Pregnancy After Bariatric Surgery-Experience from a Tertiary Center.

INTRODUCTION: It is estimated that most people undergoing bariatric surgery are women of reproductive age; nonetheless, its effects on pregnancy outcomes are not yet fully understood. METHODS: Retrospective observational study, conducted in a tertiary center in Portugal, included participants in two groups: (1) pregnant women with a history of bariatric surgery (n = 89) and (2) pregnant women with a BMI ≥ 35 kg/m2, without previous bariatric surgery (n = 176). Data was collected from the medical files. Multivariate analysis was conducted to adjust for confounders. RESULTS: Pregnancy after bariatric surgery was associated with lower risk of gestational diabetes (15.7% vs. 30.1%, p = 0.002) and cesarean delivery (20.7% vs. 33.5%, p = 0.007), and a higher gestational weight gain (10.58 ± 9.95 vs. 7.33 ± 6.00 kg, p < 0.001). Participants in the bariatric surgery who experienced a gestational weight gain ≤ 10.0 kg had a higher risk of preterm delivery (16.7% vs. 2.5%, p = 0.031). No significant differences were found regarding hypertensive diseases of pregnancy between groups (4.5% vs 11.4%, p = 0.147). Pregnancy after bariatric surgery was associated with lower neonate weight percentile (34.24 ± 21.09 vs. 48.77 ± 27.94, p < 0.001), higher risk of fetal growth restriction (5.6% vs. 0.6%, p = 0.018), and lower risk of fetal macrosomia (0.0% vs. 7.5%, p = 0.005). There were no significant differences in the risk of SGA (12.5% vs. 7.0%, p = 0.127) or LGA neonates (2.3% vs. 6.4%, p = 0.069). CONCLUSION: Pregnancy after bariatric surgery is associated with both risks and benefits, which should be considered by healthcare providers. Pregnancy after bariatric surgery requires individualized care, to ensure adequate gestational weight and avoid micronutrient deficiencies.

Secondary Hyperparathyroidism Among Bariatric Patients: Unraveling the Prevalence of an Overlooked Foe.

INTRODUCTION: Bariatric surgery (BS) is the most effective therapeutic approach to obesity. It is associated with great gastrointestinal anatomic changes, predisposing the patients to altered nutrient absorption that impacts phosphocalcium metabolism. This study aimed to clarify the prevalence of secondary hyperparathyroidism (SHPT) and its predictors in patients submitted to BS. METHODS: Retrospective study of 1431 patients who underwent metabolic surgery between January 2010 and June 2017 and who were followed for at least 1 year. We compared the clinical and biochemical characteristics of patients with and without secondary hyperparathyroidism (considering SHPT a PTH ˃ 69 pg/mL). Two different analyses were performed: (1) paired analysis of participants before and 1 year after surgery (N = 441); (2) Cross sectional analysis of participants submitted to bariatric surgery before (N = 441), 1 year after (N = 1431) and 4 years after surgery (N = 333). Multiple logistic regression models were used to evaluate possible predictors of SHPT after BS. RESULTS: The overall prevalence of SHPT was 24.9% before surgery, 11.2% 1 year after surgery and 21.3% 4 years after surgery. Patients submitted to LAGB had the highest prevalence of SHPT 1 year after surgery (19.4%; vs RYGB, 12.8%, vs SG, 5.3%). Four years after surgery, RYGB had the highest prevalence of SHPT (27.0%), followed by LAGB (13.2%) and SG (6.9%). Higher body mass index and age, decreased levels of vitamin D and RYGB seem to be independent predictors of SHPT 1 year after surgery. The only independent predictor of SHPT 4 years after surgery was RYGB. CONCLUSION: The prevalence of SHPT is higher before and 4 years after BS than 1 year after surgery. This fact raises some questions about the efficacy of the implemented follow-up plans of vitamin D supplementation on the long term, mainly among patients submitted to RYGB.

