The Predictors of Postoperative Cerebrospinal Fluid Leak in Endoscopic Endonasal Pituitary Surgery: The Role of Tumor Volume.

Objectives Postoperative cerebrospinal fluid (Po-CSF) leak is still a challenging complication of endoscopic endonasal skull base surgery. However, data describing the predictive factors of Po-CSF leak in pure pituitary adenomas is lacking. Aim of this study is to determine the risk factors of Po-CSF leak in a pituitary adenoma group operated via pure transsellar endoscopic approach. Design This is a retrospective cohort study. Setting A single-center academic hospital. Participants Patients operated for a pituitary adenoma between 2015 and 2021 and followed up until June 2022 were included. Main Outcome Measures Demographics, comorbidities, imaging, and outcome were recorded. Univariate and multivariate logistic regression analyses were used to determine the risk factors of Po-CSF leak. Results Of the total 170 patients with a mean age of 47.5 ± 13.8 (min: 15; max: 80), 11 (6.5%) had Po-CSF leak. Univariate analysis revealed age, diabetes mellitus (DM), and tumor volume as predictors of Po-CSF leak. According to the receiver operating characteristic analysis, 7.5 cm 3 of tumor volume was found to be a good cutoff value with a sensitivity of 82% and a specificity of 75%. Hence, multivariable logistic regression model adjusted by age showed that a tumor volume of > 7.5 cm 3 (odds ratio [OR]: 22.9; 95% confidence interval [CI]: 3.8-135.9, p = 0.001) and DM (OR: 8.9; 95% CI: 1.7-46.5; p = 0.010) are strong independent risk factors of Po-CSF leak in pure endoscopic endonasal pituitary surgery. Conclusion Besides younger age and DM, a cutoff value for tumor volume > 7.5 cm 3 is the most remarkable risk factor for Po-CSF leak in pure endoscopic pituitary surgery. These patients should carefully be assessed preoperatively and potential preemptive surgical strategies should be taken into consideration to avoid complications.

Landscape of congenital adrenal hyperplasia cases in adult endocrinology clinics of Türkiye-a nation-wide multicentre study.

BACKGROUND AND AIMS: Congenital adrenal hyperplasia (CAH) is a group of disorders that affect the production of steroids in the adrenal gland and are inherited in an autosomal recessive pattern. The clinical and biochemical manifestations of the disorder are diverse, ranging from varying degrees of anomalies of the external genitalia to life-threatening adrenal insufficiency. This multicenter study aimed to determine the demographics, biochemical, clinical, and genetic characteristics besides the current status of adult patients with CAH nationwide. METHODS: The medical records of 223 patients with all forms of CAH were evaluated in the study, which included 19 adult endocrinology clinics. A form inquiring about demographical, etiological, and genetic (where available) data of all forms of CAH patients was filled out and returned by the centers. RESULTS: Among 223 cases 181 (81.16%) patients had 21-hydroxylase deficiency (21OHD), 27 (12.10%) had 11-beta-hydroxylase deficiency (110HD), 13 (5.82%) had 17-hydroxylase deficiency (17OHD) and 2 (0.89%) had 3-beta-hydroxysteroid-dehydrogenase deficiency. 21OHD was the most prevalent CAH form in our national series. There were 102 (56.4%) classical and 79 (43.6%) non-classical 210HD cases in our cohort. The age of the patients was 24.9 ± 6.1 (minimum-maximum: 17-44) for classical CAH patients and 30.2 ± 11.2 (minimum-maximum: 17-67). More patients in the nonclassical CAH group were married and had children. Reconstructive genital surgery was performed in 54 (78.3%) of classical CAH females and 42 (77.8%) of them had no children. Thirty-two (50.8%) NCAH cases had homogenous and 31 (49.2%) had heterogeneous CYP21A2 gene mutations. V281L pathological variation was the most prevalent mutation, it was detected in 35 (55.6%) of 21OHD NCAH patients. CONCLUSION: Our findings are compatible with the current literature except for the higher frequency of 110HD and 17OHD, which may be attributed to unidentified genetic causes. A new classification for CAH cases rather than classical and non-classical may be helpful as the disease exhibits a large clinical and biochemical continuum. Affected cases should be informed of the possible complications they may face. The study concludes that a better understanding of the clinical characteristics of patients with CAH can improve the management of the disorder in daily practice.

Genetic Testing in Hereditary Pituitary Tumors.

