Ferihan Aral

Changes in bone turnover on deoxypyridinoline levels in diabetic patients

In this study, we evaluated bone turnover in 35 patients with non- insulin-dependent diabetes mellitus with no complications and in 35 healthy volunteers who formed the control group and whose ages matched those of the patients. We determined serum osteocalcin (OC) and total alkaline phosphatase levels as markers of bone formation, and urinary deoxypyridinoline (DPD) and urinary calcium levels as markers of bone resorption. Statistical comparison of the levels of these markers between sexes in diabetic and control groups revealed that the OC levels were significantly decreased in males and females in the diabetic group compared with those of the control group. No significant difference was observed for other markers. It was found that the OC levels of diabetic subjects were not affected by the type of therapy. No statistically significant difference was found in serum calcium, phosphorus and magnesium levels between the diabetic and the control groups. In our study, the finding that, in spite of the decrease in the OC levels in the diabetic group no difference was observed in DPD levels, was attributed to the fact that only the formation phase was affected in diabetes, while the resorption phase remained unaltered.

Bromocriptine-induced cerebrospinal fluid fistula in patients with macroprolactinomas : report of three cases and a review of the literature

Bromocriptine therapy for macroprolactinoma induced cerebrospinal fluid (CSF) rhinorrhea in three patients. The tumor had extended well beyond the sella turcica and caused bony erosion in all the cases. All three patients responded to bromocriptine therapy rapidly. CSF fistula occurred concomitantly with the reduction of tumor size and caused meningitis in two of the patients. Withdrawal of bromocriptine resulted in cessation of the leakage. One of the patients underwent transsphenoidal repair. Two patients refused surgery. This potentially lethal complication encountered in these three cases demonstrates the need for close supervision of macroprolactinoma patients with skull base erosion placed under bromocriptine therapy.

Risk factors of incidental parathyroidectomy after thyroidectomy for benign thyroid disorders

BACKGROUND Incidental resection of parathyroid tissue is not uncommon during thyroidectomy and may occur even in the hands of experienced thyroid surgeons. We aimed to investigate the clinical relevance of incidental parathyroidectomy and to determine which risk factors are important for it. PATIENTS Four hundred and forty consecutive patients with non-toxic multinodular goitre treated by total and near-total thyroidectomy were included prospectively in the present study. Patients in group 1 (n=48) had inadvertent resection of parathyroid gland, whereas patients in group 2 (n=392) did not have parathyroid glands removed. RESULTS There was a positive correlation between the incidental parathyroidectomy and total thyroidectomy (r(s)=0.519, p=0.0001), and thyroid pathology (r(s)=0.338, p=0.0001) and intrathyroid parathyroid locations. Incidental parathyroidectomy did not have an impact on postoperative hypocalcemia. The risk for incidental parathyroidectomy was increased 13-fold for patients who underwent total thyroidectomy (OR: 13.7; 95% CI:4.08-46.05), 4-fold for patients with substernal goitre (OR: 4.1; 95% CI: 1.1-14.3). CONCLUSIONS Total thyroidectomy, thyroid pathology, and intrathyroid parathyroid locations are risk factors for incidental parathyroidectomy. All established risk factors for incidental parathyroidectomy are also risk factors for postoperative hypocalcemia. Incidental parathyroidectomy during thyroid surgery may be a potential complication.

Investigation of early atherosclerotic changes in acromegalic patients

Background:  Functional and morphological changes of endothelium were risk factors for mortality attributed to atherosclerosis. Studies investigating early atherosclerotic alterations and the effect of the treatment of acromegaly on these alterations gave conflicting results.

The characteristics of concomitant thyroid nodules cause false-positive ultrasonography results in primary hyperparathyroidism

BACKGROUND Concomitant thyroid nodules are the most common reason for false-positive ultrasonography (US) results in primary hyperparathyroidism. The aims of this prospective clinical study were to evaluate false-positive US results according to the characteristics of concomitant thyroid nodules and to determine which characteristics of thyroid nodules are important. STUDY DESIGN This prospective study included 120 consecutive patients with primary hyperparathyroidism. The patients were divided into 2 groups according to preoperative US results. Group 1 consisted of 32 patients with false-positive US results and group 2 consisted of 88 patients with true-positive US results. RESULTS The risk for false-positive US result was increased 25-fold for patients with parathyroid adenoma weight of more than 500 mg (odds ratio [OR], 25; 95% confidence interval [CI], 8.6-74.5), 75-fold for more than 1 posteriorly located thyroid (OR, 75; 95% CI, 19.3-293.4), 358-fold for the presence of exophytic thyroid nodules (OR, 358; 95% CI, 42.3-3036), and 423-fold for the presence of posteriorly located thyroid nodules (OR, 423; 95% CI, 49-3662). CONCLUSION Although there was no particular characteristic of concomitant thyroid nodules that contributes to false-positive US results, the posteriorly located thyroid nodules were the strongest correlate for the false-positive US results to other features.

