Uğur Ünlütürk

Ultrasound Elastography Is Not Superior to Grayscale Ultrasound in Predicting Malignancy in Thyroid Nodules

BACKGROUND Several studies have evaluated the ability of ultrasound elastography (USE) to diagnose malignant nodules. However, these studies had important limiting factors, selection bias and small sample size. The aims of the present study were to prospectively assess, in a large group of patients, the diagnostic power of USE for detecting malignancy in thyroid nodules, and to compare this technique with B-mode grayscale ultrasonography (BUS) and power Doppler ultrasonography (PD). METHOD There were 194 patients with 237 thyroid nodules who were examined using BUS, PD, and USE. USE scores were classified according to the elasticity: score 1 as high, score 2 as intermediate, and score 3 as low (i.e., a high degree of stiffness). Fine-needle aspiration cytology (FNAC) was performed in all nodules at least two different times. Nodules having two benign FNAC readings that did not change the diameter during a 6-month follow-up period were classified as benign. Patients having thyroid nodules with indeterminate, suspicious, or malignant cytology had total or hemithyroidectomy to remove the nodule and treat the malignancy. RESULTS Fifty eight (25%) nodules in 45 (23%) patients were found to be malignant. USE had a limited sensitivity and a positive predictive value in detecting malignant thyroid nodules and was not superior to BUS. USE had almost the same specificity and a negative predictive value as BUS. A power Doppler type-3 pattern was not of sufficient sensitivity to detect malignancies in thyroid nodules. CONCLUSIONS In contrast to earlier reports, this current study noted a lower sensitivity and specificity of USE for the diagnosis of malignancy in thyroid nodules than previously reported.

Management of Differentiated Thyroid Cancer in the Presence of Resistance to Thyroid Hormone and TSH-Secreting Adenomas: A Report of Four Cases and Review of the Literature

BACKGROUND An increased or normal serum TSH concentration, despite elevated thyroid hormone levels, is observed in resistance to thyroid hormone (RTH) and TSH-secreting adenomas (TSHomas). When coexistent with a differentiated thyroid cancer (DTC), maintenance of a suppression of TSH is challenging. OBJECTIVES The aim of the study was to discuss the pitfalls arising from the failure to suppress TSH secretion in DTC and the strategies for proper treatment of DTC in association with RTH and TSHoma. METHODS Four unusual cases of DTC associated with TSHoma (2 cases), RTH (1 case), and an elevated TSH of unknown etiology (1 case) are presented, and the literature is reviewed. RESULTS Although a persistent mild TSH elevation may not be a risk factor for the development of DTC, it represents an important problem during the treatment of DTC. Aggressive treatment options should be applied in the proper order to prevent tumor recurrence and persistence in the absence of ideal TSH suppression. CONCLUSIONS Although there is no agreed consensus regarding the management of DTC in the presence of persistent hyperthyrotropinemia, complete tumor removal followed by radioablation and attempts to reduce the serum TSH to the lowest tolerable level are recommended. The outcomes in the reported cases have not been unfavorable, despite the persistence of nonsuppressed TSH.

The role of ultrasound elastography in preoperative localization of parathyroid lesions: a new assisting method to preoperative parathyroid ultrasonography.

Background  After the definition of minimally invasive procedures, preoperative localization of parathyroid lesions is now crucial. False‐positive results up to 30% were reported by B‐mode grayscale ultrasonography (US) in localization of parathyroid lesions. Parathyroid adenomas are relatively stiff lesions. Ultrasound elastography (USE) can accurately evaluate tissue stiffness and might detect the stiff parathyroid lesions.

Clinical significance of thyroid incidentalomas identified by 18F-FDG PET/CT: correlation of ultrasonograpy findings with cytology results.