Genetic testing is becoming part of mainstream endocrinology. An increasing number of rare and not-so-rare endocrine diseases have an identifiable genetic cause, either at the germline or at the somatic level. Here we summerise germline genetic alterations in patients with pituitary neuroendocrine tumors (pituitary adenomas). These may be disorders with isolated pituitary tumors, such as X-linked acrogigantism, or AIP-related pituitary tumors, or as part of syndromic diseases, such as multiple endocrine neoplasia type 1 or Carney complex. In some cases, this could be relevant for treatment choices and follow-up, as well as for family members, as cascade screening leads to early identification of affected relatives and improved clinical outcomes.

Is mean platelet volume a simple marker of non-alcoholic fatty liver disease?

BACKGROUND: Due to the increasing prevalence of non-alcoholic fatty liver disease (NAFLD), there was a need to establish non-invasive tests for its detection. Mean platelet volume (MPV) is an inexpensive, practical and easily accessible marker of inflammation in many disorders. Our study was aimed at investigating the relationship between MPV and both NAFLD and liver histology. METHODS: Total 290 patients with biopsy-proven NAFLD (n = 124) and 108 control patients were included in the study. To exclude the effect of other diseases on MPV, we included 156 patient controls in our study. Those whohave liver-related diseases and those who use drugs that may cause fatty liver were not included in the study. Liver biopsy was performed for those whose alanine aminotransferase level persisted for >6 months above the upper limits. RESULTS/CONCLUSION: We found that MPV was significantly higher in the NAFLD group compared with the control group, and MPV had an independent predictive value for the development of NAFLD. We determined that the number of platelets was significantly lower in the NAFLD group compared with that in the control group. We compared MPV values histologically with both stage and grade in all patients with biopsy-proven NAFLD and found that MPV had a significant positive correlation with stage. We observed a positive correlation between MPV and non-alcoholic steatohepatitis grade, but this was not statistically significant. MPV can be useful because it is simple, easy to measure, cost-effective, and routinely tested in daily practice. MPV can be used as a simple marker of NAFLD and an indicator of fibrosis-stage in NAFLD.

A machine learning approach to distinguishing between non-functioning and autonomous cortisol secreting adrenal incidentaloma on magnetic resonance imaging using texture analysis.

PURPOSE: To investigate the possibility of distinguishing between nonfunctioning adrenal incidentalomas (NFAI) and autonomous cortisol secreting adrenal incidentalomas (ACSAI) with a model created with magnetic resonance imaging (MRI)-based radiomics and clinical features. METHODS: In this study, 100 adrenal lesions were evaluated. The lesions were segmented on unenhanced T1-weighted in-phase (IP) and opposed-phase (OP) as well as on T2-weighted (T2-W) 3Tesla MRIs. The LASSO regression model was used to select potential predictors from 108 texture features for each sequence. Subsequently, a combined radiomics score and clinical features were created and compared. RESULTS: A significant difference was found between median rad-scores for ACSAI and NFAI in training and test sets (p < 0.05 for all sequences). Multivariate logistic regression analysis revealed that the length of the tumor (OR = 1.09, p = 0.007) was an independent risk factor related to ACSAI. Multivariate logistic regression analysis was used for building clinical-radiomics (combined) models. The Op, IP, and IP plus T2-W model had a higher performance with area under curve (AUC) 0.758, 0.746, and 0.721 on the test dataset, respectively. CONCLUSION: ACSAI can be distinguished from NFAI with high accuracy on unenhanced MRI. Radiomics analysis and the model constructed by machine learning algorithms seem superior to another radiologic assessment method. The inclusion of chemical shift MRI and the length of the tumor in the radiomics model could increase the power of the test.

Regional variability of modified Ferriman-Gallwey scorring in premenopausal healthy women in Southern Turkey.

ObjectiveAlthough modified Ferriman-Gallwey (mF-G) scorring has been the gold standard for assessing hirsutism, also known that this scorring could show variability according to ethnicity. Hence, false positive hirsutism diagnosis and unnecessary anti-androgen therapy can prescribed. It was aimed to disclose the regional characteristics of this scorring in healthy women living in Southern Turkey.Methods360 women between 18 and 50 years of age were randomly screened. Their medical history, including ovulation periods, gestation(s), family history, known drug use was obtained. Physical examination with mF-G scoring and serum hormone measurements were performed. Women with hirsutism who scored ≥ 8 were further investigated for any underlying disease or cause of hirsutism. After these investigations, the women were divided into three groups according to the mF-G ≥ 8 score and evaluated. Group A (n = 59) had an mF-G ≥ 8 and, revealed an underlying disease causing hirsutism; group B (n = 42) had an mF-G ≥ 8, but no underlying disease responsible for hirsutism; and the third group (Group C, n = 259) had an mF-G ≤ 8 and thus, no signs of hirsutism.ResultsThe mean mF-G scores of three groups were 12.78 ± 4.4, 11.48 ± 4.6, and 5.53 ± 3.4, respectively. Of the 59 (16.1%) women in Group A, 46 (44.2%) were diagnosed as polycystic ovary syndrome (PCOS), 8 (7.7%) had idiopathic hyperandrogenism, 7 (6.7%) had nonclassic congenital adrenal hyperplasia, and 1 (1%) had a prolactinoma. When compared to group B, group A women had significantly decreased fertility (p = .001) and menstrual irregularities (p = .001).ConclusionsIn this study, results revealed a significant rate of healthy women (11.6%) who had an mF-G ≥ 8, but no underlying disease causing hirsutism yet were considered hirsute according to their mF-G cutoff. Also, the majority of the studied women (71.9%) living in Southern Turkey were found to have a hair-pattern similar to the European Women. Therefore, we suggest that regional and ethnical body-hair patterns should be considered before prescribing anti-androgen therapy.

