Neslihan Cuhaci

Gynecomastia: Clinical evaluation and management

Gynecomastia is the benign enlargement of male breast glandular tissue and is the most common breast condition in males. At least 30% of males will be affected during their life. Since it causes anxiety, psychosocial discomfort and fear of breast cancer, early diagnostic evaluation is important and patients usually seek medical attention. Gynecomastia was reported to cause an imbalance between estrogen and androgen action or an increased estrogen to androgen ratio, due to increased estrogen production, decreased androgen production or both. Evaluation of gynecomastia must include a detailed medical history, clinical examination, specific blood tests, imaging and tissue sampling. Individual treatment requirements can range from simple reassurance to medical treatment or even surgery. The main aim of any intervention is to relieve the symptoms and exclude other etiological factors.

Evaluation of biochemical and clinical markers of endothelial dysfunction and their correlation with urinary albumin excretion in patients with type 1 diabetes mellitus

Objective Endothelial dysfunction (ED) plays an important role in the pathogenesis of diabetic nephropathy. The purpose of the study was to determine flow mediated endothelial dependent vasodilatation (FMD) measurements and serum soluble (s) endothelin-1 (ET-1), intercellular adhesion molecule-1 (ICAM-1) and vascular cell adhesion molecule (VCAM-1) levels in patients with type 1 diabetes mellitus (T1DM) with or without increased urinary albumin excretion (UAE) and compare them with the healthy controls. Subjects and methods Seventy three patients with T1DM were enrolled. Patients were divided into two subgroups according to microalbumin measurements in 24-hr urine collections. The diabetic patients without microalbuminuria (41 patients) were defined as Group I and those with microalbuminuria (32 patients) were defined as group II. A hundred age and sex matched healthy subjects participated as the control group (Group III). Serum sET-1, sICAM-1, sVCAM-1 levels and FMD measurements were determined in all participants. Results Median FMD measurement was significantly lower in the diabetic groups compared with the control group (6.6, 6.4 and 7.8% in Group I, II and III, respectively) (p < 0.05). FMD was negatively correlated with age (p = 0.042). Median serum sICAM-1 level was higher in the patient groups compared to the control group (p < 0.05). Median serum sVCAM-1 level was higher in the group of patients with increased albuminuria compared to the normoalbuinuric and the control group (p < 0.05). Serum sVCAM-1 level was found to be positively correlated with degree of urinary albumin excretion (p < 0.001). Conclusion We assume that sVCAM-1 may be used as a predictive marker for risk stratification for nephropathy development and progression.

Effective treatment of severe pregnancy and lactation-related osteoporosis with teriparatide: case report and review of the literature

Abstract Pregnancy or lactation-related osteoporosis (PLO) is a very rare and debilitating condition which is usually diagnosed during the last trimester of the pregnancy or early postpartum period. Herein, we report a case with severe PLO and multiple vertebral compression fractures that were successfully treated with teriparatide. Twenty-three-year-old female patient was admitted to our clinic two months after her first spontaneous vaginal delivery with the complaint of severe back pain. Bone mineral density was measured using dual energy X-ray absorptiometry (DEXA), and low T- and Z-scores were observed in lumbar vertebras. In vertebral MRI, severe height loss was detected in thoracic (T) 5,7,10,11,12 vertebras. After exclusion of the other possible causes of OP, she was diagnosed to have PLO and the lactation was stopped. She was treated with calcium 1000 mg/day, cholecalciferol 800 mg/day and teriparatide 20 µg/day. At the 12th and 18th month of therapy, BMD was increased by 8% and 27%, respectively, at the lumbar spine and pain was completely relieved in few months. There are pharmacological therapy modalities that can be used in PLO. Bisphosphonates are effective, but there are some concerns that they accumulate in bone and may expose fetus in subsequent pregnancies. Teriparatide is a strong candidate to be the optimal medical therapy in severe cases since it is effective and safe.

