Concurrent mutations of germline GPR101 and somatic USP8 in a pediatric giant pituitary ACTH adenoma: a case report.

BACKGROUND: Cushing's disease (CD) is rare in pediatric patients. It is characterized by elevated plasma adrenocorticotropic hormone (ACTH) from pituitary adenomas, with damage to multiple systems and development. In recent years, genetic studies have shed light on the etiology and several mutations have been identified in patients with CD. CASE PRESENTATION: A girl presented at the age of 10 years and 9 months with facial plethora, hirsutism and acne. Her vision and eye movements were impaired. A quick weight gain and slow growth were also observed. Physical examination revealed central obesity, moon face, buffalo hump, supra-clavicular fat pads and bruising. Her plasma ACTH level ranged between 118 and 151 pg/ml, and sella enhanced MRI showed a giant pituitary tumor of 51.8 × 29.3 × 14.0 mm. Transsphenoidal pituitary debulk adenomectomy was performed and immunohistochemical staining confirmed an ACTH-secreting adenoma. Genetic analysis identified a novel germline GPR101 (p.G169R) and a somatic USP8 (p. S719del) mutation. They were hypothesized to impact tumor growth and function, respectively. CONCLUSIONS: We reported a rare case of pediatric giant pituitary ACTH adenoma and pointed out that unusual concurrent mutations might contribute to its early onset and large volume.

Somatostatin Treatment for Ectopic ACTH Syndrome due to Pancreatic Neuroendocrine Tumors: Review of the Literature.

Objectives: To analyze and summarize the effect of SSA treatment on EAS due to p-NETs (EAS-p-NETs). Methods: Thirteen patients with EAS-p-NETs treated with SSAs at our center or described in the literature were included in this study. Clinical characteristics, laboratory data, imaging studies, histopathologic results, the effect of SSA treatment, and the prognosis of these EAS-p-NET patients were evaluated. Results: Four males and 9 females with an average age of 42.9 years were included in the study. The mean duration of follow-up was 38.8 ± 28.2 months. As one of the combined treatment measures, SSAs controlled the levels of ACTH and cortisol in 9 of the 13 patients (69.2%). Partial response was observed in 3 patients (23.1%), stable disease in 2 patients (15.4%), and progressive disease in 6 patients (46.2%). The median time to tumor progression was 24 months, and the median overall survival was 61 months. The side effects of SSA treatment included temporary mild abdominal pain, diarrhea, gallstones, and cholecystitis. Conclusions: As a supplemental therapy, SSA treatment led to clinical and biochemical improvement with a good safety profile in patients exhibiting EAS-p-NET with metastasis. However, tumor progression was inhibited by SSA treatment in only a few patients. Combined with other treatments, SSAs may improve the prognosis of patients with EAS-p-NETs.

Cushing's disease with pulmonary Cryptococcus neoformans infection in a single center in Beijing, China: A retrospective study and literature review.

BACKGROUND: Patients with Cushing's disease (CD) with hypercortisolism have an increased risk of opportunistic infection. However, most CD patients exposed to infections are diagnostic latency, leading to a poor prognosis. METHODS: Six patients in our hospital and an additional six patients in the literature were included in this study. Clinical information of CD patients with pulmonary Cryptococcus neoformans are reviewed. RESULTS: The average baseline total cortisol and ACTH in serum at 8 am of all the patients was 44.85 µg/dL (normal range 4.0-22.3 µg/dL) and 200.3 pg/mL (normal range 0-46 pg/mL), respectively. Lymphopenia was found in 2 out of 6 patients in our hospital. The pulmonary radiologic findings included nodules (4/12), masses with or without a cavity (5/12), infiltration (5/12), and consolidation (4/12). The diagnosis of C.neoformans was established by lung pathology results (7/12), microorganism culture (3/12), and serum cryptococcal polysaccharide antigen (4/12). Lung lobectomy was performed in two patients who had a nodule in one lung lobe. Antifungal drugs were administered, including amphotericin-B (7/12), fluconazole (4/12), flucytosine (2/12) and liposomal amphotericin (1/12). Additional therapies for CD included trans-sphenoidal pituitary adenoma surgery (9/12), adrenalectomy (1/12) and ketoconazole (2/12). Seven patients survived, and five patients died. CONCLUSION: Pulmonary C.neoformans is an uncommon but fatal opportunistic infection in CD patients. Pulmonary nodules or masses should be aggressively investigated to exclude the C.neoformans among CD patients. The infiltration lesions in chest CT scan and lymphopenia are associated with poor prognosis.