PLXNB1 mutations in the etiology of idiopathic hypogonadotropic hypogonadism.

Idiopathic hypogonadotropic hypogonadism (IHH) comprises a group of rare genetic disorders characterized by pubertal failure caused by gonadotropin-releasing hormone (GnRH) deficiency. Genetic factors involved in semaphorin/plexin signaling have been identified in patients with IHH. PlexinB1, a member of the plexin family receptors, serves as the receptor for semaphorin 4D (Sema4D). In mice, perturbations in Sema4D/PlexinB1 signaling leads to improper GnRH development, highlighting the importance of investigating PlexinB1 mutations in IHH families. In total, 336 IHH patients (normosmic IHH, n = 293 and Kallmann syndrome, n = 43) from 290 independent families were included in the present study. Six PLXNB1 rare sequence variants (p.N361S, p.V608A, p.R636C, p.V672A, p.R1031H, and p.C1318R) are described in eight normosmic IHH patients from seven independent families. These variants were examined using bioinformatic modeling and compared to mutants reported in PLXNA1. Based on these analyses, the variant p.R1031H was assayed for alterations in cell morphology, PlexinB1 expression, and migration using a GnRH cell line and Boyden chambers. Experiments showed reduced membrane expression and impaired migration in cells expressing this variant compared to the wild-type. Our results provide clinical, genetic, molecular/cellular, and modeling evidence to implicate variants in PLXNB1 in the etiology of IHH.

Is it Possible to Assess the Functional Status of Hormone Secretion or Non- Secretion of Adrenal Masses Through Their Magnetic Resonance Imaging (MRI) Characteristics?

BACKGROUND: Diagnostic imaging techniques, including magnetic resonance imaging (MRI) should be performed on all patients with incidentalomas. However, limited number of studies on whether the quantitative measurements (signal intensity index, adrenal to spleen ratio) in MRI could predict the functional status of adrenal adenomas are available. METHODS: Between 2015-2020, 404 patients (265 females, 139 males) with adrenal mass who were referred to the university hospital for further investigation were included. After detailed diagnostic hormonal evaluation, all patients were examined with the MRI 1.5 T device (Signa, GE Medical Systems; Milwaukee, USA). The signal intensities of the adrenal lesions on T2W images were qualitatively evaluated and noted as homogenous or heterogeneous in comparison with the liver signal intensity (SI). A chemical-shift SI index and chemical shift adrenal-to-spleen SI ratio were also calculated. RESULTS: While 331(81.9%) of the patients had nonfunctional adrenal mass, the rest (n=73, 18.1%) were patients with functional (autonomous cortisol secretion-ACS, Cushing syndrome-CS, pheochromocytoma, primary hyperaldosteronism-PA) adrenal masses. In phase vs. phase values of patients with NFAI, Pheo(n=17), ACS (n=30), CS (n=11), and PA (n=15) were 474.04±126.7 vs. 226.6±132.4, 495.3±182.8 vs. 282.17±189.1, 445.2±134.8 vs. 203.3±76.2, 506.8±126.5 vs. 212.2±73.6 and 496.2±147.5 vs. 246.6±102.1, respectively. Mean signal intensity index (SII) and adrenal to spleen ratio (ASR) of all groups (NFAI, Pheo, ACS, CS, PA) were 52.0±24.8 and 0.51, 44.9±22.5 and 0.55, 49.5±24.5 and 0.53, 56.2±16.4 and 0.43, 47.6±25.1 and 0.54, respectively. Based on the currently accepted measurements in the case of ASR and SII, all lesions were similar and observed as fat rich adenomas (p*= 0.552, p** = 0.45). CONCLUSION: The quantitative assessment (SII, ASR) of intracellular lipids in an incidentally discovered adrenal tumor could only help distinguish adrenal masses in the case of adenomas or non-adenomas. As an initial diagnostic evaluation, clinical and laboratory assessment to distinguish hormone secretion should be done for all patients with adrenal incidentalomas.