Comparison of 68Ga-DOTATATE PET-CT, 18F-FDG PET-CT and 99mTc-(V)DMSA scintigraphy in the detection of recurrent or metastatic medullary thyroid carcinoma

PurposeWe aimed to compare the efficacies of gallium-68 (68Ga) DOTATATE PET-computed tomography (CT), fluorine-18 fluorodeoxyglucose (18F-FDG) PET-CT and technetium-99m (99mTc)-(V)DMSA scintigraphy in the detection of residual/metastatic medullary thyroid carcinoma (MTC). Materials and methodWe retrospectively evaluated DOTATATE PET-CT, 18F-FDG PET-CT and (V)DMSA scintigraphy of 22 MTC patients, all taken within a 6-month period in each patient, because of high levels of calcitonin (Ct) and carcinoembryonic antigen (CEA). We investigated the relationships between the results of the imaging modalities and tumour marker levels and the sporadic versus hereditary nature of the disease, as well as the effect of imaging results on patient management. ResultsThe ages of the patients at diagnosis were between 20 and 69 years. The median levels of Ct and CEA were 871.5 pg/ml and 11.2 ng/ml, respectively. In the patient-based analysis, we observed at least one focus of abnormal uptake in 15 of 22 DOTATATE PET-CT (68.2% sensitivity), eight of 18 18F-FDG PET-CT (44.4% sensitivity) and five of 15 (V)DMSA scans (33.3% sensitivity). These data showed a significant difference between DOTATATE PET-CT and (V)DMSA scintigraphy (P=0.016), whereas the relationships between DOTATATE PET-CT and 18F-FDG PET-CT and between 18F-FDG PET-CT and (V)DMSA scintigraphy showed no significant differences (P>0.05). In the lesion-based analysis, 134 lesions were detected with DOTATATE PET-CT, 76 lesions with 18F-FDG PET-CT and nine lesions with (V)DMSA scintigraphy. ConclusionDOTATATE PET-CT is an efficient imaging modality in MTC patients with increased Ct and CEA (especially >1000 pg/ml and 50 ng/ml, respectively) for localizing recurrent or metastatic disease. 18F-FDG PET-CT can be performed if DOTATATE PET-CT is not available, but (V)DMSA scintigraphy is not recommended.

Pituitary infiltration by non-Hodgkin's lymphoma: a case report

IntroductionPituitary adenomas represent the most frequently observed type of sellar masses; however, the presence of a rapidly growing sellar tumor, diabetes insipidus, ophthalmoplegia and headaches in an older patient strongly suggests metastasis to the pituitary. Since the anterior pituitary has a great reserve capacity, metastasis to the pituitary and pituitary involvement in lymphoma are usually asymptomatic. Whereas diabetes insipidus is the most frequent symptom, patients can present with headaches, ophthalmoplegia and bilateral hemianopsia.Case presentationA 70-year-old woman with no previous history of malignancy presented with headaches, right oculomotor nerve palsy and diabetes insipidus. As magnetic resonance imaging revealed a sellar mass involving the pituitary gland and infundibular stalk, which also extended into the right cavernous sinus and sphenoid sinus, the patient underwent an immediate transsphenoidal decompression surgery. Her prolactin was 102.4 ng/ml, whereas her gonadotropic hormone levels were low. A low level of urine osmolality after overnight water deprivation, along with normal plasma osmolality suggested diabetes insipidus. Histological examination revealed that the mass had been the infiltration of a high grade B-cell non-Hodgkins lymphoma involving respiratory system epithelial cells. Paranasal sinus computed tomography scanning and magnetic resonance imaging of the thorax and abdomen were performed. Since magnetic resonance imaging did not reveal any abnormality, after paranasal sinus computed tomography was performed, we concluded that the primary lymphoma originated from the sphenoid sinus and infiltrated the pituitary. Chemotherapy and radiotherapy to the sellar area were planned, but the patient died and her family did not permit an autopsy.ConclusionLymphoma infiltration to the pituitary is difficult to differentiate from pituitary adenoma, meningioma and other sellar lesions. To plan the treatment of lymphoma infiltration of the pituitary gland, it must be differentiated from other sellar lesions.

