Characterization of adrenal lesions using MDCT wash-out parameters: diagnostic accuracy of several combinations of intermediate and delayed phases.

PURPOSE: To evaluate the diagnostic accuracy of wash-out parameters calculated using multiple intermediate and delayed phases. MATERIALS AND METHODS: This prospective study had institutional review board approval and informed consent was obtained from all patients. Between January 2012 and October 2016, 108 consecutive oncologic patients (59 males, 49 females, mean age 52.6 years; 129 diagnosed lesions) underwent multiphasic CT protocol including unenhanced (UE), arterial (AE), portal (PE), 5-min (DE-5) and the 15-min (DE-15) delayed phases of adrenal glands. All images were randomly reviewed in consensus by two radiologists experienced in abdominal CT, unaware of clinical or pathologic data. Location, size and density were recorded. Absolute wash-out, percentage wash-out (PWO) and percentage enhancement wash-out ratio were calculated. The thresholds yielding the best accuracy in differentiating adenomas from nonadenomas were retrospectively determined on the basis of ROC curves. The corresponding diagnostic accuracy values were calculated. Paired sample t test was used to assess differences among imaging parameters within subgroups. Student t test was applied to compare lesions between independent subgroups. p values ≤ 0.05 were considered significant. RESULTS: The final diagnosis included 82 adenomas (62 lipid-rich and 20 lipid-poor) and 47 nonadenomas (42 metastases, 3 pheochromocytomas, 2 carcinomas). All the 62 lipid-rich adenomas were correctly diagnosed as benign lesions on the basis of their UE attenuation < 10 HU. The PEAK attenuation was achieved during AE phase for 51/129 lesions (39.5%) and at the time of PE phase in 78/129 lesions (60.5%). The best overall accuracy in diagnosing adenomas (97.6%; 126/129 lesions correctly diagnosed) was obtained using 40% threshold for calculating PWO from PEAK to DE-15 scan. CONCLUSIONS: If only an intermediate phase is available, the 15-min delayed scan should be acquired to avoid any drop in diagnostic accuracy. The availability of two intermediate phase may be used to easy CT schedule by obviating the need to acquire a longer delayed phase.

Is the incidence of differentiated thyroid cancer increased in patients with thyrotropin-secreting adenomas? Report of three cases from a large consecutive series.

BACKGROUND: Patients with a thyrotropin-secreting pituitary adenoma (TSHoma) are exposed to unregulated and inappropriately high levels of thyrotropin (TSH). Given the rarity of this condition, it is not known whether this chronic TSH stimulation of the thyroid gland might represent a risk factor for the development of differentiated thyroid cancer (DTC). We analyzed the incidence of DTC in a large cohort of patients with TSHomas. METHODS: The study population consisted of all consecutive patients who underwent neurosurgery for a TSHoma between 1990 and 2013. Criteria for the diagnosis of TSHoma in patients without previous thyroid ablative procedures included elevated free thyroid hormones and normal/high serum TSH concentrations, presence of a lesion at magnetic resonance imaging (MRI), and abnormal response of TSH to at least one dynamic test. Patients who had received thyroid ablative procedures were required to have a pituitary lesion on MRI and TSH levels not suppressed while on levothyroxine therapy at doses causing elevation of free thyroid hormone levels. RESULTS: Sixty-two patients (32 females, 30 males) underwent surgery for a TSHoma at our center. Among them, 3 patients had a coexistent diagnosis of DTC with an estimated incidence of 4.8%. In 2 patients, DTC was diagnosed during the evaluation for suspected TSH-dependent hyperthyroidism, whereas in the third patient, diagnosis of DTC preceded the detection of the pituitary tumor. CONCLUSIONS: The elevated incidence of DTC in patients with TSHoma suggests a possible role of TSH hypersecretion in the development of thyroid tumors. A formal high-resolution ultrasound of the thyroid is recommended in patients diagnosed with a TSHoma, especially if a long history of the pituitary tumor is suspected. Moreover, suspicion about the presence of TSHoma should be raised by the lack of suppression of TSH levels despite adequate doses of levothyroxine after thyroidectomy for DTC.