Novel Classification of Acromegaly in Accordance with Immunohistochemical Subtypes: Is There Really a Clinical Relevance?

According to the recent studies, immunohistochemical subtypes of growth hormone (GH) secreting adenomas have been considered as a predictive factor in determining the clinical outcomes including biochemical, radiologic, and endocrine remission. In a 20 year-of time period, acromegaly patients who were treated and followed at the Endocrinology Department of our University Hospital were screened for the study. Of total 98 patients, 65 patients who had been operated by transsphenoidal surgery and having postoperative specimens were included. Postoperative specimens of the surgery of the patients were classified into 3 groups based on the histochemical characteristics (densely, sparsely, and mixed). Parasellar extensions of pituitary tumors were classified into the five grades according to Knosp classification. The patients were investigated and evaluated for postoperative clinical progress, remission rates, comorbidities regarding with the histopathological patterns. Of total 65 patients, 31 were classified as densely granulated (group 1), 32 were classified as sparsely granulated (group 2), and 2 patients were assessed as mixed granulated (group 3). There was no difference between groups for age and gender. Pre-treatment of adenoma size in all groups was correlated with each other and the frequency of macroadenoma (1 vs. 2, 77.4 vs. 84.3%) was higher in two groups. Although mean initial GH levels in group 1 was higher than the other groups (p=0.03), IGF1 levels (age and gender matched) were similar in each group. Adenomas in all groups demonstrated noninvasive radiological characteristics (Knosp grade 0-1-2). Ki-67 proliferation index of both groups (64.5 vs. 50%) was predominantly 1%. With a similar follow-up period, the endocrine remission rates (GH<1 µg/l) in groups were 64 vs. 69%, respectively. In conclusion, classification according to immunohistochemical subtypes of growth hormone secreting adenomas may not be a qualified parameter to evaluate patients with patterns of aggressiveness, clinical outcomes, or treatment response.

Which predictors could effect on remission of type 2 diabetes mellitus after the metabolic surgery: A general perspective of current studies?

BACKGROUND: The alarming rise in the worldwide prevalence of obesity is paralleled by an increasing burden of type 2 diabetes mellitus (T2DM). Metabolic surgery is the most effective means of obtaining substantial and durable weight loss in individual obese patients with T2DM. There are randomized trials that justify the inclusion of metabolic surgery into the treatment algorithm for patients with T2DM, but remission rates of T2DM after metabolic surgery can display great variability. AIM: To discuss the most commonly used surgical options including vertical sleeve gastrectomy, adjustable gastric banding, Roux-en-Y gastric bypass, and biliopancreatic diversion with duodenal switch. METHODS: We also report from observational and randomized controlled studies on rate of remission of T2DM after the surgical procedures. RESULTS: In light of the recent findings, metabolic surgery is a safe and effective treatment option for obese patient with T2DM, but further studies are needed to clarify better the rate of diabetes remission. CONCLUSION: In light of the recent findings, metabolic surgery is a safe and effective treatment option for obese patients with T2DM, but further studies are needed to clarify better the rate of diabetes remission.

Pituitary Volume in Patients with Primary Empty Sella and Clinical Relevance to Pituitary Hormone Secretion: A Retrospective Single Center Study.

BACKGROUND: According to neuroradiological findings, empty sella seems to be deprived of pituitary tissue in sella turcica. Changing size of the pituitary volume is closely related to the occurrence of primary empty sella. The aim of the study is to determine pituitary dysfunction in patients with partial or total primary empty sella and the significance of pituitary volume measurements in these patients. METHODS: This study was designed retrospectively. 67 patients (55 females, 12 males) diagnosed with primary empty sella syndrome between the years of 2015-2019 were included in the study. Patients were divided into two groups: partial (PES) and total (TES) empty sella by magnetic resonance imaging (MRI). Basal anterior pituitary and its hormones were assessed. We also included 26 healthy control subjects (19 females, 7 males) to compare the differences in pituitary volumes. Volumes were measured by using Osirix Dicom Viewer (Pixmeo SARL, Geneve, Swiss) in 3.0 Tesla scanner MRI. RESULTS: 82.1% (n=55) of all patients were PES and the others were (n=12) TES. Hypopituitarism, known as one or more pituitary hormones deficiency, was found in 12 patients (17.9%). While 9 of them had total PES, the others had partial PES. Secondary adrenal insufficiency and gonadotropin deficiency were more prevalent in patients with TES. Mean volume measurements of patients with TES, PES and healthy subjects were 0.23±0.17, 0.35±0.15, 0.54±0.17 cm3, respectively. Except for IGF1 values (p=0.026), there was not any significant correlation found between the anterior pituitary hormones and volume measurements. CONCLUSION: Although volume measurement has helped in the diagnosis of pituitary empty sella (partial or total), it does not seem to have any significant correlation with pituitary secretory function.

