ACTA ENDOCRINOLOGICA (BUC)

Introduction: Pseudo-primary hyperaldosteronism of pregnancy was previously reported by our group during correction in twin-to-twin transfusion syndrome (TTTS). Aim: Focus on plasma volume changes and renin-angiotensin (RAS) and aldosterone response in 45 TTTS patients requiring amnioreductions above 1000 ml for severe hydramnios. Methods: 45 patients necessitating placental surgery and amnioreduction >1000ml for severe TTTS, under local anesthesia, as previously described. Assesment of plasma volume variations (%ΔPV) and simultaneous assays of aldosterone, renin, angiotensin II and ANP performed by standard kits prior to, 6 hours after and 12-24 hours after procedure. Statistical results expressed as median and interquartile ranges for non-parametric data, after correction of post-op levels with %ΔPV. Results: Depletion of 1600 ml (1000-3700) amniotic fluid (extravascular depletion) unexpectedly increased the intravascular plasma volume by 20,38% and dramatically changed the hormonal picture of primary hyperaldosteronism. Aldosterone decreased from a median of 730 pg/ml (T0) to 553 pg/ml (T6) to 515,9 pg/ml (T24). ANP increased from 8,95 pg/ml (T0) to 14,51pg/ml (T6) to 19,9 pg/ml (T24) pg/ml (ANOVA p=0,0036), while renin and angiotenin II stayed unchanged (ANOVA p=0,91). Conclusion: Depletion of extracelular fluid (amnioreduction) is indicated for the correction of hyperaldosteronism in pregnancies with severe hydramnios, to reduce to normal the aldosteron levels without the interference of the renin-angiotensin system, while natriuretic activity increases through ANP and, possibly, other less known natriuretic factors .

Introduction. Surgery has lost a lot of ground as the main therapy of most prolactinomas as it is clear from the current guidelines in most prolactin secreting adenomas, even in the setting of optic compression. However, we believe that surgery is still an important part in the treatment of this type of adenomas. This study is aimed to define what is the role of pituitary surgery in the current setup of prolactinoma management. Material and methods. In this retrospective, single-center study we analyzed 12 consecutive patients who underwent primary endoscopic transsphenoidal surgery for prolactinomas, between 2013 and 2022. Surgical indication, previous dopamine agonist (DA) treatment, remission rates, surgical complications, pituitary function and imagistic appearance are presented. Results. Of the 12 patients included, 4 had giant PRL and 8 macroadenomas, while 9 of them had previous DA treatment. The main surgical indication was pituitary apoplexy in 5 patients followed by CSF leak after DA treatment, 3 cases, and DA resistance in 3 cases. The main surgical complications were transitory diabetes insipidus in 7 cases. Normalization of prolactin levels was achieved in 2 patients. Conclusions. Surgical intervention should be strongly considered in all patients with neurologic symptoms referable to the lesion, resistance to medical therapy, other treatment failure or with complications after DA treatment. The endoscopic endonasal surgery offers good surgical outcomes with low rates of surgical complications and should remain an open option for specific cases.

Background. Occult papillary thyroid carcinoma presented as isolated cervical lymphadenopathy without clinical and radiologic findings has been rarely reported. Case report. A 47 years old female patient admitted to otorhinolaryngology clinic with 4X3 cm sized cervical mass. Physical examination of the patient was noted as a nontender, firm, mobile lymph node at right lateral cervical region. There was no inflammatory or infection disease in the history of patients anamnesis and no abnormal value on laboratory tests. Ultrasound screening of the neck detected a lymph node with suspicious features for malignancy. Head and neck examination was normal and there is no evidence of a tumoral mass or nodule in the thyroid gland. Whole body scan of MRI showed no pathologic sign both in the neck and body. Excisional biopsy was performed and revealed a carcinoma with papillary morphology. Immunohistochemical staining features of the tumor confirmed a papillary carcinoma derived from the thyroid gland. Second look USG of the neck and thyroid was performed but it revealed no tumoral mass. The patient underwent total thyroidectomy with right functional and central lymph node dissection. Histological examination of the thyroid gland showed multicentric 2 mm sized, three foci of papillary carcinoma located in bilateral thyroid lobes and metastatic lymph nodes in the right side of the neck. Conclusion. A metastatic cervical lymph node can be evidence of a clinically undetected occult papillary thyroid carcinoma. Specific immunohistochemistry staining of specimen may lead to appropriate surgery and progression of carcinoma may be hindered by application of additional RAI therapy.

