Preoperative predictors and prognosis of bilateral multifocal papillary thyroid carcinomas.

BACKGROUND: The characteristics of multifocal PTC remain controversial. Surgical approach to multifocal tumor changes between centers. This study aimed to evaluate the incidence of bilateral involvement, predictive factors for bilaterality and whether bilaterality was related with more aggressive histopathologic features or prognosis 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 divided into two subgroups as unilateral-multifocal PTCs and bilateral multifocal PTCs. Those two groups were compared regarding to demographic, clinical and histopathological features. 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). Bilateral and unilateral tumors had similar local/regional and distant recurrence rates. 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 prognosis.TSH can be taken as a preoperative indicator able to predict multifocal cancers and guide clinical decision making and surgical management.

A cancer of undetermined significance: Incidental thyroid carcinoma.

INTRODUCTION: The incidence of thyroid cancer is increasing which can be attributed in part to improved ultrasonography (US) methods and increased detection of incidental thyroid carcinomas (ITC). We aimed to compare ITC with nonincidental thyroid carcinomas (NITC) in this study. METHODS: Retrospective analyses of 906 individual patients who were operated for benign and malignant thyroid disease and had a final histopathological diagnosis of thyroid carcinoma were enrolled in this study. Preoperative US examination and fine needle aspiration (FNA) biopsy results were evaluated. The tumor foci in thyroidectomy specimens that were not represented in preoperative US or FNA reports were classified as ITC. The tumor foci that match with the lesions defined in US or FNA results were classified as NITC. RESULTS: Final histology revealed ITC in 326 patients (36%) and NITC in 580 patients (64% Mean age was 51.7 ± 11.11 in ITC group and 48.15 ± 13.1 in NITC group (P < .001). In NITC group 322 (55.5%) of the patients were operated for suspicious cytology while only 29 (8.9%) of the patients in the ITC group were operated because of this indication (P < .001). There were 1301 cancer foci in histopathology specimens. Among all these cancer foci, 434 (33.3%) were detected incidentally and 867 (66.7%) were detected non-incidentally. About 779 (89.9%) of nonincidental cancer foci were papillary cancer (PTC), while all of the incidental cancer foci were PTC. Mean size was 13 mm in NITC group and it was 3 mm in the ITC group and differed significantly between the groups (P < .001). Tumor size was ≤1 cm in 35.2% of the patients with NITC while 98.5% of patients with ITC had tumor ≤1 cm. The occurrence of multinodularity was higher in ITC than the NITC group (P < 001). Median TSH level was higher in patients with NITC than ITC while both were in the reference range (1.53 vs 1.03 µIU/mL, P < .001). The frequency of thyroiditis detected by US, and thyroid peroxidase antibody and thyroglobulin antibody positivities were similar in patients with ITC and NITC (P = .2, P = .86, and P = .26, respectively). The frequencies of capsular invasion (29.1% vs 7.9%), extrathyroidal extension (13% vs 4.2%), multifocality (35.8% vs 24.2%), non-complete resection (9.2% vs 1.8%), and lymph node metastasis (9.5% vs 1.8%) were significantly higher in the NITC group (P < .001, for each). Persistent/recurrent disease in patients with NITC was more frequent than patients with ITC (P = .004). This outcome was similar for cancers measuring ≤1 cm (P = .001). CONCLUSION: ITC is often encountered in older patients and frequently determined in early stages with more favorable histopathological features and better prognosis.

Effects of Radioactive Iodine Therapy on Ovarian Reserve: A Prospective Pilot Study.

