain the relationship between RTH and DTC which might be helpful for the treatment of these patients.

Transformation of nonfunctioning pancreatic tumor into malignant insulinoma after 3 years: an uncommon clinical course of insulinoma

A 62-year-old man admitted to our outpatient clinic with two months of recurrent life threatening hypoglycemia episodes. He was diagnosed as malignant insulinoma with multiple metastases of liver and peripancreatic lymph nodes. Liver biopsy specimen was demonstrated grade 2 neuroendocrine tumor compatible with clinical and radiological results. He was followed under the treatment of continuous intravenous glucose infusion during the diagnostic procedures. He had a pancreatic lesion history measured 20 x 12 mm in diameter via the abdominal tomography examination approximately two years before the diagnosis. Unusual course of this case suggests the transformation of nonfunctioning pancreatic neuroendocrine tumor into functional insulin secreting tumor with metastases. The patient was found inoperable and started on chemotherapy. Arch Endocrinol Metab. 2015;59(3):270-2.

The association of autoimmune thyroiditis and non-functional adrenal incidentalomas with insulin resistance

Objective Patients with incidental nonfunctioning adrenal adenoma are associated with increased risk of obesity, impaired glucose tolerance and dyslipidemia. We aimed to investigate the relationship between thyroid function, serum lipids and insulin resistance in patients with nonfunctioning adrenal incidentaloma. Subjects and methods Forty patients who had diagnosed as adrenal incidentaloma (AI) in our department were included in the study. Serum free triiodothyronine (fT3), free thyroxine (fT4), thyroid stimulating hormone (TSH), anti-thyroperoxidase antibody (anti-TPO Ab) and anti-thyroglobulin antibody (anti-Tg Ab), lipid profile, hs-CRP, fasting insulin levels were measured and insulin resistance calculated by HOMA-IR. Thyroid volume (TV) was assessed. Results None of the patients showed specific signs and symptoms of hormone excess. TV, TSH and fT3 levels in the patient and control groups did not differ significantly (p > 0.05). The serum fT4, anti-TG Ab, anti-TPO Ab levels in the patient group were significantly higher than in the control group (p = 0.013, p < 0.0001, p = 0.016 respectively). The HOMA-IR, hs-CRP and HDL cholesterol levels in the AI patients were significantly higher than the control group (p = 0.034, p = 0.041, p = 0.002, respectively). Statistically significant relationship was found between HOMA-IR and thyroid volume (r = 0.373, p = 0.018), fT4 (r = 0.382, p = 0.015), hs-CRP (r = 0.512, p = 0.001), HDL cholesterol (r = 0,351 p = 0.026) in AI patients. There were significant correlation between anti-TG Ab, anti-TPO Ab and TSH levels in AI patients (r = 0.431 p = 0.006, r = 0.402 p = 0.012). Conclusions Patients with nonfunctioning adrenal incidentaloma have several metabolic disturbances. At the same time autoimmune thyroid disorders are more frequent in nonfunctioning adrenal incidentaloma patient so that thyroid functions must be evaluated in those patients. Arch Endocrinol Metab. 2015;59(1):42-6 .

Papillary thyroid cancer case masked by subacute thyroiditis / Caso de carcinoma papilar de tiroide mascarado por tireoidite subaguda

Subacute thyroiditis (SAT) association with thyroid carcinoma has been rarely reported in the literature. We present a patient with SAT and papillary thyroid cancer that was suspected by ultrasonographic evaluation (US) following SAT treatment. A fifty-four-year old female patient referred to our department due to tachycardia, jitteriness and pain in cervical region for the past one month. SAT diagnosis was established by physical examination, laboratory and ultrasonographic findings. After treatment, control thyroid US revealed regression of the hypoechogenic regions seen in both lobes, and a previously unreported hypoechogenic lesion with microcalcification focus that had irregular borders and was not clearly separated from the surrounding parenchyma located in the posterior aspect of the lobe (Elasto score: 4, Strain index: 7.08). Fine needle aspiration biopsy was taken from this nodule; cytology was assessed to be compatible with papillary thyroid carcinoma. Postsurgical pathology evaluation showed a papillary microcarcinoma. SAT may produce ultrasound changes that obscure the coexistence of papillary carcinoma. We recommend that patients with SAT have ultrasonography after they recover. Hypoechogenic regions bigger than 1 cm that are present in the follow-up post-therapy US should be assessed by biopsy.

A associação da tireoidite subaguda (TSA) com o carcinoma de tiroide foi raramente relatada na literatura. Apresentamos uma paciente com TSA e tumor papilar de tiroide suspeito na ultrassonografia (US) após o tratamento para a TSA. Uma mulher de 54 anos de idade foi encaminhada ao nosso departamento com taquicardia, agitação e dor na região cervical, com duração de 1 mês. O diagnóstico de TSA foi estabelecido pelo exame físico, e pelos achados laboratoriais e ultrassonográficos. Depois do tratamento, o US para controle da tiroide mostrou regressão das regiões hipoecoicas vistas em ambos os lobos e uma lesão hipoecoica anteriormente não observada com focos de microcalcificação, bordas irregulares, não claramente separada do parênquima circundante e localizada na região posterior do lobo. (Escore elástico: 4, índice de deformação: 7,08). Foi feita uma biópsia do nódulo por meio de aspiração por agulha fina. A citologia mostrou-se compatível com um carcinoma papilar de tiroide. A avaliação pós-cirúrgica mostrou um microcarcinoma papilar. A TSA pode produzir alterações ultrassonográficas que obscurecem a coexistência de carcinoma papilar. Recomendamos que pacientes com TSA passem por exame ultrassonográfico após a recuperação. Regiões hipoecoicas maiores que 1 cm encontradas no US para acompanhamento pós-tratamento devem ser avaliadas por biópsia.