Aim. The aim of our study was to investigate the effect of pioglitazone on glycemic and blood pressure control, on inflammation markers in diabetic patients.\r\nPatients and methods. Forty-nine diabetic patients who had been followed up as outpatients for 2.7 years and HbA1c was >7% were included in the study. The patients had never received thiazolidinedione therapy before. Clinical, metabolic variables, high-sensitive Creactive protein (hsCRP), homocysteine (HCY) and asymmetric dimethylarginine (ADMA) levels were measured. 30 mg pioglitazone were administered. The patients were followed up for six months and all the measurements were re-evaluated for comparison.\r\nResults. Body mass index (BMI) significantly increased after treatment. Fasting glucose, HbA1c and HsCRP were decreased. Insulin resistance was improved and HOMA-IR index was decreased after pioglitazone treatment [8 (?6.5) vs 4(?3.1); p<0.0001]. Pioglitazone improved lipid metabolism. Mean total cholesterol and LDL cholesterol levels were decreased and HDL cholesterol was increased after treatment. The decrease in triglyceride and homocysteine levels did not reach significance. Mean ADMA level did not change after therapy [0.62 (?0.39) vs 0.61 (?0.44); p=0.85].\r\nConclusion. Pioglitazone treatment in type 2 DM produced significant improvements in measures of glycemic control, plasma lipids, blood pressure and homocysteine levels. Pioglitazone had no influence on ADMA levels.

Purpose. To investigate the association between papillary thyroid cancer (PTC) and Hashimoto’s thyroiditis (HT). Design. This study is a retrospective study that conducted during 7 consecutive years with a median 119.5 months follow-up. Subjects and Method. Patients who underwent thyroidectomy in Dokuz Eylül University Hospital during 7 consecutive years were included. Patients’ demographics, biochemical, radiological, and pathological results were retrospectively assessed. Results. Four hundred sixty nine patients were evaluated. Among 469 patients who underwent thyroidectomy, 132 (28.1%) were malignant, while 182 patients were diagnosed with HT (38.8%). PTC was ranked first at 92.4% (n: 122). The prevalence of HT was 54.9% in patients with PTC and 33.1% in patients without PTC diagnosis (p<0.001). Younger age and the presence of HT were independently associated with PTC. The presence of HT was associated with increased risk of development of PTC (OR: 2.2, %95 CI: 1.4-3.5, p<0.001) but not with TNM stage or recurrence. Lymph node metastasis at presentation was the strongest predictor of recurrence (OR: 13.9, CI: 3.5-54.6, p<0.001) Conclusions. HT was an independent risk factor for development of PTC. According to our findings, HT patients (particularly with nodular HT) should be observed carefully and thyroid fine needle aspiration biopsy (TFNAB) should be encouraged if necessary.

Context. Besides its typical features, hypothyroidism comes to notice sometimes with neurologic features like reversible cerebellar ataxia, dementia, peripheral neuropathy, coma, etc. Therefore hypothyroidism should be suspected in all cases of cerebellar ataxia, as it is easily treatable. Objective. Here we illustrate a case of hypothyroidism initially reported with cerebellar ataxia. Case report. A 40 year-old male presented with history of gait-ataxia. His investigations revealed frank primary hypothyroidism with positive anti-TPO antibody. The patient was put on thyroxine and he improved completely within eight weeks. Conclusions. This case report emphasizes that hypothyroidism can present with ataxia as one of the initial features. Therefore, hypothyroidism should be considered in all cases of cerebellar ataxia as it is a reversible cause of ataxia

Context. Pheochromocytomas and paragangliomas (PCC/PGLs) are diagnosed variously with increasing incidence and changing clinical and pathology pattern. Objective. The aim was to further characterize PCC/PGLs in a stable population. Methods. A retrospective, single institution study analysed adrenalectomies for PCC/PGLs between January 2010 - January 2019. Demographics, symptoms, blood pressure, preoperative hormones, imaging, histology, hospital stay, complications and three subgroups [based on the modality of diagnosis - incidentaloma group (IG), genetic group (GG) and symptomatic group (SG)] were noted. Results. 86 patients included IG 51 (59.3%), GG 10 (11.62%) and SG 25 patients (29.06%). Incidence was 5.30 cases/1 million population. 33.34% of the IG had a delayed diagnosis with a mean interval of 22.95 months (4- 120 months). Females presented more often with paroxysmal symptoms (PS) (p=0.011). Patients with PS and classic symptoms were younger (p=0.0087, p=0.0004) and those with PS required more inotropes postoperatively (p=0.014). SG had higher preoperative hormone levels (p=0.0048), larger tumors (p=0.0169) and more likely females. GG are younger compared with those from the IG (p=0.0001) or SG (p= 0.178). Conclusion. Majority of patients had an incidental and delayed diagnosis. If symptomatic, patients are more likely to be young females with higher hormone levels and larger tumors.