Background: Thyroid carcinoma is the most common endocrine malignancy. Surgery is the standard therapeutic approach for patients with differentiated thyroid carcinoma (DTC), followed by radioiodine (RAI) therapy if indicated. For women with DTC, the effects of RAI therapy on gonadal and reproductive function are an important consideration. This study aimed to evaluate the effects of RAI therapy on ovarian function. Methods: A total of 33 premenopausal women were enrolled in this study. Serum follicle-stimulating hormone (FSH), luteinizing hormone (LH), estradiol, and anti-Müllerian hormone (AMH) levels during the early follicular phase were measured before and 3, 6, and 12 months after RAI therapy. The Friedman and Wilcoxon tests were used to detect changes in FSH, AMH, LH, and estradiol levels induced by RAI therapy over time. Results: The patients' ages ranged from 21 to 38 years, with a mean age of 31.15 ± 4.83 years. The median follow-up was 19 months (range 4-26 months). The median AMH levels were 3.25 ng/mL (range 0.32-17.42 ng/mL), 1 ng/mL (range 0.01-3.93 ng/mL), 1.13 ng/mL (range 0.08-6.12 ng/mL), and 1.37 ng/mL (range 0.09-6.1 ng/mL) before and at 3, 6, and 12 months after RAI therapy, respectively. The median FSH levels were 6.6 mIU/mL (range 3.78-15.5 mIU/mL), 5.83 mIU/mL (range 4.19-35.36 mIU/mL), 7.71 mIU/mL (range 4.24-16.25 mIU/mL), and 7.04 mIU/mL (range 4.93-19.96 mIU/mL) before and at 3, 6, and 12 months after RAI therapy, respectively. The AMH levels were higher before than after RAI therapy (p = 0.001). The AMH levels did not differ significantly between the three time points (p > 0.05). The FSH, LH, and estradiol levels were similar before and after RAI therapy (p > 0.05). Conclusion: AMH is considered an important marker of ovarian reserve. Ovarian reserve decreased after RAI therapy. More attention may be needed when considering RAI therapy for patients with reduced ovarian reserve.

Structural tendon changes in patients with acromegaly: assessment of Achilles tendon with sonoelastography.

AIMS: To describe the sonoelastographic appearance of the Achilles tendon in acromegalic patients and to determine whether the blood concentrations of growth hormone (GH) and insulin-like growth factor (IGF-1) are associated with the various sonographic elasticity types of Achilles tendons. MATERIAL AND METHODS: Eighty-four Achilles tendons of 42 acromegaly patients and 84 Achilles tendons of 42 healthy volunteers were assessed with sonoelastography. The tendons were classified into two main types according to the elasticity features: type 1 blue/green (hard tissue) and type 2 yellow/red within green (intermediate-soft tissue). Two subtypes of these types were also defined. According to the definition, the elasticity of the tissue was in a spectrum ranging from hard to soft as the type progressed from 1a to 2b. RESULTS: The mean thickness of Achilles tendons in patients with acromegaly was significantly higher compared with healthy Achilles tendons (5.1+/-0.7 mm vs. 4.4+/-0.5, p<0.001), and patients with active disease had thicker Achilles tendons (5.5+/-0.8 mm vs. 4.8+/-0.5 mm in inactive disease, p=0.003). A significantly higher proportion of acromegaly patients had type 2 sonoelastographic appearance of the Achilles tendon (124/252 third; 49.2% vs. 81/252 third; 32.1%, p=0.0001). Activity status of acromegaly and GH/IGF-I levels were similar in patients with different types of elasticity (p>0.05). CONCLUSIONS: Sonoelastography revealed structural changes in the tendinous tissue of patients with acromegaly, but it was not sensitive enough to reflect changes in the serum levels of GH/IGF-1.

Higher TSH can be used as an additional risk factor in prediction of malignancy in euthyroid thyroid nodules evaluated by cytology based on Bethesda system.

Recently, it has been suggested that thyrotropin (TSH) concentration can be used as a marker for prediction of thyroid malignancy. In this study, we aimed to investigate the association between TSH levels and prediction of malignancy in euthyroid patients with different Bethesda categories. 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. 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, and 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 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). 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). Moreover, TSH levels showed to increase from Bethesda categories II to VI. In addition to cytology, higher TSH levels can be used as a supplementary marker in prediction of malignancy in certain Bethesda categories.

Thyroid Disorders in Young Females with Polycystic Ovary Syndrome and Correlation of Thyroid Volume with Certain Hormonal Parameters.