THYROID NODULES WITH 2 PRIOR INADEQUATE FINE-NEEDLE ASPIRATION RESULTS: EFFECT OF INCREASING THE DIAMETER OF THE NEEDLE

OBJECTIVE The major limitation of ultrasound-guided fine-needle aspiration biopsy (US-FNAB) procedures of thyroid nodules are the cytologically nondiagnostic results. The role of increasing the diameter of the needle in the third FNAB (FNAB#3) due to inadequate cytology has as yet not been investigated. The aim of the present study was to evaluate whether increasing the needle diameter could improve the cytologic sampling of thyroid nodules following 2 previous nondiagnostic US-FNAB results. METHODS Between July 2012 and December 2012, 140 consecutive patients with 2 prior nondiagnostic US-FNAB results were enrolled in this prospective investigation. Group 22G consisted of 70 patients (78.5% women; mean age, 52 years) having nodules examined with a 22-gauge (G) needle. Group 27G consisted of 70 patients (75.7% women; mean age, 53 years) having nodules examined with a 27-G needle. RESULTS The rate of nondiagnostic FNAB results was 42.8% (30 of 70) in group 22G and 64.3% (45 of 70) in group 27G, which was a significant difference (P = .011). The large-bore (22 G) needle was found to be statistically significantly superior compared with the small-bore (27 G) needle in diagnostic ability for predominantly solid (P = .014), irregular (P = .013), and halo-free (P = .021) nodules. The accuracy rate was 64.6 and 38% for large-bore (22 G) and small-bore (27 G) needles, respectively. CONCLUSION The results of our study showed that increasing the needle lumen diameter significantly improves diagnostic performance in terms of adequate aspirated material and diagnostic accuracy rate following 2 prior nondiagnostic US-FNABs.

Evaluation of cytopathological findings in thyroid nodules with macrocalcification: macrocalcification is not innocent as it seems

OBJECTIVE Microcalcification is strongly correlated with papillary thyroid cancer. It is not clear whether macrocalcification is associated with malignancy. In this study, we aimed to assess the result of fine needle aspiration biopsies (FNAB) of thyroid nodules with macrocalcifications. SUBJECTS AND METHODS We retrospectively evaluated 269 patients (907 nodules). Macrocalcifications were classified as eggshell and parenchymal macrocalcification. FNAB results were divided into four groups: benign, malignant, suspicious for malignancy, and non-diagnostic. RESULTS There were 79.9% female and 20.1% male and mean age was 56.9 years. Macrocalcification was detected in 46.3% nodules and 53.7% nodules had no macrocalcification. Parenchymal and eggshell macrocalcification were observed in 40.5% and 5.8% nodules, respectively. Cytologically, malignant and suspicious for malignancy rates were higher in nodules with macrocalcification compared to nodules without macrocalcification (p = 0.004 and p = 0.003, respectively). Benign and non-diagnostic cytology results were similar in two groups (p > 0.05). Nodules with eggshell calcification had higher rate of suspicious for malignancy and nodules with parenchymal macrocalcification had higher rates of malignant and suspicious for malignancy compared to those without macrocalcification (p = 0.01, p = 0.003 and p = 0.007, respectively). CONCLUSIONS Our findings suggest that macrocalcifications are not always benign and are not associated with increased nondiagnostic FNAB results. Macrocalcification, particularly the parenchymal type should be taken into consideration.

Evaluation of Postural Parathyroid Hormone Change in Patients with Primary Hyperparathyroidism

Purpose. In the present study, we aimed to investigate postural change of PTH in normal individuals and in patients with primary hyperparathyroidism (PHPT). Methods. Twenty-two patients with PHPT and nine healthy controls were enrolled. Following 12 h of fast, patients stayed in recumbent position for an hour and PTH and total Ca measurements were performed at the 45th and 60th minutes of resting. Afterwards, the patients resumed an upright posture for an hour and again blood samples were taken at the 45th and 60th minutes of standing. Results. In the PHPT group, mean PTH was calculated as 153.9 pg/mL in the recumbent position while it was 206.3 during upright position (Δ change was 47.7) (P < 0.001). In the control group mean serum PTH was measured as 41.2 pg/mL in the recumbent position while it was 44.8 pg/mL in the upright position (Δ change was 1.7) (P = 0.11). In both groups, serum Ca was higher in the upright position compared to the recumbent position (P < 0.001). Conclusion. Postural change of serum PTH is significant only in PHPT group. Postural PTH test may give a clue to the clinician when the diagnosis of PHPT is equivocal.

Can ratio of the biggest tumor diameter to total tumor diameter be a new parameter in the differential diagnosis of agressive and favorable multifocal papillary thyroid microcarcinoma