AimThe aim of this study was to investigate the clinical importance of incidental focal or diffuse fluorine-18 fluorodeoxyglucose (18F-FDG) uptake in the thyroid gland on positron emission tomography (PET)/computed tomography (CT) and to evaluate the additive value of thyroid ultrasonography (US) in defining the malignancy potential of thyroid incidentalomas. Patients and methodsA total of 1450 patients, who had undergone a PET/CT scan for staging or restaging of various malignancies, were screened retrospectively and 52 (3.6%) patients with focal or diffuse 18F-FDG uptake in the thyroid gland on PET/CT were enrolled in the study. None of the patients had any history of thyroid diseases. Thyroid US with elastography for a thyroid nodule was performed for all the patients cross-sectionally. Thyroid fine-needle aspiration biopsy (FNAB) was also applied at the same time as the thyroid US to 34 patients with a nodule(s) 10 mm or more in diameter or less than 10 mm, but with malignancy potential ultrasonographically. The cytology results were compared with the thyroid US and 18F-FDG PET/CT findings. ResultsAlthough 39 patients had focal (group 1) 18F-FDG uptake in the thyroid gland, the remaining 13 patients had diffuse (group 2) uptake. In group 1, FNAB was performed in 32 patients. In 10 of 32 (31%) patients, FNAB results were concordant with malignant cytology (seven primary thyroid malignancy and three metastasis to thyroid). In group 2, in one of two patients who had undergone FNAB, malignant cytology (metastasis to thyroid) was detected. Although the difference between the maximum standardized uptake value (SUVmax) of malignant and benign nodules was statistically significant (10.2±8.9 vs. 5.6±3.0, P=0.013), the difference between the nodule sizes was not statistically significant (20.0±7.3 vs. 16.7±7.4, P=0.923). The presence of suspicious US findings and a high elastography score (≥4) were also statistically significant (P<0.001 and P=0.035, respectively). In the receiver–operator characteristic analysis, a 5.3 cut-off SUVmax was calculated with 82% sensitivity and 65% specificity for predicting malignant cytology. ConclusionFocal 18F-FDG uptake was associated with a higher prevalence of malignant thyroid nodule compared with diffuse 18F-FDG uptake. In particular, if a focal thyroid incidentaloma with high SUVmax (>5.5), suspicious US findings, and a high elastography score (≥4) is detected, a pathological diagnosis, either by histology or by cytology examination, should be made, especially when the patient has a long life expectancy.

Acute suppurative thyroiditis following fine‐needle aspiration biopsy in an immunocompetent patient

The thyroid gland is remarkably resistant to infectious agents owing to several protective mechanisms. Acute suppurative thyroiditis after fine‐needle aspiration (FNA) in an immunocompetent patient is very rare. We report the case of a 50‐year‐old immunocompetent male patient who presented with painful cervical swelling, fever, and chills after an FNA of the thyroid. His physical and laboratory examination suggested an acute suppurative thyroiditis. Repeat FNA results were consistent with thyroid abscess. Physicians should be aware of the probability of acute bacterial thyroiditis after FNA.

The Effect of Scrubbing Hands with Iodine-Containing Solutions on Urinary Iodine Concentrations of the Operating Room Staff

BACKGROUND Excessive iodine exposure is associated with thyroid dysfunction and thyroid autoimmunity. Most surgical hand-scrub solutions contain large amounts of iodine, and transcutaneous and mucosal absorption of iodine from these antiseptic solutions has been demonstrated. In this study we determined the effect of hand scrubbing with iodine-containing surgical hand-scrub solutions on urinary iodine concentrations (UICs) in operating room staff. METHODS The study included 117 surgeons and surgical nurses from two different hospitals who often used surgical hand-scrub solutions as the iodine exposure group and 92 age-matched hospital staff from nonsurgical units of the same hospitals as the controls. In the iodine exposure group, 39 subjects (from hospital 1) used iodine-containing hand scrub solutions intermittently, and the remaining 78 in the surgical staff (from hospital 2) used only iodine-containing hand-scrub solutions. Morning spot urine specimens were collected from all participants for the analysis of UIC. RESULTS The operating room staff had significantly higher UICs compared to the control group (142 μg/L [12-822 μg/L] vs. 89 μg/L [10-429 μg/L], p<0.001). UICs from 39% of the subjects from hospital 2 were found to reach levels higher than 300 μg/L. CONCLUSION Scrubbing with iodine-containing solutions might lead to iodine excess among surgical staff. Further studies investigating the effects of hand scrubbing with iodine-containing products on thyroid function and on thyroid antibodies of the operating room staff are needed to determine the consequences of this high iodine exposure.

Annexin V expression and anti-annexin V antibodies in type 1 diabetes.

BACKGROUND Annexin V (AnxV) has potent anticoagulant properties and regulatory functions for apoptosis and inflammation. Antibodies against annexin V (anti-AnxVs) may inhibit AnxV functions, leading to thrombosis during autoimmune diseases. Type 1 diabetes is an autoimmune disease and related with an ongoing autoimmune inflammation and thrombotic complications. There is no study evaluating anti-AnxVs/AnxV in a disease setting. OBJECTIVE The aim of this study was to evaluate the status of AnxV and anti-AnxVs in patients with type 1 diabetes. METHODS One hundred twenty-one patients with type 1 diabetes and 92 healthy controls were included in this study. Serum levels of AnxV and anti-AnxVs and expression of the AnxV gene and its common polymorphism in Kozak sequence (-1C>T) were studied. As a functional assay, the binding capacity of AnxV to platelets was evaluated. RESULTS As compared with controls, type 1 diabetic patients had significantly low serum AnxV levels and AnxV gene expression. The number of anti-AnxV positivity and their serum levels were significantly higher in type 1 diabetic patients than controls. AnxV binding to platelets were significantly decreased in the type 1 diabetic patients. The frequencies of the -1C>T polymorphism of AnxV gene did not differ between groups. CONCLUSIONS This study demonstrated the significant changes in AnxV levels and its function in type 1 diabetic patients. These results support the hypothesis that the defective AnxV system may have a role in ongoing autoimmune activity and the development of thrombotic complications in type 1 diabetes. Further studies are necessary to elucidate the clinical impact of anti-AnxVs and dysregulated AnxV function in type 1 diabetes.