Detailed Componential Characterization of Extractable Species with Organic Solvents from Wheat Straw.

Componential analysis of extractives is important for better understanding the structure and utilization of biomass. In this investigation, wheat straw (WS) was extracted with petroleum ether (PE) and carbon disulfide (CS2) sequentially, to afford extractable fractions EFPE and EFCS2, respectively. Detailed componential analyses of EFPE and EFCS2 were carried out with Fourier transform infrared (FTIR) spectroscopy, gas chromatography/mass spectrometry (GC/MS), X-ray photoelectron spectroscopy (XPS), transmission electron microscopy (TEM), energy dispersive spectrometry (EDS), and electron probe microanalysis (EPMA). Total extractives were quantified 4.96% by weight compared to the initial WS sample. FTIR and GC/MS analyses results showed that PE was effective for the extraction of ketones and waxes derived compounds; meanwhile CS2 preferred ketones and other species with higher degrees of unsaturation. Steroids were enriched into EFPE and EFCS2 with considerable high relative contents, namely, 64.52% and 79.58%, respectively. XPS analysis showed that most of the C atoms in extractives were contained in the structures of C-C, C-COOR, and C-O. TEM-EDS and EPMA analyses were used to detect trace amount elements, such as Al, Si, P, S, Cl, and Ca atoms. Detailed characterization of extractable species from WS can provide more information on elucidation of extractives in biomass.

[A compound heterozygous mutation in CYP17A1 gene in a female subject with partial 17α-hydroxylase/17, 20 lyase deficiency].

OBJECTIVE: To explore the clinical and molecular genetic characteristics of a Chinese female patient with partial 17α-hydroxylase/17, 20 lyase deficiency (17OHD), a rare type of congenital adrenal hyperplasia. METHODS: Her clinical features and laboratory data were collected. Genomic DNA was extracted from leukocytes of peripheral blood of her and her mother. All eight exons of CYP17A1 gene, including flanking regions of introns, were amplified by PCR. The mutations of CYP17A1 gene were identified by direct sequencing or cloning and sequencing the amplified DNA fragments. RESULTS: The patient presented with hypertension, hypokalemia and irregular menstruation. DNA sequencing results demonstrated a compound heterozygous mutation in CYP17A1 gene. One allele of her had the deletion of phenylalanine (TTC) at either codon 53 or 54 and the other allele contained a base transversion at codon 329 (TAC/AA) and leading to a missense mutation of tyrosine to lysine and the open reading frame shift following this codon to produce a truncated enzyme with 417 amino acids and without activity site. Her mother was a heterozygous carrier of the latter allele. CONCLUSION: The partial 17OHD in this patient is caused by a compound heterozygous mutation in CYP17A1 gene.

Growth and development of adolescent patients with Cushing's syndrome / 中国医学科学院学报

<p><b>OBJECTIVE</b>To elucidate the growth and development of patients with Cushing's syndrome (CS) in adolescence.</p><p><b>METHODS</b>We analyzed the clinical data of 19 patients aged under 18 with CS. We divided the patients into two groups according to the height at diagnosis. The patients under the 3rd percentile were in the short stature group (n=12), and the others in the non-short stature group (n=7). The intergroup differences in disease course, age of onset, and 24-hour urinary free cortisol were analyzed.</p><p><b>RESULTS</b>The median age at diagnosis was 13 years. The median disease course was 0.9 years. All those patients presented with typical clinical characteristics of CS. Twelve cases (63.2%) were in short stature group. The disease course of the short stature group was found significantly longer than that of the non-short stature group [(2.7∓1.7) years vs. (0.8∓0.6) years, P=0.013], but no significant difference was found in the age of onset (P=0.530) or 24-hour urinary free cortisol (P=0.919) between the two groups.</p><p><b>CONCLUSIONS</b>The data suggest that short stature is common in adolescent CS patients. The growth delay may be correlated to the disease course of CS.</p>

[The relationship between hyperlipidemia and lower limb arterial disease in elderly diabetes patients].