OBJECTIVE: To investigate the prevalance of hypothyroidism, thyroid autoimmunity, and ultrasonographic features in polycystic ovary syndrome (PCOS) patients and compare them with a control group, and to detect correlation of thyroid volume [TV] with luteinizing hormone (LH), insulin-like growth factor binding protein-3 (IGFBP-3), and IGF-1 in patients with PCOS. STUDY DESIGN: Seventy PCOS patients' and 84 age-matched controls were enrolled. The patient and control groups were compared according to hormonal parameters, anthropometric measures, TV, echogenicity on ultrasonogram, and autoimmunity. We also investigated the correlation between TV and homeostasis model assessment (HOMA), serum LH, IGF-1 and IGFBP-3 levels in the PCOS group. RESULTS: Body mass index (BMI), Ferriman Gallwey score, fasting insulin level, DHEAS, total and free testosterone, LH, TV, and IGFBP-3 levels were significantly higher in PCOS patients as compared to control group. TV was similar in patients with or without insulin resistance diagnosed with HOMA-estimated insulin resistance (IR). There was no difference in prevalence of hypothyroidism or ultrasonographic features in the groups. We have detected a positive and significant correlation between TV and BMI. We have found that there was no meaningful correlation between the TV and serum IGF-1 levels, whereas TV was positively correlated with serum LH. CONCLUSION: We could not find any correlation between TV and IGF-1, but the most likely etiology of the increased TV in PCOS appears to be related to elevated LH levels in those patients.

Real-time sonoelastography and ultrasound evaluation of the Achilles tendon in patients with diabetes with or without foot ulcers: a cross sectional study.

BACKGROUND: Diabetes mellitus (DM) is an endocrine disease characterized by metabolic abnormalities and long-term complications. The Achilles tendon (AT) plays an important role in foot biomechanics. We aimed to investigate the effect of DM on the Achilles tendon, which may contribute to long-term complications in the foot-ankle complex. METHODS: Seventy-eight patients with diabetes, with (35 patients, group I) or without (43 patients, group II) foot ulcers were recruited from the endocrinology clinic. Thirty-three age-, gender-, and BMI-matched healthy individuals were selected as controls. All participants underwent ultrasonography and sonoelastography of their AT in order to evaluate Achilles tendon thickness (ATT) and stiffness (ATS). Each patient was also tested for fasting plasma glucose (FPG) and glycosylated hemoglobin (HbA1C) as a measure of diabetes control. Other chronic complications were also evaluated in all patients with diabetes. RESULTS: The AT was significantly thicker in group I compared to group II and the controls. HbA1C, FPG, and duration of diabetes were higher in group I. We observed that ATT was positively correlated with neuropathy, retinopathy, nephropathy, peripheral arterial disease and coronary arterial disease in group II while this correlation was not detected in group I. ATS was reduced in group I more than group II and control groups. CONCLUSION: Changes in the structure of the AT may precede foot ankle disorders in patients with diabetes. This is the first study that reported the results of sonoelastosonography of AT in patients with diabetes and revealed the correlation between ATT and other chronic complications of diabetes.

Effective treatment of severe pregnancy and lactation-related osteoporosis with teriparatide: case report and review of the literature.

Pregnancy or lactation-related osteoporosis (PLO) is a very rare and debilitating condition which is usually diagnosed during the last trimester of the pregnancy or early postpartum period. Herein, we report a case with severe PLO and multiple vertebral compression fractures that were successfully treated with teriparatide. Twenty-three-year-old female patient was admitted to our clinic two months after her first spontaneous vaginal delivery with the complaint of severe back pain. Bone mineral density was measured using dual energy X-ray absorptiometry (DEXA), and low T- and Z-scores were observed in lumbar vertebrae. In vertebral MRI, severe height loss was detected in thoracic (T) 5,7,10,11,12 vertebrae. After exclusion of the other possible causes of OP, she was diagnosed to have PLO and the lactation was stopped. She was treated with calcium 1000 mg/day, cholecalciferol 800 mg/day and teriparatide 20 µg/day. At the 12th and 18th month of therapy, BMD was increased by 8% and 27%, respectively, at the lumbar spine and pain was completely relieved in few months. There are pharmacological therapy modalities that can be used in PLO. Bisphosphonates are effective, but there are some concerns that they accumulate in bone and may expose fetus in subsequent pregnancies. Teriparatide is a strong candidate to be the optimal medical therapy in severe cases since it is effective and safe.

The evaluation of QT intervals during diagnosis and after follow-up in acromegaly patients.

