Nese Colak

The Use of the Bethesda Terminology in Thyroid Fine-Needle Aspiration Results in a Lower Rate of Surgery for Nonmalignant Nodules A Report From a Reference Center in Turkey

The Bethesda system (BS) for reporting thyroid fine-needle aspiration (FNA), which classifies nodules as nondiagnostic (ND), benign (B), atypia/follicular lesion of undetermined significance (AUS/FLUS), suspicious for follicular neoplasm (SFN/FN), suspicious for malignancy (SFM), or malignant (M), uses clinically valuable management guidelines. The authors employed a similar in-house classification system (IS) for thyroid FNAs, using the categories of ND, B, suspicious follicular cells (SFC), follicular lesion/neoplasm (FL/FN), SFM, and M. The authors compared IS and BS, and assessed the utility of BS in clinical practice. A total of 581 nodules with cytological/histological follow-up were examined and indeterminate lesions by BS were reclassified. The sensitivity and specificity for malignancy using IS were similar to that of BS (77% vs 99%). However, when SFN/FN and SFM were both considered positive, the results for IS and BS were as follows: sensitivity, 85% versus 85%; specificity, 87% versus 94%; and diagnostic accuracy, 86% versus 90%, respectively. Discrepancies between cytological and histological data were evident in 35 cases among all categories of BS except AUS/FLUS. The rate of surgery for nonmalignant nodules was lesser (20% vs 9%) by BS. Among 34 AUS/FLUS cases with follow-up data, hypocellularity was the case in 11 (46%) nonneoplastic and 10 (100%) neoplastic nodules. The use of BS results in a lower rate of surgery for nonmalignant nodules even though patients with borderline cytopathologic features are still encountered. AUS/FLUS category can be separated into subgroups according to the factors causing difficulties in the interpretation. There is a need of accumulation of AUS/FLUS cases to do further evaluations and studies.

Multiple gastrointestinal stromal tumors and pheochromocytoma in a patient with von Recklinghausen's disease

INTRODUCTION Neurofibromatosis type 1 is a genetic disease characterized by neoplastic and non neoplastic disorders involving tissues of neuroectodermal and mesenchymal origin. Herein, we present a case with von Recklinghausens disease, right adrenal heochromocytoma and multiple gastrointestinal stromal tumors. PRESENTATION OF CASE A forty-eight year old male patient was admitted to our Emergency Department with melena. His physical examination revealed multiple neurofibromas all over the skin, kyphosis, multiple cafe au lait spots and Lisch nodules on the eye and, melena on digital rectal examination. Abdominal computerized tomography scan showed a mass on right adrenal gland and multiple soft tissue mass lesions between distal part of pancreas and small bowel. Adrenal mass was determined as a pheochromocytoma and small bowel lesions were verified as stromal tumors. DISCUSSION In patients with NF1, pheochromocytomas and GISTs are well known neoplasms seen with increased incidence than the general population. CONCLUSION In patients with NF1, any symptoms with other systems should be managed carefully for underlying malignity.

Thyroid hormone receptor beta gene mutation (P453A) in a family producing resistance to thyroid hormone.

BACKGROUND Resistance to thyroid hormone (RTH) is a dominantly inherited syndrome characterized by decreased responsiveness of target tissues to thyroid hormone. Two members of a Turkish family, a mother and son, had thyroid function tests suggestive of resistance to thyroid hormone (RTH). METHODS The clinical presentation was, however, different. The mother (proposita) had palpitation, weakness, tiredness, nervousness, dry mouth and was misdiagnosed as having multinodular toxic goiter which was treated with antithyroid drugs and partial thyroidectomy. Her younger son had attention deficit hyperactivity disorder and primary encopresis, but normal intellectual quotient. Both had elevated serum iodothyronine levels with nonsuppressed thyrotropin. RESULTS A mutation in one allele of the thyroid hormone receptor beta gene (P453A) was identified, providing a genetic confirmation for the diagnosis of RTH. CONCLUSION Mutational analysis of the TRss gene allows definitive diagnosis of RTH, potentially avoiding the need for protracted and expensive pituitary function testing.

Radio-guided excision of parathyroid lesions in patients who had previous neck surgeries: A safe and easy technique for re-operative parathyroid surgery

BACKGROUND Several methods have been recommended to detect parathyroid lesions in patients who have previously undergone neck surgeries, including radio-guided surgery or intraoperative ultrasounds. In this study, we aimed to investigate whether the radio-guided excision of pathologic parathyroid lesions allowed us to find affected lesions in patients who had previously undergone neck operations. METHODS This prospective study included 18 patients with primary hyperparathyroidism who had previously undergone neck surgeries. The pathologic parathyroid lesions were localized by ultrasonography, and a radiotracer was injected directly into the lesions. RESULTS Careful dissections were carried out by following the area of maximum radioactivity until the lesions were identified and excised. Eighteen parathyroid adenomas were removed in 18 patients. The median count from each lesion was significantly higher than the values measured from the adjacent tissues and the lesion beds (12550/20 s, 370/20 s, and 35/20 s, respectively; p < 0.001). CONCLUSION Radio-guided excision of parathyroid lesions can be performed safely for re-operative parathyroid surgery.

Pituitary Metastasis of Breast Carcinoma

Rarely, primary carcinomas can metastasize to the pituitary. Mostly the posterior lobe is affected and diabetes insipidus can develop. We report a 47-year-old woman who was on follow-up for metastatic breast carcinoma and admitted to the endocrinology unit for polyuria and polydypsia, which had worsened gradually. Her laboratory findings were compatible with diabetes insipidus. Magnetic resonance imaging revealed a huge mass involving the suprasellar cistern, surrounding the cavernous sinus and compressing the optic chiasm and infundibulum. Radiotherapy for the sellar region and chemotherapy were performed and desmopressin was started. The symptoms were controlled with desmopressin. Increased amounts of urine output and oral fluid intake in a patient with a diagnosis of carcinoma should alert the physicians of a possibility of pituitary metastasis, and the hormonal insufficiency should be corrected to increase the patient’s quality of life.