ACTA ENDOCRINOLOGICA (BUC)

Context. We report the use of subcutaneous somatostatin injection three times a day to decrease hypercortisolism in a patient who had Cushing’s syndrome induced by bronchial carcinoid tumour progressive pneumonia due to immune suppression. Subject and Method. A 46-yearold man with 7-month history of DM type-2, hypertension and cerebrovasculardisease, vertebral compression-fracture was admitted to our clinic. Physical examination was consistent with Cushing’s syndrome. Laboratory results revealed hyperglycemia (143 mg/dL; reference range, <100 mg/dL) and hypokalemia (2.29 mEq/L; reference range, 3.5-5.1 mEq/L). His morning serum cortisol was 40 μg/dL (reference range 6.7- 22.6 μg/dL), urine cortisol-excretion was 2245 μg/24 hours (reference range 58-403 μg/24 hours), after 1 mg dexamethasonesuppression test serum cortisol was 28 μg/dL (6.7-22.6 μg/dL) and ACTH 354 pg/mL (reference range 7.9-66 pg/mL). Adrenal CT and hypophyseal MRI were normal. An ectopic source was searched for Cushing’s syndrome. Chest CT scan of the right lung showed 12x9 mm nodule. High fever cough occurred on the followp. Chest radiograph revealed diffuse pneumonic infiltration. Despite 3-drug antibiotic combination therapy, infection did not improve. Subcutaneous injection of octreotide 3x100 μ/g was initiated to decrease hypercortisolism. The infection improved rapidly after the therapy. The morning serum cortisol, urine cortisol-excretion, ACTH was at the upper normal range (77.1 pg/mL, reference range 7.9-66 pg/mL) on 10th day of treatment. The patient was a consulted for surgery and the nodule was excised. The pathology was consistent carcinoid tumor. Conclusion. Subcutaneous octreotide treatment may be helpful to gain time for exploring the focus in ectopic cushing’s syndrome and to control the serious infections due to hypercortisolism.

Aim. We aimed to determine styles of coping with stress, emotion regulation skills, eating attitudes and quality of life in children with DM type-1 and comparison of findings with healthy children. In addition, it was aimed to investigate the relationship between these findings and the presence of psychopathology, emotion regulation skills and styles of coping with stress in their mothers. Method. The study included 70 diabetic,70 healthy children and their mothers. During the evaluation, the Children’s Depression Inventory, the Screen for Children Anxiety Related Disorders (SCARED), the Difficulties in Emotion Regulation Scale (DERS), the Eating Attitudes Test (EAT), the Pediatric Quality of Life Inventory (PedsQL) and Ways of Coping Inventory (COPE) were applied to all children. In addition, DERS, COPE, Beck depression and Beck anxiety scales were applied to all mothers. Results. It was found significantly more problems in diabetic group in the DERS-impulse subscale, COPEhelplessness, PedsQL-physical subgroup, EAT, SCARED scores experienced than the control group. In the scales applied to mothers of diabetic children, significantly higher scores were found in the DERS-nonacceptance subscale, deficits in emotional clarity subscale and impulse subscale, COPE-helplessness subgroup, and Beck Depression Scale. Conclusions. DM creates problems in patients' and mothers' emotional regulation skills and coping styles with stress; it also negatively affects the quality of life and eating attitudes of children.

Context. Prognostic considerations include assessing the risk of liver fibrosis in people with nonalcoholic fatty liver disease (NAFLD). Objectives. This study evaluates the use of hematologic and metabolic parameters regarding liver steatosis and fibrosis scores (FLI and Fib-4) in non-obese type 2 diabetes mellitus (t2DM) patients with NAFLD. Methods. Subjects underwent abdominal ultrasound examinations, and FLI and Fib-4 scores were calculated to evaluate liver steatosis and the risk of liver fibrosis non-invasively: 61 non-obese NAFLD subjects with t2DM were included in the cohort study and were divided into 2 groups depending on the t2DM treatment regimen. Results. Fib-4 and WBC count demonstrated a significant inverse correlation (OR = 0.509, p = 0.007). WBC count had an R2 of 0.237, indicating that this marker could account for up to 23.7% of a variation in Fib-4. Fib- 4 and FFA had positive correlation which did not achieve statistically significant prediction (OR=7.122, p=0.062). Additionally, a significant prediction of HbA1c (OR=1.536, p=0.016) and haemoglobin (OR=1.071, p=0.020) for FLI was revealed. Conclusion. HbA1c and other haematological and metabolic parameters, such as haemoglobin and WBC, may be another non-invasive tool for determining whether nonobese NAFLD patients with t2DM are at risk of developing liver steatosis and fibrosis.

Background. The most serious complication of central neck dissection (CND) is inadvertent parathyroidectomy. There is no definitive method for intraoperative diagnosis of this complication. Method. We studied on CND indicated 17 thyroid cancer patients (14 female, 3 male, age range: 21-67, mean age: 43.4). The excised CND material was kept in 50 ml of normal saline for 30 minutes. A 2 ml sample was taken from this fluid and sent to biochemistry for rapid parathyroid hormone (PTH) measurement. Results. PTH values were <10pg/mL in 14 patients. PTH values of three patients were very high (112pg/mL, 167pg/mL, 210pg/mL respectively). When the excised tissue in these patients was evaluated intraoperatively with loop glasses, one parathyroid tissue was found in each of the three cases and these were auto-transplanted intramuscularly. After this procedure we kept CND tissue material again in another normal saline of 50mL in 30 minutes and PTH was measured. The values came back as <10pg/mL. No parathyroid gland was found in any case in the postoperative routine histopathological evaluation. No patient had symptoms of hypocalcemia during the eightweeks postoperative follow-up. Conclusion. Inadvertent parathyroidectomy due to CND is a serious complication. This complication can be prevented with the simple method we recommend here.