Clinical and Radiological Features of Adrenal Cysts

Adrenal cysts are very rare lesions, usually asymptomatic or without characteristic symptoms. They are classified as pseudocysts, endothelial cysts, epithelial cysts or parasitic cysts. Although pseudocysts are reported to be the most common clinically recognized adrenal cysts in surgical series, endothelial cysts are more common in autopsy series. We studied 15 consecutive patients with adrenal cysts who underwent surgical resection at our institution from 1990 to 2005. Of 15 patients with adrenal cysts, 10 had pseudocysts, 3 epithelial cysts, 1 an endothelial cyst and 1 a parasitic cyst. In conclusion, a better understanding of cystic adrenal masses is necessary to recognize true adrenal cysts and differentiating them from adrenal carcinoma or adenoma by demonstrating the foci of cystic or degenerative changes.

An unusual patient with hypercalciuria, recurrent nephrolithiasis, hypomagnesemia and G227R mutation of Paracellin-1. An unusual patient with hypercalciuria and hypomagnesemia unresponsive to thiazide diuretics.

A 19-year-old female patient with hypercalciuria and recurrent nephrolithiasis/urinary tract infection unresponsive to thiazide type diuretics is presented. The patient first experienced nephrolithiasis at the age of 4 years. Afterwards, recurrent passages of stones and urinary tract infection occurred. On diagnostic evaluation at the age of 19 years, she also had hypocitraturia and hypomagnesemia. Her serum calcium concentrations were near the lower limit of normal (8.5–8.8 mg/dl; normal range: 8.5–10.5), her serum magnesium concentrations were 1.15–1.24 mg/dl (normal range: 1.4–2.5) and urinary calcium excretion was 900 mg/24 h. PTH concentrations were increased (110–156 pg/ml; normal range: 10–65). We tried to treat the patient with hydrochlorothiazide at a dose of 50 mg/day. During treatment with thiazide diuretics, PTH concentration remained high and the patient had recurrent urinary tract infections and passages of stones. Serum magnesium concentration did not normalize even under the parenteral magnesium infusion. Her mother had a history of nephrolithiasis 20 years ago. Severe hypomagnesemia in association with hypercalciuria/urinary stones is reported as a rare autosomal recessive disorder caused by impaired reabsorption of magnesium and calcium in the thick assending limp of Henle’s loop. Recent studies showed that mutations in the CLDN16 gene encoding paracellin-1 cause the disorder. In exon 4, a homozygous nucleotide exchange (G679C) was identified for the patient. This results in a point mutation at position Glycine227, which is replaced by an Arginine residue (G227R). The mother was heterozygous for this mutation. G227 is located in the fourth transmembrane domain and is highly conserved in the claudin gene family. This case indicates the pathogenetic role of paracellin-1 mutation in familial hypomagnesemia with hypercalciuria and nephrocalcinosis and further underlines the risk of stone formation in heterozygous mutation carriers.

Management and follow-up results of an incidental thyroid carcinoma in a young woman with ovarian teratoma

Abstract Thyroid cancer in ovarian teratoma is reported to be rare and experiences are limited. A 26-year-old woman had undergone bilateral cystectomy and omentectomy for bilateral cystic adnexial masses. Pathological examination showed 1.5 cm follicular variant papillary thyroid carcinoma on the basis of unilateral mature cystic teratoma. Increased CA-125 and CA19-9 levels decreased to normal reference ranges after surgery, but postoperative magnetic resonance imaging indicated multiple abdominal cystic loci. After total thyroidectomy, high dose I-131 was administered to ablate thyroid tissue. Thereafter, levothyroxine was started to achieve subclinical hyperthyroidism. No iodine uptake was detected in post-therapeutic whole body scan (WBS) other than thyroid bed. This finding supported that tumor did not show dissemination to abdomen. No uptake on the first-year evaluation with low-dose I-131 WBS suggested the complete ablation of the thyroid gland. It is recommended that thyroid carcinoma arising from ectopic thyroid tissue in a teratoma should be managed as thyroid carcinoma in thyroid. However, direct dissemination to contiguous regions in abdomen and hematogenous dissemination to distant organs should be in mind. Radical surgery including total abdominal hysterectomy, bilateral salphingo-oopherectomy, pelvic and paraaortic lymph node excision and thyroidectomy is recommended. Fertility preserving surgery may be the surgical procedure as in the present case.