OBJECTIVES In this study, we aimed to evaluate the usefulness of a new parameter -ratio of the biggest tumor diameter to total tumor diameter- for the differentiation of agressive and favorable papillary thyroid microcarcinomas (PTMC). MATERIALS AND METHODS The diameter of the biggest tumor focus was taken as the primary tumor diameter. Total tumor diameter was calculated as the sum of the maximal diameter of each lesion. Ratio of primary tumor diameter to total tumor diameter was defined as tumor diameter ratio (TDR). Positive and negative predictive value, sensitivity and specificity of TDR to predict capsular invasion, extrathyroidal extension (ETE) and lymph node metastasis (LNM) were determined. RESULTS Mean TDR was significantly lower in multifocal PTMC patients with capsular invasion, ETE, lymphovascular invasion and LNM compared to patients without these features. The sensitivities of TDR for the detection of LNM, ETE and capsular invasion were 100%, 100% and 94.2%, respectively. Specificity of TDR was 86.2% for LNM, 88% for ETE and 94.7% for capsular invasion. Best cut off values of TDR that can predict capsular invasion, ETE and LNM in multifocal PTMC were 0.62, 0.57 and 0.56, respectively. Multifocal papillary thyroid carcinoma patients with capsular invasion, ETE and LNM had significantly lower mean TDR when compared to ones without these features. CONCLUSION Decreased TDR was associated with capsular invasion, ETE and LNM in patients with multifocal PTMC and PTC. This new parameter might be particularly helpful for the detection of aggressive behavior in multifocal PTMCs.

Idiopathic adrenal hematoma mimicking neoplasia: A case report

Highlights • Adrenal haemorrhage is a relatively rare condition.• An adrenal hematoma should be kept in mind when adrenal masses assessing.• In idiopathic adrenal hematoma cases, there is not a specific ethology.

Nonclassical Congenital Adrenal Hyperplasia and Pregnancy

Objective. The most common form of congenital adrenal hyperplasia (CAH) is 21-hydroxylase (21-OH) deficiency due to mutation of the CYP21A2 gene. Patients with nonclassical CAH (NC-CAH) are usually asymptomatic at birth and typically present in late childhood, adolescence, or adulthood with symptoms of excessive androgen secretion. Subfertility is relative in NC-CAH, but the incidence of spontaneous miscarriage is higher. Here, we report a previously undiagnosed female who gave birth to a normal male child and is planning to become pregnant again. Case Report. A 32-year-old female was referred to our clinic for obesity. Her medical history revealed that she had had three pregnancies. She was planning to become pregnant again. Her laboratory results revealed that she had NC-CAH. Since her husband is the son of her aunt and she had miscarriages and intrauterin exitus in her history, their genetic analyses were performed. Conclusion. Since most patients with NC-CAH have a severe mutation, these patients may give birth to a child with the classical CAH (C-CAH) if their partner is also carrying a severe mutation. Females with NC-CAH who desire pregnancy must be aware of the risk of having an infant with C-CAH.

Does testosteron have an effect on bone mineral density in postmenopausal women

Background: Osteoporosis is a common problem in postmenopausal women. There is limited data about the physiological importance of endogenous testosterone (T) on bone mineral density (BMD) in older women is poorly understood. Aim: The aim of this study was to evaluate association of endogeneous T with BMD and body mass index( BMI ). Materials-methods: This cross-sectional study included 64 patients (45-85 year) postmenopausal women; their demographic features, BMD and serum total testosteron levels and relationship between T and BMD were evaluated. When the patients divided into three cathegories according to BMD; Group 1A: normal; Group 1B:osteopenic; Group 1C:osteoporotic (Table 1) Results: Serum total testosterone levels were found not to be correlated with BMD. We didn’t find any differences in serum testosterone levels between three BMD groups. Conclusion: This study suggests that endogenous androgens are influential on bone density in postmenopausal women. However, we didn’t find any relationship. Effects of endogenous testosterone level on BMD is controversial. Table 1. Demographic parameters and laboratory results of three groups. Group 1A (n=22) Group 1B (n=21) Group 1C (n=21) P-value Age (years) 54±6.3 56±7.9 58±1.0 0.058 Menopausal age 46±4.0 44±5.4 43±6.6 0.131 Height (cm) 158±6.2 1.58±4.9 155±6,1 0.304 Weight (kg) 75±13.4 71±15.0 68±12.5 0.383 BMI (kg/m2 ) 30.5±5.1 28±5.3 27.6±4.3 0.450 Calcium (mg/dl) 9.45±0.56 9.40±0.42 9.40±0.57 0.984 Phosphorus (mg/dl) 3.7±0.79 3.6±0.59 3.5±0.48 0.684 Albumin (g/dL) 4.4±0.31 4.3±0.40 3.5±0.48 0.933 PTH (pg/mL) 55.1±2.98 60±3.5 43.6±1.37 0.045 25-OH D vit (μ/L) 21.5±16.3 24.8±13.8 23.7±14.2 0.986 Testosterone (ng/dL) 38.6±20.2 27.1±14.7 28.6±19.2 0.712