INTRODUCTION: It was aimed to calculate QT intervals in patients with acromegaly and to reveal its correlation between QT intervals, and growth hormone and insulin like growth factor-1. MATERIAL AND METHODS: Forty-one patients with acromegaly were enrolled into the study. Another 41 individuals with similar features, such as comorbid diseases, age and sex constituted the control group. The electrocardiographies of patients with acromegaly were evaluated at the baseline and after the follow-up. Only one electrocardiography was performed for controls. QT maximum, QT minimum, QT dispersion, corrected QT maximum, corrected QT minimum and corrected QT dispersion were calculated. RESULTS: Baseline QT maximum, QT dispersion, corrected QT maximum and corrected QT dispersion were significantly longer than the values of controls. Corrected QT maximum and corrected QT dispersion were significantly shorter after the follow-up, compared to the baseline in patients. QT maximum, QT dispersion, corrected QT maximum and corrected QT dispersion after the follow-up were not statistically different from the values of controls. Except the negative correlation between growth hormone and corrected QT dispersion in patients after the follow-up, no other correlation was detected between QT values and growth hormone or insulin like growth factor-1 levels. Corrected QT dispersion was found to be related with the disease duration in patients. DISCUSSION: For acromegaly patients, it is important to detect clinical predictors of cardiac arrhytmias. QT dispersion is considered a beneficial predictor for ventricular arrhytmias. When compared to controls, prolonged QT intervals were determined in our acromegalic patients. CONCLUSION: We consider that QT intervals may also be utilized in the evaluation of increased cardiovascular risk in patients with acromegaly.

Introdução: O estudo teve como objectivo a determinação do intervalo QT em doentes com acromegália e a análise da correlação entre o intervalo QT e a concentração de hormona do crescimento e de IGF-1 (insulin-like growth factor-1). Material e Métodos: O estudo englobou 41 doentes com acromegália. O grupo de controlo englobou 41 indivíduos com características semelhantes no que se refere a comorbilidades, idade e género. A electrocardiografia de doentes com acromegália foi obtida no início do estudo e após o follow-up. Foi apenas obtido um electrocardiograma no grupo de controlo. Foram calculados o QT máximo, QT mínimo, dispersão do intervalo QT, QT máximo corrigido, QT mínimo corrigido e dispersão do intervalo QT corrigido. Resultados: Os valores do QT máximo basal, dispersão do intervalo QT, QT máximo corrigido e dispersão do QT corrigido foram significativamente mais prolongados no grupo de doentes com acromegália do que nos controlos. O QT máximo corrigido e a dispersão do QT corrigido foram significativamente mais curtos durante o seguimento clínico, quando comparados com os valores basais dos doentes. O QT máximo, dispersão do QT, QT máximo corrigido e dispersão do QT corrigido durante o seguimento clínico não foram estatisticamente diferentes dos valores obtidos nos controlos. Com excepção de uma correlação negativa entre os valores da hormona do crescimento e a dispersão do QT corrigido em doentes durante o seguimento clínico, nenhuma outra correlação foi assinalada entre os valores do intervalo QT e as concentrações de hormona do crescimento e de IGF-1. Concluiu-se que a dispersão do intervalo QT está correlacionada com a duração da doença nos doentes com acromegália. Discussão: Em doentes com acromegália, é importante a detecção de preditores clínicos de arritmia cardíaca. A dispersão do intervalo QT é considerada um preditor relevante de arritmias ventriculares. Os doentes com acromegália englobados no nosso estudo apresentaram intervalos QT prolongados, quando comparados com os controlos. Conclusão: A avaliação do risco cardiovascular em doentes com acromegália deve englobar a determinação do intervalo QT.

Gynecomastia: Clinical evaluation and management.

Gynecomastia is the benign enlargement of male breast glandular tissue and is the most common breast condition in males. At least 30% of males will be affected during their life. Since it causes anxiety, psychosocial discomfort and fear of breast cancer, early diagnostic evaluation is important and patients usually seek medical attention. Gynecomastia was reported to cause an imbalance between estrogen and androgen action or an increased estrogen to androgen ratio, due to increased estrogen production, decreased androgen production or both. Evaluation of gynecomastia must include a detailed medical history, clinical examination, specific blood tests, imaging and tissue sampling. Individual treatment requirements can range from simple reassurance to medical treatment or even surgery. The main aim of any intervention is to relieve the symptoms and exclude other etiological factors.