Hypothyroidism, new nodule formation and increase in nodule size in patients who have undergone hemithyroidectomy

Introduction The current medical literature has conflicting results about factors related to hypothyroidism and nodular recurrences during follow-up of hemithyroidectomized patients. We aimed to evaluate factors that may have a role in new nodule formation, hypothyroidism, increase in thyroid lobe and increase in nodule volumes in these patients with and without Hashimotos thyroiditis (HT), and with and without levothyroxine (LT4) use. Material and methods We enrolled 140 patients from five different hospitals in Ankara and evaluated their thyroid tests, autoantibody titre results and ultrasonographic findings longitudinally between two visits with a minimum 6-month interval. Results In patients with HT there was no significant difference between the two visits but in patients without HT, thyroid stimulating hormone (TSH) levels and nodule volume were higher, and free T4 levels were lower in the second visit. Similarly, in patients with LT4 treatment there was no difference in TSH, free T4 levels, or lobe or nodule size between the two visits, but the patients without LT4 had free T4 levels lower in the second visit. Regression analysis revealed a relationship between first visit TSH levels and hypothyroidism during follow-up. Conclusions Patients who have undergone hemithyroidectomy without LT4 treatment and without HT diagnosis should be followed up more carefully for thyroid tests, new nodule formation and increase in nodule size. The TSH levels at the beginning of the follow-up may be helpful to estimate hypothyroidism in hemithyroidectomized patients.

Hyalinizing trabecular tumor in a background of lymphocytic thyroiditis: a challenging neoplasm of the thyroid.

OBJECTIVE To describe a case of hyalinizing trabecular tumor (HTT) in a background of lymphocytic thyroiditis that was misdiagnosed as papillary thyroid carcinoma (PTC) based on fine-needle aspiration (FNA) cytologic findings and overtreated with total thyroidectomy. METHODS We present a case report, including the imaging and pathologic findings, of a 68-year-old woman who presented with a multinodular goiter that was suspicious for PTC. RESULTS On the basis of FNA cytologic findings, she underwent a total thyroidectomy, and histologic examination of the thyroid gland revealed HTT in a background of lymphocytic thyroiditis. Radioiodine treatment was not administered because of the tumors low risk profile. No metastatic foci were established under nonsuppressive levothyroxine therapy after 3 years of follow-up. CONCLUSIONS HTT is a challenging entity because of the uncertainty of its nature, the diagnostic challenges, and the mimicry of other types of thyroid tumors. In order to avoid overtreatment, endocrinologists and thyroid surgeons should be aware of the features of HTT, and suspicious cases should be evaluated by experienced cytopathologists.

Course of aggressive somatotroph, corticotroph and mammotroph tumors under temozolomide; report of three cases and review of the literature

Treatment of aggressive pituitary tumors may be challenging. Temozolomide (TMZ) is a promising agent when conventional treatment methods fail. We present three patients with aggressive pituitary tumors with atypical morphology, who were resistant to conventional treatments and treated with TMZ. First case had a somatotroph adenoma, second a corticotroph adenoma, and the third a macroprolactinoma. We also reviewed the literature reporting TMZ efficacy in somatotroph, corticotroph and mammotroph tumors of pituitary. TMZ, 150-200 mg/m2 for 5 days in 28 days schedule was given to all patients. Among our patients, even though only the case of macroprolactinoma had a favorable response to TMZ treatment, both radiological and hormonal recurrences occurred 30 months after cessation of TMZ treatment. Then TMZ treatment was applied again. Cases of somatotroph and corticotroph adenomas had progressed under TMZ treatment and patients were lost due to mass effect of the tumor. Review of the literature demonstrated 67.3%, 60% and 26.7% overall response rates to the TMZ treatment in prolactinoma, corticotropinoma and somatostatinoma cases, respectively. There is still need to define response criteria uniformly to TMZ treatment in aggressive pituitary tumors and duration of response should be reported for reliable evaluation of results.