Gorana Mirošević

Intrathyroid Parathyroid Carcinoma with Intrathyroidal Metastasis to the Contralateral Lobe: Source of Diagnostic and Treatment Pitfalls

Intrathyroidal parathyroid carcinoma is extremely rare clinical entity with potentially multiple diagnostic pitfalls. We report a case of 40-year-old man presented with classical manifestations of primary hyperparathyroidism, severe hypercalcemia and profoundly increased serum parathyroid hormone level. Neck ultrasonography demonstrated multinodular goiter with predominant 34 mm nodule in left thyroid lobe. Additional 16 mm nodule was found beneath the left lobe. Routine percutaneous fine-needle aspiration of predominant nodule indicated follicular thyroid carcinoma, while left inferior nodule was confirmed to be of parathyroid origin. The patient underwent surgery, during which frozen sections identified medullary thyroid carcinoma with metastasis to upper mediastinal lymph node. Permanent sections of the predominant left lobe nodule revealed intrathyroidal parathyroid carcinoma surrounded with multiple microscopic metastases. Left inferior nodule was metastatic lymph node. Additional 10 mm intrathyroidal metastasis of primary parathyroid carcinoma was found within right thyroid lobe. This case indicates that fine-needle-aspiration and intraoperative biopsy are of limited value in diagnosing parathyroid carcinoma, especially if localized intrathyroidally. Oncological en-block resection is treatment of choice, implying ipsilateral lobectomy in case of thyroid invasion. This firstly described case of intrathyroidal parathyroid carcinoma causing intrathyroidal dissemination may influence future treatment strategies.

Decrease in insulin resistance has a key role in improvement of metabolic profile during intragastric balloon treatment

To the Editor, Obesity is a chronic polygenic disease in most cases [1]. Despite the different pathogenesis, all obese individuals have something in common: low growth hormone (GH) levels and increased insulin levels [2]. This hormonal imbalance plays an important role in other metabolic disorders, such as glucose intolerance and dyslipidemia. Adipose tissue mass is also important factor. It is an endocrine organ that secrets several metabolic hormones and proinflammatory cytokines. The intensity of their secretion positively correlates with adipose tissue mass [3]. Weight loss improves metabolic profile, although the exact mechanism is poorly understood. A detailed study regarding this matter was published only 1 year ago. The authors disclosed that diet-induced weight loss increases GH and ghrelin levels and decreases insulin and leptin levels [2]. However, neither one study analyzed parallel changes in metabolic hormones and metabolic profile in short time intervals during weight loss. Hence, the exact causative relations between these hormones are unknown. BioEnterics intragastric balloon (BIB) is a endoscopic method in obesity treatment. The balloon placed in the stomach delays stomach emptying and enhances the feeling of satiety [4]. We aimed to investigate changes in serum insulin, C-peptide, GH, blood glucose, glycated hemoglobin, insulin resistance and lipid profile in first, third and sixth month after BIB placement. Since our previous study showed that the change in ghrelin and leptin levels during BIB treatment considerably depends on body mass index (BMI) [5], we analyzed those changes separately in obese (BMI \40 kg/m) and morbid obese (BMI \40 kg/m) patients.

Changes in metabolic hormones after bariatric surgery and their predictive impact on weight loss

Although various metabolic hormones have been implicated in bariatric‐related weight loss, their use as predictors of weight loss is unknown. Our study evaluates changes in metabolic hormones after bariatric surgery, and their role as predictors of weight loss.

The possible role of stress induced hormonal disbalance in the patophysiology of insulin resistane in lean individuals

Insulin resistance (IR) is a common denominator of metabolic and hemodynamic disorders simultaneously present in one person and responsible for elevated risk of developing type 2 diabetes (T2DM) and cardiovascular incidents. According to the latest research, IR is present in 25-45% of the general population. Therefore, the mechanism of its development is in the center of scientific and professional interest. Established or acquired factors, or combinations thereof, which disturb any step of the physiological insulin action mechanism: its binding to the cellular receptor, through the complex cascade of intracellular signaling pathways might cause IR. Although the adiposity and its underlying risk factors are considered to be the primary cause of IR, it is present in a great porportion in lean individuals as well. There are insights of the possible role of psychological factors: exposure to stress and deprssion to IR development, although the mechanism of this relationship has not been comperhensively studied. Data driven from cell cultures and experimental animal models suggest that there is an elevated level of counter-regulatory insulin hormones: growth hormone, prolactin and cortisol due to acute stress exposure. However, the relationship between these psychological disorders with the hyperreactivity of the axis of the hypothalamic-pituitaryadrenal axis as the underlying mechanism in the patophysiology of IR in lean individuals has not been systematically investigated. Based on the aforementioned, we hypothesise that this mechanism would be responsible for the formation of IR, and consequently, T2DM in lean individuals. The possible effect of the amount of stress in conjunction with the serum concentration of growth hormone, cortisol, prolactin and dehydroepiandrostendone to the abnormal 5-h oral glucose tollerance test results could contribute to the primary prevention of diabetes and its complications.