OBJECTIVE: To evaluate the correlation between hyperlipidemia and lower limb arterial disease in elderly diabetic patients with color Doppler ultrasonography. METHODS: Two hundred and sixty elderly diabetic patients and 206 normal subjects were enrolled in the study. Doppler ultrasonographic manifestations of lower limb arterial disease, blood pressure and blood biochemistry parameters including fasting plasma glucose (FPG), postprandial plasma glucose (PPG), TC, TG, HLD-C, LDL-C, apoprotein B (apoB), very low density lipoprotein cholesterol (VLDL-C), apoprotein A1 (apoA1) and fibrinogen (Fb) were compared between the 2 groups. RESULTS: (1) The blood biochemistry parameters, including the levels of FPG, PPG, TC, TG, VLDL-C, LDL-C, apoB and Fb were higher in diabetic patients than in normal subjects, while HDL-C was lower (all P < 0.05). (2) The thickness of intima-media (IMT) in the lower limb arterial disease group was significantly increased and the presence of arterial stenosis and wall plaques more in diabetic patients [IMT in 205 cases (78.85%), atherosclerotic plaque in 241 cases (92.69%), multivessel disease (more than 2 vessels) in 60 cases (23.08%) and arterial stenosis in 89 cases (34.23%)] than in normal subjects [IMT in 37 cases (17.96%), atherosclerotic plaque in 51 cases (24.76%), multivessel disease in 27 cases (13.11%) and arterial stenosis in 3 cases (0.01%)], all P < 0.01. (3) Regression analysis showed that lower limb arterial disease was correlated with high level of LDL-C and low level of HDL-C. CONCLUSIONS: Arteriosclerotic plaque is one of the early manifestations in elderly diabetic patients and hyperlipidemia may provide the basis of its formation. Doppler ultrasonographic examination of lower limbarterial discloses the early arteriosclerotic changes of lower limb arterial disease in elderly patients and offers the basic data of indication for clinical treatment.

[Bone loss is more severe in younger Cushing's syndrome women than in older ones: comparison of bone mineral density between Cushing's syndrome and healthy women].

OBJECTIVE: To investigate the influence of age on bone mass in Cushing's syndrome patients. METHODS: Measurement of bone mineral density (BMD) was conducted among 57 women with Cushing's syndrome (CS) and 49 healthy women. There were 14 CS women and 14 healthy women in the group aged 20 - 29; 27 CS women and 15 healthy women in the group aged 30 - 39; and 16 CS women and 20 healthy women in the group aged 40 - 49. RESULTS: Among the healthy women the peak bone mass of lumbar spine was in the group aged 30 - 39, while the peak bone mass of hip was in the group aged 20 - 29. The BMD values of the CS women were lower than those of the healthy women, especially those in lumbar spine and in Ward's triangle. The younger the CS women, the lower the BMD Z-score (for the BMD Z-score of lumbar spine P = 0.021, for the BMD Z-score of femoral neck P = 0.020, and for the BMD Z-score of Ward's triangle P = 0.026). Seventeen of the 57 (29.8%) CS women had osteoporosis, 29 (50.9%) of the 57 had osteopenia, and 15 (26.3%) had fractures. The CS women with bone fractures had lower BMD Z-score than those without fractures (for lumbar fracture P = 0.003). CONCLUSION: The BMD of CS women is lower than that of the healthy women. Bone loss is more severe in younger CS women than in older ones. CS women with low BMD are prone to have bone fracture.

[New compound heterozygous mutation causes partial combined 17 alpha-hydroxylase/17,20-lyase deficiency].

OBJECTIVE: To investigate the CYP17A1 gene mutations in a Chinese 46,XX patient with partial combined 17 alpha-hydroxylase/17,20-lyase deficiency. METHODS: Clinical data were retrospectively analyzed. The genomic DNA of the patient and her parents was isolated from whole blood. Seven pairs of primers were used to amplify eight exons and exon-intron boundaries of the CYP17A1 gene. The amplified PCR products were purified by agarose gel and then directly sequenced. In order to confirm the DNA sequences of different alleles, some fragments were inserted into pMD 18-T vector and then subclone sequenced. Sequencing results were compared to the established human CYP17A1 sequence. RESULTS: The patient was new compound heterozygous of 5994-5995 delAT/7541 C>T. The mutation 5994-5995 del AT, causing amino acid I259H, 274X, was proposed to result early truncated protein which was lack of the activity center site of P450C17, whereas missense mutation 7541 C>T causing A398V did not lie in the active site of the enzyme according to the computer model of human P450C17. The 46, XX case had irregular menstruation and slightly hypertension and hypokalemia. The ACTH stimulating test as well as the result of the sex hormones suggested that there was partial 17 alpha-hydroxylase/17, 20-lyase enzyme activities in the adrenal and sexual gland. We speculate that A398V might conserve partial of the enzyme's activities. The genotype was coincident with phenotype. CONCLUSION: More study should be done to have better understanding of the function of the mutated P450C17 enzymes.