Possible role of the receptor of advanced glycation end products (RAGE) in the clinical course of prostate neoplasia in patients with and without type 2 diabetes mellitus.

AIM: The expression of the cognate receptor of advanced glycation end products (RAGE) in malignant tissues of patients with type 2 diabetes has been suggested as a co-factor determining the clinical course and prognosis. We aimed to investigate the relationship between RAGE expression and clinicopathological features of prostate neoplasia. METHODS: Tissue samples of 197 patients, 64 (24 patients with type 2 diabetes and 40 controls) with benign prostate hyperplasia (BPH) and 133 (71 patients with type 2 diabetes and 62 controls) with localised or metastatic prostate cancer (LPCa/MetPCa) were included in the study. The expression of RAGE in prostate specimens was studied immunohistochemically. RAGE scores were determined according to the extent of immunoreactivity and staining intensity. RESULTS: RAGE expression in BPH group (patients with type 2 diabetes and controls) was negative. Patients with both LPCa and MetPCa had significantly higher scores than those with BPH (P < .001). The mean RAGE scores of patients with type 2 diabetes LPCa and MetPCa were 4.71 ± 3.14 and 4.97 ± 3.69. The mean scores of control LPCa and MetPCa were 1.52 ± 1.87 and 1.69 ± 1.58, respectively. The scores of patients with type 2 diabetes LPCa and MetPCa were significantly higher than those of control LPCa and MetPCa (P = .01 and P < .001, respectively). CONCLUSION: We found higher RAGE expression levels in malignant prostate neoplasia than in BPH. As expected, patients with diabetes had higher scores than control patients. Disease progression and survival parameters were worse in patients with high RAGE levels. RAGE expression may be a useful biomarker for the diagnosis and prognosis of prostate cancer.

Comparison of 24-Hour Electrocardiogram Parameters in Patients with Graves' Disease Before and After Anti-Thyroid Therapy.

BACKGROUND: We aimed prospectively to investigate the laboratory and electrocardiographic parameters (heart rate, QRS, QT, QTc, Tpe, Tpe/QTc, and arrhythmia prevalence) in patients with Graves' disease before and after antithyroid therapy. METHODS: Seventy-one patients (48 female, and 23 male), of age between 18-50 years (mean±SD: 36.48±12.20) with GD were included in the study. Patients were treated with antithyroid therapy (thioamides and/or surgical therapy) to maintain euthyroid status. Patients were examined in terms of electrocardiographic parameters before and after the treatment. RESULTS: Mean TSH, free thyroxin (fT4), and tri-iodothyrionine (fT3) levels of all patients were 0.005±0.21, 3.27± 1.81, 11.42±7.44, respectively. While 9 patients (group 2) underwent surgical therapy, had suspicious malignant nodule or large goiter, and unresponsiveness to medical treatment; the other patients (n=62, group 1) were treated with medical therapy. Patients with surgical therapy had more increased serum fT4 (p=0.045), anti-thyroglobulin value (p=0.018) and more severe graves orbitopathy (n=0.051) before treatment when compared to a medical therapy group. Baseline Tpe duration and baseline Tpe/QTc ratio and frequency of supraventricular ectopic beats were found to be significantly higher in group 2 when compared to group 1 (p=0.00, p=0.005). Otherwise, the baseline mean heart rate, QRS duration, QTc values of both groups were similar. Although the patients came at their euthyroid status, group 2 patients still suffered from more sustained supraventricular ectopics beats than group 1. CONCLUSION: Distinct from the medical treatment group, surgical treatment group with euthyroidism for at least 3 months still suffered from an arrhythmia (Tpe, Tpe/QTc, supraventricular and ventricular ectopic beats).

Hospitalization costs associated with diabetic foot ulcers treated by a multidisciplinary team in clinical practice. A retrospective study from southern Turkey.