Should We Inspect Small Intestine During Laparoscopic Bariatric Surgery

Dear Editor, General agreement exists that all patients should undergo upper gastrointestinal endoscopy prior to bariatric surgery. Significant pathological findings are observed in approximately 20% of patients, and these may influence decisionmaking regarding the surgical procedure [1]. The majority of these patients had inflammatory disorders, but malignant tumors are also sometimes encountered. There are several reports on incidental finding of gastric carcinoma, gastrointestinal stromal tumors [2], carcinoids [3], and lymphoma [4]. However, preoperative examination of the small intestine is not feasible and colonoscopy is not routinely performed. A question regarding necessity of the inspection of the small intestine in patients undergoing bariatric surgery came to our minds after the case of one patient with incidental carcinoid tumor of the Meckel’s diverticulum. A 36year-old patient with body mass index of 43.5 kg/m underwent biliopancreatic diversion. Approximately 80 cm from the ileocecal valve, a Meckel’s diverticulum was noted, with no signs of inflammation or tumor. Thorough inspection of the abdominal cavity did not reveal any abnormalities. Meckel’s diverticulum was resected, and biliopancreatic diversion was performed according to Scopinaro’s standard procedure, with a 90-cm common channel. Pathohistological examination of the Meckel’s diverticulum disclosed two G1 (Ki67 <2%) carcinoid tumors (2 and 7 mm large), that were confound to the submucosa. Laboratory evaluation and computed tomography of the abdomen were performed 2 months after the surgery. Serum chromogranin A and urinary 5HIAA levels were normal, and computed tomography showed no signs of recurrence or metastases. During a 4year follow-up, the patient has lost a total of 60 kg (%WL of 34%), and his serum chromogranin A and urinary 5-HIAA are within normal range. Carcinoids of the Meckel’s diverticulum are rare. According to Surveillance, Epidemiology, and End Results (SEER) database, only 121 cases were detected until year 2011 in USA [5]. To the best of our knowledge, this is the first case of carcinoid of the Meckel’s diverticulum, that is incidentally found during bariatric surgery. We can only speculate on clinical course of this patient if intestinal carcinoids were not detected during bariatric surgery, which would probably be the case if we performed laparoscopic sleeve resection. This raises questions regarding the feasibility and the need for inspection of the small intestine during laparoscopic bariatric surgical procedures. Several studies have reported higher incidence of appendiceal carcinoids in obese patients undergoing bariatric surgery. Crea et al. reported that appendiceal carcinoids were found in 1.6% of patients who underwent bariatric surgery, which is substantially higher than those reported on autopsy series (0.6%) [6]. In the latter study, the presence of carcinoid tumor correlated positively with body mass index (BMI). Keshishian et al. reported three patients with small intestinal carcinoids, which were all found within 200 cm proximal to the ileocecal valve during gastric reduction-duodenal switch operation for the treatment of morbid obesity [7]. Interestingly, the prevalence of intestinal carcinoids in this * Ivan Kruljac ivkruljac@gmail.com

The Impact of Hyperosmolarity on Long-Term Outcome in Patients Presenting with Severe Hyperglycemic Crisis: A Population Based Study

AIMS We compared characteristics of patients with hyperglycemic hyperosmolar state (HHS) and patients with severe hyperglycemia without the signs of hyperosmolarity and ketoacidosis; analyzed long-term all-cause mortality and potential prognostic factors. METHODS The studied population included 261 749 adults. HHS was diagnosed in patients with plasma glucose >33.0 mmol/L, ketonuria <1+, and serum osmolarity >320 mmol/L. Patients with plasma glucose >33.0 mmol/L, ketonuria <1+ and serum osmolarity <320 mmol/L were considered as controls (nHHS). RESULTS During the 5-year period, we observed 68 episodes of HHS in 66 patients and 51 patients with nHHS. Patients with HHS were significantly older, had lower BMI, higher serum C-reactive protein and used diuretics and benzodiazepines more frequently. Mortality rates one, three and 12 months after admission were 19.0, 32.1 and 35.7% in the HHS group, and 4.8, 6.3 and 9.4% in the nHHS group (P<0.001). However, after adjustment for patient age, these differences were not statistically significant. In multivariate Cox regression in HHS group, mortality was positively associated with age, male gender, leukocyte count, amylase, presence of dyspnea and altered mental status, and the use of benzodiazepines, ACE inhibitors and sulphonylureas, while it was inversely associated with plasma glucose, bicarbonate, and the use of thiazides and statins. A nomogram derived from these variables had an accuracy of 89% in predicting lethal outcome. CONCLUSIONS Infection, use of furosemide and benzodiazepines may be important precipitating factors of HHS. Prospective clinical trials are mandatory to analyze the safety of ACE-inhibitors and benzodiazepines in elderly patients with diabetes.