Sunitinib therapy in metastatic papillary thyroid cancer.

We present the case of a 51-year-old woman with a follicular variant of papillary thyroid carcinoma. After surgery she experienced a relapse. Chemotherapy treatment led only to disease stabilization. In August 2009, we decided to start therapy with sunitinib 50 mg daily in an intermittent schedule (4 weeks on/2 weeks off). A CT scan after 3 months of treatment showed partial remission of disease according to the RECIST criteria. The patient continued sunitinib until January 2011, when CT evidenced progression in the mediastinal lymph nodes and pleura. Genetic analyses were carried out to determine if the clinical response in our patient was correlated with the presence of RET or BRAF mutations. No RET/PTC rearrangements or BRAF-V600E mutation, which are the two most common genetic alterations detected in papillary thyroid carcinoma, were found. It can be hypothesized that the activity of sunitinib in this patient was due to its antiangiogenic properties.

Serum thyroglobulin reference values according to NACB criteria in healthy subjects with normal thyroid ultrasound.

BACKGROUND: The present study was undertaken to establish serum thyroglobulin (Tg) normal reference values in a large group of healthy subjects. METHODS: Four hundred and thirty-eight non-smoking healthy subjects were selected to assess the Tg reference values (209 males, 229 non-pregnant females, age 34.7±13.1 years). Inclusion criteria were: no personal or familial history of thyroid disease, thyrotropin levels from 0.5 to 2.00 mUI/L, negative thyroperoxidase and thyroglobulin antibodies. In addition, the patients had a normal size thyroid (females ≤18 mL, males ≤25 mL) without nodules on the thyroid ultrasound (TUS). According to National Academy of Clinical Biochemistry (NACB) criteria the Tg results were transformed to a logarithmic scale and reference ranges were calculated as mean±2 SD. RESULTS: Serum Tg was measured on the Beckman Coulter UniCel DxI 800 automated platform by the simultaneous 1-step immunoenzymatic Access Thyroglobulin assay (Beckmann-Coulter SA, Nyon, Switzerland). Serum Tg levels were higher in females than in males (p=0.0022). Accordingly, gender-specific reference values were calculated (i.e., males: 1.40-29.2 ng/mL; females: 1.50-38.5 ng/mL). CONCLUSIONS: To the best of the authors' knowledge, the first reference interval study for Tg that integrates NACB criteria and TUS assessment for the selection of the reference population is provided here.

Familial hypocalciuric hypercalcemia revealed by chondrocalcinosis.

BACKGROUND: Calcium pyrophosphate dihydrate crystal deposition disease (CPPD-CDD) has been associated to hypercalcemia. Familial hypocalciuric hypercalcemia (FHH) is a rare but important consideration in the differential diagnosis of hypercalcemia. This autosomal dominantly inherited condition is characterized by elevated plasma calcium levels, relative or absolute hypocalciuria, and normal to moderately elevated plasma PTH level. The disease is caused by inactivating mutations in the calcium-sensing receptor gene. CASE REPORT: We describe a 77-year-old Italian man with arthritis secondary to CPPD-CDD and hypercalcemia. Clinical and biochemical data (s-Ca: 2.94 mmol/L; PTH: 5.9 pmol/L; 24 h urinary calcium: 69.6 mg; calcium/creatinine clearance: 0.004) suggested the diagnosis of FHH. Mild hypocalciuric hypercalcemia was also found in five of seven relatives confirming the diagnosis, of these one showed chondrocalcinosis. CONCLUSIONS: It is important to screen for FHH using fractional urinary excretion of calcium in subjects with CPPD-CDD associated to hypercalcemia, this approach may prevent unnecessary parathyroidectomy.