[Brief introduction of the construction of legal system of traditional Chinese medicine in modern China].

Since the foundation of PRC, the people's government attaches great importance to the development of traditional Chinese Medicine. With the efforts of people from Chinese medicine and the Party Central Committee's concern, the legal system of traditional Chinese medicine has been progressing step by step. Since 1949, the construction of legal system of traditional Chinese medicine can be divided into three periods with lessons and achievements, each with its own features. Through the retrospect of the history of our legal system of traditional Chinese medicine from 1949 to modern times, and its analytical summary, we could obtain a lot of inspiration for the construction of modern legal system of traditional Chinese medicine.

[Incomplete P450 17 alpha enzyme deficiency: report of six cases].

OBJECTIVES: To summarize the characteristics, differential diagnosis and management of incomplete 17 alpha-hydroxylase/17, 20-lyase deficiency (17 OHD) of Chinese patients. METHODS: Six cases of incomplete 17 OHD from Peking Union Medical College Hospital were studied retrospectively through analyzing their clinical data, and the molecular pathogenic mechanism was discussed after literature review. RESULTS: Four cases of 46, XX incomplete 17 OHD were reported. The clinical characteristics included female phenotype, various degrees of breast development and absent or sparse axillary/pubic hair, oligomenorrhea or secondary amenorrhea, recurrent luteinized ovarian cysts, hypogonadism with persistent hyperprogesteronemia or high serum 17 alpha-hydroxyprogesterone level, with or without hypokalemic hypertension. There were also 2 cases of 46, XY incomplete 17 OHD, in which ambiguous genitalia were present besides hypokalemic hypertension. CONCLUSIONS: Incomplete 17 OHD is a very rare form of congenital enzymatic deficiencies of steroid synthesis, which should be included in the differential diagnosis when there are menstrual disorders, sexual infantilism, recurrent ovarian cysts or ambiguous genitalia. Under such circumstances, hyperprogesteronemia offers a valuable clue for further investigation.

[A neglected master on integrative medicine: Wei-Ju ZHU].

Through analyzing the academic ideas in Shanghan Zhinan written by Wei-Ju ZHU, a modern famous physician, it is pointed out that ZHU's achievement on integrative medicine has been overlooked. Taking the theory of syndrome differentiation of six channels from Shanghan Lun as an example, ZHU presumed that the essence of therapeutic theory of traditional Chinese medicine was to conform to or strengthen human body's self-healing and self-regulating abilities. Since Yangqi is the major force in the body to help heal disease when it occurred, ZHU often took measures to strengthen Yang first in treating disease and also was good at using hot-natured herbs, such as Radix aconiti lateralis preparata. ZHU's thoughts on integrative medicine were concerned with etiology, pathology and therapeutics. In addition, ZHU generalized the syndrome differentiation into the theory of five phases and eight principles, and made important contributions to the history of integrative medicine. His thinking will provide valuable revelation for clinical practice and modern research on traditional Chinese medicine.

Study on the genetic mutations of 17 alpha-hydroxylase/17,20-lyase deficiency in Chinese patients.