PURPOSE: Diabetic foot ulceration (DFU) is a common problem throughout the world and results in major economic consequences for the patients and country. We aim to describe the estimated cost of illness in patients with DFU in southern Turkey. METHODS: A total of 148 (F=55, M=93) patients with DFU were included in this retrospective study. Patients characteristics, duration time of hospitalisations, biochemical parameters and the presence of diabetic retinopathy, nephropathy, neuropathy, coronary artery disease and peripheral artery disease were recorded from our database. The cost of each patient was recorded from financial affairs and the billing department unit of our hospital. RESULTS: The average unit cost of each patient was £ 730.90±664.9. The major component in the total cost were medication (£ 258.8±360.9) and hospitalisation fees (£ 76.58±56.3). One hundred and fifteen (77.7%) of the patients had peripheral arterial diseases. While we could not determine significant correlations between the patients' demographical features (age, gender, p>0.05), biochemical parameters (plasma glucose, hemoglobin A1c % (HbA1c %)) and year of diagnoses with diabetes mellitus , the length of hospitalisation, presence of peripheral artery diseases and whether amputation (minor or major) was performed were significantly correlated with the total expenses. CONCLUSION: The study revealed that the cost of DFU could show variability in relation to countries' level of development. We highlighted similar studies in other countries; the major factors of total expenses were length of hospitalisation, medication prescription and use of surgery. KEY WORDS: Costs, Diabetic foot, Multidisciplinary team.

Clinical Relevance and Immunohistochemical Patterns of Silent Pituitary Adenomas: 10 Years of Single-centre Experience.

BACKGROUND: Silent pituitary adenomas are clinically non-functional (i.e., without clinically evident pituitary hormone production). INTRODUCTION: The aim of this study was to investigate subjects with silent pituitary adenomas for possible variations in their clinical status. METHODS: A total of 102 patients who had undergone surgery for pituitary adenoma and had been diagnosed with silent pituitary adenoma was included in the study. The patients' preoperative and postoperative hormonal parameters and magnetic resonance imaging (MRI) features were collected, and pathological specimens were re-evaluated. RESULTS: Immunohistochemistry results of the 102 patients were as follows: hormone-negative adenomas (n=35) 35.5%; FSH+LH-positivity (n=32) 31.3%; ACTH-positivity (n=11) 10.7%; α-subunit- positivity (n= 9) 8.8%; prolactin-positivity (n=8) 7.8%; GH-positivity (n=6) 5.4%; and plurihormonal adenoma (n=1). The mean sizes of SGA, SGHA, and SCA were 28.0±12.7, 30.0±16.0, and 27.7±8.9mm (p>0.05), respectively. With the exception of silent gonadotroph adenomas (SGAs), female gender dominance was shown in patients with silent growth hormone adenoma (SGHA) and silent corticotroph adenoma (SCA). Although no clinical relevance was observed in relation to hormonal excess, preoperative GH (4.21±4.6, vs. 0.27±0.36 p=0.00) was slightly more elevated in SGHA than in GH-negative adenomas. Additionally, preoperative basal ACTH values (47.3±28.7 vs. 23.9±14.4, p=0.003) were also higher in SCA compared to the other types. Our findings revealed SCAs to be of more aggressive behaviour than SGHAs and SGAs due to invasiveness in radiological imaging, their elevated re-operation, and postoperative ACTH values. CONCLUSION: Silent pituitary adenomas represent a challenging diagnostic tumour group. Careful initial evaluation of patients with pituitary adenomas should consider any mild signs and symptoms of functionality, particularly in cases of GH- and ACTH-secreting adenomas.

Increased Rates of Coronary Artery Calcium Score in Patients with Non - Functioning Adrenal Incidentaloma.

AIM: We evaluated cardiovascular (CV) risk stratification for nonfunctioning adrenal incidentalomas (NFAIs) via the coronary-artery-calcium (CAC) score. MATERIALS AND METHODS: The participants were patients with NFAI (n = 55). They were compared to patients with chest pain, a low-intermediate Framingham-risk score, and a non-diagnostic treadmill- exercise test, which served as the control group (n = 49). Subsequently, the NFAI group was subdivided according to a CAC score of <100 Agatston units - mild coronary-artery calcification (n = 40) - and ≥100 Agatston units - moderate-to-severe calcification (n = 15). RESULTS: Similar rates of traditional risk factors were observed between the NFAI and control groups, and lower low-density lipoprotein cholesterol rates were observed in the NFAI group. The CAC score was significantly higher for the NFAI group than the control group. Glucose, potassium, adrenocorticotropic-hormone, and basal-cortisol levels were higher in those with a CAC score of ≥100. High-density-lipoprotein cholesterol estimated glomerular filtration rate and ejection fraction (EF) were higher in those with a CAC score of <100. Adenoma size and location were similar between the groups. Age, EF, and glucose were the most significant variables related to CAC score in patients with NFAI, at ≥100 Agatston units. DISCUSSION: Patients with a low-intermediate CV risk profile and NFAI have a higher risk of atherosclerosis when compared to patients with a low-intermediate CV risk profile, but no NFAI. CONCLUSION: In patients with NFAI, CAC score evaluation may be used to predict increased atherosclerosis, especially in patients of an older age with higher glucose and decreased EF.