Aim. This study aimed to investigate the clinical presentation and treatment outcomes of newly diagnosed acromegaly patients treated with various combinations\r\nof treatment modalities.\r\nMaterials and Methods. Eighty-four acromegaly patients (42 female, 42 male, mean age 40.29?13.32 y), followed and\r\ntreated between 2000 and 2010 were included. Data on patient demographics, delay between onset of symptoms and the\r\ndiagnosis, details of treatments, and treatment- or disease-related morbidity and mortality were collected and analyzed. The median delay time for diagnosis was 60.71 ? 56.19 months. Patients received various combinations of surgery, gamma knife radiotherapy or conventional radiotherapy,\r\nlong acting somatostatin analogue, and dopamine agonist.\r\nResults. After ten years of treatment, median GH and IGF-1 values decreased from 13.7 ng/mL (IQR: 5.3- 34) to 1.04\r\nng/mL (IQR: 0.52-2.7) and from 600 &#956;g/L (IQR: 460.5-787.5) to 194 &#956;g/L (IQR :157-356), respectively (p<0.0001).\r\nMedian GH during 75 g oral glucose tolerance test (OGTT) decreased from 4.35 ng/mL (IQR: 1.87-13.15) to 1.40 ng/mL\r\n(IQR: 0.60-3.40) (p<0.0001). Fifty patients (59.5%) were in remission according to IGF-1 values and 52 patients (62 %) were cured according to nadir GH during OGTT respectively. The mortality rate was 5.9%.\r\nIn conclusion. Strict biochemical control following appropriate intervention significantly reduces both morbidity and mortality in acromegaly patients.

-

Background. Thyroid nodules are a common pathology worldwide. Fine needle aspiration biopsy (FNAB) is an important diagnostic method for the investigation of malignancy in thyroid nodules. However, according to the Bethesda System used to classify the results, patients with atypia of undetermined significance/follicular lesion of undetermined significance (AUS / FLUS) may not be classified as benign or malignant. Therefore, it may be necessary to determine some clinical risk factors to apply the best treatment in these patients. Aim. To determine the factors that increase the risk of malignancy in this patient group. Methods. A retrospective study including 138 patients with an FNAB categorized as AUS/FLUS and operated between June 2015–September 2018. Demographical, Laboratory (TSH) and Ultrasound variables (number, size and characteristics of nodules) of the patients were compared among postoperative histopathological results. Results. Hypo-echoic structure, microcalcification and irregular margin of the nodules were detected to be associated with malignancy in patients with FNAB results of AUS/FLUS (p <0.001). Conclusion. We suggest that surgical treatment should be considered if the patients have nodules with the hypo-echoic structure, microcalcification and irregular margin with an FNAB histopathological result of AUS / FLUS.

Background. Langerhans cell histiocytosis (LCH) is a rare group of neoplastic diseases resulting from Langerhans dendritic cells. The most common site (80%) is bones. Thyroid gland involvement is exceedingly rare and usually expected to be seen as a part of multisystemic disease. Case Report. We present a 45 year old male patient operated due to multinodular goiter and neck pain, and diagnosed with LCH in his postoperative pathologic examination. As a result of the systemic screening performed after the pathological diagnosis, the disease was interestingly localized to the thyroid gland. Systemic involvement did not develop in the two-year follow-up of the patient who did not receive additional chemotherapy treatment. Conclusion. It is difficult to diagnose LCH in the thyroid gland before surgery. Although surgical treatment with or without chemotherapy is recommended, surgery is not recommended alone since it is generally systemic involvement. However, in primary thyroid LCH cases limited to the thyroid gland, we recommend that only total thyroidectomy treatment should be kept in mind.

Context. Hyponatremia is a common electrolyte abnormality. Objective. We report a patient who presented with hyponatremia and diagnosed as small cell lung cancer metastatic to hypothalamus and pituitary. Case report. A 68 year old male patient was admitted with fever and cough and pneumonia was considered. Serum sodium level was 113 mmol/L. Syndrome of in appropriate ADH (SIADH) is considered. Thyroid function tests and cortisol levels pointed out a central deficiency in both axes. Pituitary MRI was performed and a hypothalamic and pituitary mass were observed. Prednisolone therapy was started followed by L thyroxine replacement. A chest computer tomography (CT) was taken 2 weeks later revealed a mass lesion. Bronchoscopic biopsy was performed and histopathological diagnosis of the tumor was reported as small cell lung cancer. Result. Many mechanisms were considered as the cause of hyponatremia in our patient. SIADH, secondary adrenal insufficiency and secondary hypothyroidism due to pituitary metastasis are possible causes. Conclusion. The reason of hyponatremia is sometimes complex. When the underlying causes of hyponatremia are not evaluated in detail, many diagnoses can be missed.

Differentiated thyroid cancer (DTC) generally has an excellent prognosis, yet treatment strategies have traditionally been aggressive, often involving total thyroidectomy followed by radioactive iodine (RAI) ablation and long-term suppressive levothyroxine therapy even in cases considered to be low- or intermediate-risk. In recent years, several guidelines have recommended a more individualized, risk-based approach aiming for a more conservative treatment plan. Despite this paradigm shift, there is a gap between recommendations and actual clinical practice as many centers continue to advocate the more aggressive treatment model. De-escalating the care of selected patients with thyroid cancer include the avoidance of surgery in tumors < 10 mm, the recommendation for thyroid lobectomy for tumors < 4cm, the avoidance of prophylactic lymph node dissection. Evidence based studies show that such strategies do not worsen long-term outcomes, can reduce complications and can lead to better quality of life. Such studies will be summarized in this editorial with the aim of encouraging clinicians to reconsider established treatment protocols and empowering patients to make informed decisions for their care.