Alev Selek

The utility of preoperative acth/cortisol ratio for the diagnosis and prognosis of cushing's disease

Purpose: Cushings syndrome (CS) is a rare disease having diagnostic difficulties. Many diagnostic tests have been defined but none of these are diagnostic alone. Determination of the cause is another problem which sometimes requires more sophisticated and invasive procedures. Therefore, we aimed to evaluate the utility of pretreatment plasma adrenocorticotropic hormone (ACTH)/cortisol ratios in patients with confirmed endogenous CS for the diagnosis and differential diagnosis of CS. Materials and Methods: This retrospective evaluation included 145 patients with the diagnosis of CS, 119 patients with Cushings disease (CD), and 26 patients with ACTH-independent CS (AICS), in a university hospital. Furthermore, 114 individuals in whom CS diagnosis was excluded with at least one negative screening test were enrolled to the study as control group. The clinical, laboratory, imaging, postsurgical pathologic records and also clinical follow-up data of all patients were evaluated. Results: The median basal ACTH/cortisol ratio of the patients with CD was significantly higher than AICS and controls. A cutoff ACTH/cortisol ratio >2.5 was found to be diagnostic for CD with 82% specificity and 63% sensitivity. Among CD group, patients with recurrent disease had higher preoperative ACTH levels and ACTH/cortisol ratio than patients with sustained remission. Furthermore, these patients had more invasive, atypical, and larger tumors. Conclusion: An ACTH/cortisol ratio >2.5 would be beneficial to diagnose CD together with other diagnostic tests. It is a simple test with no additional cost. Higher ratios might be related with larger, invasive, and atypical adenoma and also might be helpful to predict recurrence.

Thyroid autoimmunity: is really associated with papillary thyroid carcinoma?

The incidence of thyroid cancer has been greatly increasing. Several studies aimed to investigate biomarkers for prediction of thyroid cancer. Some of these studies have suggested that thyroid autoantibodies (TAb) could be used as predictors of thyroid cancer risk, but the correlation between TAb and PTC is still a matter of debate. The aim of this study is to evaluate thyroid autoimmunity and TAbs in patients with PTC and benign multinodular goiter (MNG) to investigate if TAbs and autoimmune thyroid disease (ATD) could predict thyroid malignancy. A total of 577 patients with thyroid papillary carcinoma (PTC) and 293 patients with benign MNG disease were enrolled postoperatively. Demographic features, thyroglobulin (TgAb) and thyroid peroxidase antibodies (TPOAb) and histologic outcome of the patients were evaluated. The prevalence of ATD and TgAb or TPOAb measurements was not statistically different in PTC and MNG groups. However, tumors were significantly smaller and tumor capsule invasion was seen less frequently in patients with PTC and ATD than without ATD. Patients without ATD had more advanced stage (TNM stage III/IV) tumors than with ATD. Only one of the 11 patients with distant organ metastasis had ATD. The present study demonstrated that the prevalence of ATD diagnosed even with histology or TAb positivity was not different in patients with PTC and MNG. However, having ATD might be associated with a better prognosis in PTC patients.

Histologic outcome of thyroid nodules with repeated diagnosis of atypia in thyroid fine-needle aspiration biopsy.

AIM We hypothesized that the estimated risk of malignancy for atypia of undetermined significance/follicular lesion of undetermined significance (AUS/FLUS) is higher than anticipated in Bethesda system. Therefore, we analyzed the actual malignancy risk of repeated AUS/FLUS diagnosis of thyroid fine-needle aspiration biopsies (FNAB). MATERIALS & METHODS We reported retrospective analyzes of 112 cases with repeated AUS/FLUS diagnosis among 10,769 thyroid FNABs. The histologic follow-up were evaluated in the study. RESULTS 112 cases with a repeated diagnosis of AUS/FLUS, histologic follow-up revealed 56 (50%) benign, 46 (41%) malignant and ten (9%) well-differentiated tumors of uncertain malignant potential outcome. CONCLUSION The malignancy risk of AUS/FLUS category in thyroid FNABs was higher than anticipated in Bethesda system. Therefore, the management strategy of AUS/FLUS should be revised.

Kyphoscoliosis of an acrogigantic patient treated by pedicle subtraction osteotomy and posterior pedicle instrumented fusion

Acromegaly is a disorder of disproportionate skeletal, tissue, and organ growth, with a prevalence of 40–70 cases per million persons and an annual incidence of three to four new cases per million persons [1]. A small proportion of patients may develop gigantism if growth hormone (GH) exposure occurs before epiphyseal plate closure. Besides the local mass effect of pituitary tumor, disease pathogenesis involves GH hypersecretion by tumorous pituitary somatotrophic cells and results in multiple metabolic and structural dysfunctions. Up to 21 % of patients exhibit kyphoscoliosis [2]. Surgery and medical and radiation therapy have specific advantages and disadvantages that should be weighed and tailored very carefully for each patient. No single algorithm applies to all patients [3]. Large retrospective studies of acromegaly patients indicate an average 10-year reduction in life expectancy, with at least doubling of standardized mortality rates due to cardiovascular, cerebrovascular, metabolic, and respiratory comorbidities [4]. Recent studies reflect the positive impact of multimodal therapy on mortality outcomes [5]. It has even been suggested that normal insulin-like growth factor (IGF) level in patients with acromegaly predict a normal expected mortality rate [6]. The negative impact of sagittal malalignment with regard to disability, pain, and poor health-related quality of life has been well documented [7]. Spinal osteotomy and pedicle-screw instrumentation combination have demonstrated excellent radiographic and clinical outcomes for correcting sagittal malalignment [8]; to our knowledge, however, it has not been reported in kyphoscoliotic deformity of an acrogigantic patient. Whereas structures at risk when using a pedicle screw seem similar to those in patients with other types of spinal deformities, decreased vascular resistance [9–11] and fragile aorta [12] pose significant risk of aorta rupture in the surgical correction of sagittal malalignment with osteotomy in acrogigantism. The purpose of this case report is to discuss patientspecific risk factors and vertebral morphology for efficient and safe pedicle fusion and subtraction osteotomy (PSO) in an acrogigantic patient with kyphoscoliosis.