Outcomes of surgical and/or medical treatment in patients with prolactinomas during long-term follow-up: a retrospective single-centre study.

OBJECTIVES: Prolactinoma is the most common cause of pituitary tumours. Current medical guidelines recommend dopamine agonists (cabergoline or bromocriptine) as the initial therapy for prolactinoma. However, surgical removal can also be considered in selected cases, such as patients with macroadenomas with local complications (bleeding or optic chiasm pressure) or those not responding to medical treatment. METHODS: The present retrospective study included patients with prolactinomas (n=43; female, 24; male, 19) who were primarily managed with medical (n=32) or surgical (n=11) treatment. RESULTS: Macroadenoma (n=29.67%) was commonly detected in both genders (female, 54%; male, 84%). Moreover, the mean pre-treatment prolactin levels were similar in both genders (female, 683.3 ± 1347 ng/mL; male, 685.4 ± 805 ng/mL; p=0.226). Surgically treated patients had a greater reduction in tumour size (27.7 ± 17.9 mm pre-treatment vs. 8.72 ± 14.2 mm post-treatment) than non-surgically treated ones (12.5 ± 7.5 mm pre-treatment vs. 4.1 ± 4.2 mm post-treatment; p=0.00). However, the decrease in prolactin levels was similar between the two patient groups (p=0.108). During the follow-up period (10.6 ± 7.0 years), the average cabergoline dose of the patients was 1.42 ± 1.47 mcg/week. CONCLUSIONS: Although a surgical approach was considered for selected cases of prolactinoma, the average dose used for medical treatment was highly inadequate for the patients in the present study.

Diagnostic efficacy of 18F-FDG PET/CT in patients with adrenal incidentaloma.

BACKGROUND: The management of adrenal incidentaloma is still a challenge with respect to determining its functionality (hormone secretion) and malignancy. In this light, we performed 18F-FDG PET/CT scan to assess the SUVmax values in different adrenal masses including Cushing syndrome, pheochromocytoma, primary hyperaldosteronism and non-functional adrenal adenomas. METHODS: Total 109 (73 F, 36 M) patients with adrenal mass (incidentaloma), mean age of 53.3 ± 10.2 years (range, 24-70) were screened by 18F-FDG PET/CT. Data of 18F-FDG PET/CT imaging of the patients were assessed by the same specialist. Adrenal masses were identified according to the calculated standardized uptake values (SUVs). Clinical examination, 24-h urine cortisol, catecholamine metabolites, 1-mg dexamethasone suppression test, aldosterone/renin ratio and serum electrolytes were analyzed. RESULTS: Based on the clinical and hormonal evaluations, there were 100 patients with non-functional adrenal mass, four with cortisol-secreting, four with pheochromocytomas and one with aldosterone-secreting adenoma. Mean adrenal mass diameter of 109 patients was 2.1 ± 4.3 (range, 1-6.5 cm). The 18F-FDG PET/CT imaging of the patients revealed that lower SUVmax values were found in non-functional adrenal masses (SUVmax 3.2) when compared to the functional adrenal masses including four with cortisol-secreting adenoma (SUVmax 10.1); four with pheochromcytoma (SUVmax 8.7) and one with aldosterone-secreting adenomas (SUVmax 3.30). Cortisol-secreting (Cushing syndrome) adrenal masses showed the highest SUVmax value (10.1), and a cut-off SUVmax of 4.135 was found with an 84.6% sensitivity and 75.6% specificity cortisol-secreting adrenal adenoma. CONCLUSIONS: Consistent with the similar studies, non-functional adrenal adenomas typically do not show increased FDG uptake and a certain form of functional adenoma could present various FDG uptake in FDG PET/CT. Especially functional adrenal adenomas (cortisol secreting was the highest) showed increased FDG uptake in comparison to the non-functional adrenal masses. Therefore, setting a specific SUVmax value in the differentiation of malignant adrenal lesion from the benign one is risky and further studies, including a high number of functional adrenal mass are needed.

Adipocytokines in Non-functional Adrenal Incidentalomas and Relation with Insulin Resistance Parameters.