OBJECTIVE: To investigate the CYP17A1 gene mutations in Chinese patients with 17 alpha-hydroxylase/17, 20-lyase deficiency. METHODS: Clinical data were retrospectively analyzed. The CYP17A1 gene mutations were detected in 5 cases with 17 alpha-hydroxylase/17, 20-lyase deficiency and their relatives. The genomic DNA of the patients was isolated from whole blood. Seven pairs of primers were used to amplify eight exons and exon-intron boundaries of the CYP17A1 gene. The amplified PCR products were purified by agarose gel and then directly sequenced. In order to confirm the DNA sequences of different alleles, some fragments were inserted into pMD 18-T vector and then sequenced. Sequencing results were compared to the established human CYP17A1 sequence. RESULTS: Briefly, we found 2 kinds of compound mutations, of which were: (1) 6436-6438(TAC-->AA), causing amino acid Y329K, 418X; (2) 6531-6532(GC-->A), causing amino acid L361F, 418X. Among the five cases, four were homozygous for 6436-6438(TAC-->AA), whereas one was compound heterozygous for 6436-6438(TAC-->AA)/6531-6532(GC-->A). The clinical characteristics of 5 cases were all completely combined defects of 17 alpha-hydroxylase/17, 20-lyase, and they all carried two alleles of CYP17A1 gene mutations that all shifted the reading frame and resulted in truncated protein which lack of the activity center site of P450C17, of which corresponding with their clinical feature. CONCLUSION: Nine alleles have the mutation of 6436-6438(TAC-->AA), accounting for 90% of total alleles (9/10). That suggests this kind of mutation may have racial specificity. More study should be done to have better understanding of the function of the truncated P450C17 enzymes.

Effects of chai hu (radix burpleuri) containing formulation on plasma beta-endorphin, epinephrine and dopamine on patients.

Chai Hu (Radix Burpleuri), a major ingredient in many traditional Chinese medicine formulas, such as Xiao Yan Wan, is used in the treatment of liver stagnation and spleen deficiency syndrome (LSSDS). The objectives of this study were to examine the effects of Xiao Yao Wan containing Chai Hu on the changes of plasma indices in patients with LSSDS. Fifty-eight cases of LSSDS were randomly divided into two groups: 41 cases in the experimental group were treated with Xiao Yao Wan containing Chai Hu and 17 cases in the control group were treated with Zhi Bai Di Huang Wan for one consecutive month in a single blind design. Before and after treatment, high performance liquid chromatography (HPLC) was applied to determine the changes of plasma norepinephrine (NE), epinephrine (E) and dopamine (DA). Radioimmunoassay was performed to measure the amount of plasma beta-endorphin (beta-EP), adrenocorticotropin hormone (ACTH), estradiol (E2) and testosterone (T), and laser nephelometry was also conducted to measure plasma immunoglobulin A (Ig A) and G (Ig G). Compared to baseline levels, plasma beta-EP was significantly increased (p < 0.01), while E and DA were markedly decreased (p < 0.01) after the administration of Xiao Yao Wan in the experimental group. The other indices did not change. This is the first evidence showing that the effect of Xiao Yao Wan containing Chai Hu on the treatment of patients with LSSDS may be through enhancing plasma beta-EP and decreasing E and DA release. We conclude that Xiao Yao Wan containing Chai Hu regulates nervous and endocrine systems and contributes to the improvement of the clinical status of patients with LSSDS.

[Clinical characteristics of 17alpha-hydroxylase/17,20-lyase deficiency and long term follow up results].

OBJECTIVE: To improve the diagnosis and the treatment level of 17alpha-hydroxylase/17,20-lyase deficiency. METHODS: 24 patients suffering from this disease were diagnosed and treated in Peking Union Medical College Hospital from 1978 to 2002. All the patients had comprehensive hormone assay and some had bone mineral density detection. RESULTS: 20 patients with complete combined defect in this study had typical clinical presentation of hypertension and hypokalemia and presented both karyotype 46, XX or 46, XY. All had female external genitalia and lacked spontaneous puberty. The circulating concentrations of cortisol and gonadal steroids were reduced and that of gonadotropin was elevated, whereas in the remaining 4 cases with partial combined deficiencies, adrenal corticotropic hormone stimulating test as well as the results of the sex hormone determination suggested that there was partial 17alpha-hydroxylase/17,20-lyase enzyme activities in their adrenal glands or sexual glands. Long term follow up data showed that in most of the patients, small doses of dexamethasone (0.1 - 0.375 mg per day) could achieve good control of hypertension and correct hypokalemia, but in five patients other drugs were needed for normalization of blood pressure. With sex hormone replacement, the patients could keep adult female appearance, but did not have reproductive function. CONCLUSIONS: In clinical work it is necessary to enhance the recognition of partial combined 17alpha-hydroxylase/17,20-lyase deficiency. Long term regulation treatment can achieve good control of blood pressure and rectify the low blood potassium.