The thyroid gland is one of the most vascularized organs in the body. However, metastatic disease to the thyroid gland is rare. When it does occur kidney is the most common primary tumor site, followed by melanoma, lung, breast, esophagus, uterus and colon carcinoma. We describe the case of an isolated thyroid metastasis from clear cell renal carcinoma occurring 16 years after nephrectomy. An 82 years-old woman presented for the recent growth of a right thyroid nodule, diagnosed 3 years before, when a fine needle aspiration biopsy found a benign cytology suggesting a well-differentiated follicular thyroid adenoma. Her medical history included type 2 diabetes mellitus, atrial fibrillation and a right nephrectomy for a clear cell renal carcinoma done 16 years before. The patient has lost weight but she was otherwise asymptomatic. The right lobe goiter was painless, firm, and mobile with deglutition, without signs of local compression or latero-cervical lymphadenopathy. Thyroid ultrasonography revealed an enlarged (9.9 cm) macronodular right lobe, with multiple cystic areas, with normal left lobe and a thrombus in the right internal jugular vein. Thyroid function tests were normal. The patient was suspected of thyroid carcinoma and underwent a near total thyroidectomy. Histopathological examination revealed a metastasis of clear cell renal carcinoma in the right thyroid gland lobe (8.5/5/5 cm). Further imaging showed no primary tumor or other metastases. Metastatic renal carcinoma to the thyroid should be considered in any patient presenting with a thyroid mass and a medical history of operated renal cell carcinoma, since it can occur up to 25 years after nephrectomy.

Endogenous hyperinsulinemia was found in a 38-yearold female patient with recurrent neuroglycopenic symptoms (the glucose level was 25 mg/dL, insulin 43.9 μ/mL, C-peptide 5.54 ng/mL). No lesion was found on imaging tests including enhanced computed tomography (CT) methods performed with a preliminary diagnosis of insulinoma. A suspicious hyperperfusion was present in the pancreatic tail on the perfusion CT examination performed after obtaining approval. The selective arterial calcium stimulation test (SACST) result was consistent with a diffuse disease in the body and tail. The patient underwent partial (75%) pancreatectomy and is now followed up as a diabetes patient on intensive insulin treatment at the postoperative 38th month. The most common cause of endogenous hyperglycemia in hypoglycemia patients is insulinoma. The noninsulinoma pancreatogenous hypoglycemia syndrome (NIPHS) is rarely seen in the adult age group. Although invasive, SACST seems to be the most suitable test to differentiate diffuse or multiple disease from insulinoma and to guide the surgery when advanced radiological imaging methods are inadequate to detect the presence of insulinoma. Regarding perfusion CT, it would be more appropriate to wait for comparative data to be put forward in a more consistent manner. When no response can be obtained to medical treatment in NIPHS, partial/total pancreatectomy is the most appropriate treatment option as it enables recovery from the hypoglycemic episodes despite leading to a significant condition like diabetes.

Radioactive iodine (RAI) therapy is a mainstay adjuvant treatment for thyroid cancer. Administration of RAI therapy after total or near-total thyroidectomy has shown a survival advantage in numerous properly selected patients. However, the role of RAI therapy after reoperation for persistent or recurrent differentiated thyroid carcinomas (DTCs) is unclear. One reason may be the possible downregulation of the I- transport system after primary surgery. RAI is transported by the sodium iodide symporter (NIS), PENDRIN, anoctamin 1 (ANO1) and cystic fibrosis transmembrane conductance regulator (CFTR) and emits β particles that destroy follicular cells. The identification of pathways of iodide (I-) transport has allowed use of the transport system to render tumours susceptible to RAI treatment via gene therapy. This review focuses on the effect of RAI therapy in follicular cell-derived thyroid cancers and offers potential novel targets that enable improved radioiodine uptake and thus an improved prognosis of thyroid cancer.