OBJECTIVE: Adrenal incidentalomas are diagnosed incidentally during radiological screenings and require endocrinological investigations for hormonal activity and malignancy. In certain studies, it has been reported that non-functional incidentalomas can be associated with high adipocytokines levels affecting the insulin resistance just like the adipose tissue with metabolic syndrome. Here, we studied serum adipocytokine levels including leptin, resistin, visfatin, omentin 1 and adiponectin in subjects with non-functional adrenal incidentaloma. METHODS: Seventy-seven (77) patients (Female 57; Male 20) with non-functional adrenal incidentaloma (NFAI) were enrolled in the study. All patients' past medical history, physical examination including Body Mass Index (BMI) and waist circumference were performed. The patients' demographic, radiologic, hormonal and biochemical parameters were recorded. To compare the parameters, a control group (CG) (n=30) was formed from healthy volunteers. Both groups were matched for age, gender, waist circumference and BMI. Serum adipocytokines including leptin, resistin, visfatin, omentin 1 and adiponectin were measured quantitatively by ELISA. Fasting plasma glucose, insulin, sodium, potassium, cortisol, adrenocorticotropic hormone (ACTH), lipid profiles, and dehidroepiandrostenedion sulphate (DHEAS) were measured. RESULTS: Mean age of the patients was 52.2±10.4 years. BMI and waist circumference of NFAI patients were 26.2±3.28 kg/m2 and 90.2 ±7.5cm, respectively. The mean age of the control group was 48.0±8.16. BMI and waist circumference values for the control group were 25.3±3.5 kg/m2 and 88.3±9.6 cm, respectively. When both groups were compared for age, gender, BMI and waist circumference were non-significant (p>0.05). Serum fasting insulin, total cholesterol, LDL, triglyceride levels of the NFAI group were significantly higher than CG (p<0.05). The insulin resistance index (HOMAIR) values of the NFAI subjects were found to be higher than CG (2.5±1.37, 1.1±0.3 p=0.00). Resistin level of NFAI group was also found to be higher than CG [286.6 ng/L vs. 197 ng/L; (P=0,00)], respectively. Leptin levels of NFAI were significantly higher than CG [441.1 ng/mL vs. 186.5 ng/mL; (P=0.00)] respectively. Adiponectin levels were significantly reduced in the NFAI group than in the CG [10.7 mg/L vs. 30.8 mg/L; (P=0.00)]. Comparision of visfatin and omentin levels was nonsignificant. CONCLUSION: In this study on subjects with non-functional adrenal incidentaloma, we found not only significantly decreased serum adiponectin levels but also increased leptin, resistin levels as well as dyslipidemia, hypertension and high insulin resistance index. All of which could affect insulin resistance and cardiovascular risk factors. The underlying mechanisms of these findings are unknown, hence further studies are needed.

Multidisciplinary approach for patients with functional and non-functional adrenal masses and review of the literature.

BACKGROUND: Adrenal incidentalomas are adrenal masses that are discovered by imaging tests performed for other reasons. AIMS: In this retrospective study, we analysed 229 Turkish patients with adrenal masses and who presented with or without complaints. STUDY DESIGN: Descriptive retrospective study and review of the literature. METHODS: This study conducted a retrospective review of 229 patients with adrenal incidentalomas that were referred to Cukurova University Hospital's endocrinological department between 2009 and 2014. We reviewed detailed patient histories, physical examination findings, and symptoms and signs related to hormonal hypersecretion or malignant neoplasm and recorded clinical indications for performing diagnostic radiological imaging. The statistical analysis of data was performed using SPSS-19 software. RESULTS: Of the 229 patients reviewed, 195 (85.2%) had non-functional, benign adrenal adenomas, and 34 (14.8%) had functional lesions. Among those with functional lesions, 8 (3.5%) had lesions that secreted excess cortisol, 11 (4.8%) had lesions that secreted aldosterone, and 15 (6.6%) had lesions that secreted catecholamines. Eighty-four patients included in the study (36.8%) underwent adrenalectomy; in 14 of these cases, the adrenalectomy was performed before surgical treatment criteria occurred. The most frequent pathologic diagnosis was adrenal cortical neoplasia (n = 38); 32 of these patients had adenomas (Weiss <4 criteria), and 6 had carcinomas (Weiss >4 criteria). Other patient diagnoses included benign pheochromocytoma (n = 13), pseudocyst (n = 12), metastasis (n = 10), haemorrhage (n = 3), necrosis (n = 1), hyperplasia (n = 2), and other (n = 5). CONCLUSIONS: Detailed endocrinological and radiological assessments of the mass nature and hormone status are necessary in cases of adrenal incidentaloma. Appropriate surgical treatment or periodic follow-up must be determined based on the assessment results.