[Molecular characterization of mutations and phenotype/genotype correlation in Chinese patients with 21-hydroxylase deficiency].

To investigate characteristics of CYP21 mutations in Chinese patients with 21-hydroxylase deficiency (21-OHD) and the relationship between genotype and phenotype, a time saving, reliable molecular diagnosis method was developed. Eight patients with NC 21-OHD, 35 patients with classical ones and 34 normal controls were studied as followed: CYP21 gene was amplified into fragment 1 (exon1 --> exon3) and fragment 2 (exon3 --> exon10) through PCR with specific primers. The second round PCR was carried out using fragment 1 and 2 as template, and PCR products were digested by restrictive enzymes to analyze nine mutations, including Del, Exon3 Del8 bp, Q318X, R356W, Exon6Cluster, i2g, l172N, P30L and V281L. The most frequent mutation in 43 cases of Chinese 21-OHD was l172N (36.0%), followed by i2g (20.9%), Del (8.6%), P30L (7.0%), Q318X (7.0%), V281L (4.7%), R356W (2.3%), E6Cluster (2.3%) and Exon3 Del8 bp (1.2%). The most common CYP21 gene defect in salt wasting, simple virilizing and nonclassical form was Del (44.4%), l172N (44.2%) and P30L (37.5%) respectively. In addition, genotype was classified into three (severe, moderate and mild) groups according to the degree of 21-hydroxylase enzymatic compromise caused by the mutation. Age of first visit, basal 17-OHP, composition of disease subtype were significantly different among the three groups, P < 0.05. In conclusion, the most common mutations in Chinese 21-OHD were l172N, i2g and Del. The genotype of Chinese 21-OHD has strong correlation with the phenotype.

[The evaluation of the diagnosis and treatment of 32 cases with ectopic ACTH syndrome].

OBJECTIVE: To investigate and discuss the diagnosis and treatment of ectopic ACTH syndrome. METHODS: Clinical data of 32 cases of ectopic ACTH syndrome, recruited from January 1990 to April 2003 in our hospital, was analyzed. RESULTS: All of the 32 cases presented with clinical and biochemical evidences of Cushing's syndrome. Ten cases were definitively diagnosed as ectopic ACTH syndrome by finding ectopic tumors; 4 cases were highly suspected as ectopic ACTH by blood sampling from femoral vein and infra-petrosal vein and 18 cases were suspected as ectopic ACTH by imaging examinations. Fifteen cases (47%), without identified source of ectopic hormone, were treated with bilateral or unilateral total adrenalectomy, with 1-year survival rate of 60%. Seven cases (22%), with possible source of ectopic hormone, underwent no intervention, with 1-year survival rate of 0. Ten cases underwent radical resection of tumor, 6 of which were bronchial carcinoids and 4 of which were thymic carcinoids, with 1-year survival rate of 60%. CONCLUSION: It is very difficult to localize the tumor of ectopic ACTH syndrome patients. Bilateral adrenalectomy followed by hormonal replacement is effective for most of the patients without identifying source of ectopic hormone.

[A clinical analysis of 103 cases of adrenal incidentaloma].

OBJECTIVE: To improve the diagnosis and treatment of adrenal incidentaloma (AI). METHODS: Retrospective analysis of 103 AI patients in PUMC Hospital from 1994 to 2002. RESULTS: Of the 103 cases (43 men and 60 women), most patients were 40-60 years old. Eighty-five cases (82.5%) were benign masses, of which 36 (35.0%) were non-functional adrenal cortical adenoma, and 12 (11.7%) were pheochromocytoma, 1 (1%) was Cushing's syndrome and 1 for aldosteronomas. Three cases did not show clinical feature and the diagnosis of pheochromocytoma were based on 131I-MIBG. Among 18 (17.5%) malignant tumors, adrenal carcinomas account for the majority (8 cases, 7.8%). Patients with malignant masses were significantly younger than patients with adenomas (P < 0.05), and the adenomas were significantly smaller than malignancy (P < 0.001). A cut-off at 4.0 cm of tumor mass size was set for differentiating benign and malignant tumors. CONCLUSIONS: During the diagnosis of AI, it's essential to evaluate hormonal activity and assess for the risk of malignancy. If the mass size is 4 cm or larger, the risk of malignancy increases. More attention should be paid to subclinical hyperfunctional state.