The Impact of Vitamin D in Non-Alcoholic Fatty Liver Disease: A Cross-Sectional Study in Patients with Morbid Obesity.

PURPOSE: We aimed to evaluate the association between vitamin D status and hepatic function parameters and scores: Fatty Liver Index (FLI, predictor of hepatic steatosis) and BARD (BMI, AST/ALT ratio and DM, predictor of hepatic fibrosis) in patients with morbid obesity. PATIENTS AND METHODS: Cross-sectional study including patients with morbid obesity followed in our centre between January 2010 and July 2018. Patients with missing vitamin D levels or hepatic profile parameters were excluded. We divided the population according to two cut-offs of vitamin D levels (12ng/mL and 20ng/mL). RESULTS: The included population (n=1124) had an average age of 43.3±10.7 years and 84.3% were female. Seventy-point eight percent of the population had vitamin D levels lower than 20ng/mL and 34.8% lower than 12ng/dL. Patients with lower vitamin D levels (<12ng/mL) had higher BMI, hip and waist circumferences and higher prevalence of hypertension. Higher FLI scores [OR= 0.77 (0.07), p<0.01] and ALP levels [ß= -0.03 (-0.06, -0.01), p<0.01] associated to lower vitamin D levels. CONCLUSION: Vitamin D deficiency is associated with a higher risk of hepatic steatosis in individuals with morbid obesity. Correction of vitamin D deficiency may have a beneficial role in the management of NAFLD in patients with morbid obesity.

Bariatric Surgery Impact on Cardiovascular Risk Factors: Is Age a Factor to Consider?

INTRODUCTION: Despite the abundance of data addressing the influence of patient's age on surgery-related complications, its impact on cardiometabolic outcomes following bariatric surgery has been overlooked. METHODS: Retrospective unicentric study of 1,728 obese patients who underwent bariatric surgery between January 2010 and June 2015. Patients were divided in 3 age groups, according to their age at surgery: ˂40 (n = 751), 40-59 (n = 879), and ≥60 years (n = 98). Parameters with cardiometabolic impact, such as body anthropometric measures, lipid profile, and glycemic status, before and 24 months after surgery, were compared between these groups. A multiple linear regression was performed, adjusting differences between groups for sex, surgery type, and body mass index variation. RESULTS: The group ˂40 years presented more weight loss (-35.4 ± 9.0 kg, p ˂ 0.001), greater BMI reduction (-15.8 ± 6.1 kg/m2, p ˂ 0.001), and larger changes in waist (-34 ± 13.8 cm, p ˂ 0.001) and hip circumferences (-28.7 ± 11.9 cm, p ˂ 0.05). The group of ≥60 years presented the heaviest reduction in fasting glucose (-17.7 ± 32.8 mg/dL, p ˂ 0.001) and HbA1c (0.7 ± 1.0, p ˂ 0.001), and also had a tendency to have the biggest changes in systolic blood pressure (-14.7 ± 18.7 mm Hg, p = 0.071). CONCLUSION: Patients with ≥60 years benefit the most from bariatric surgery regarding cardiometabolic parameters, presenting heavier reductions in fasting glucose, as well as HbA1c and a tendency towards a higher decrease in systolic blood pressure. No clinically significant differences in lipid profile were observed between groups.

Thyroid Function and the Risk of Non-Alcoholic Fatty Liver Disease in Morbid Obesity.

Background: An association between hypothyroidism and the risk of Non-alcoholic Fatty Liver Disease (NAFLD) has been suggested. This association remains to be elucidated in patients with morbid obesity. Aim: To evaluate the association between thyroid function and parameters of liver function and hepatic scores in patients with morbid obesity. Methods: Patients with morbid obesity followed in our center between January 2010 and July 2018 were included. The ones without evaluation of liver and thyroid functions were excluded. Fatty Liver Index (FLI) and BARD scores were used as predictors of hepatic steatosis and fibrosis, respectively. Results: We observed a positive association between TSH and both BARD (OR 1.14; p = 0.035) and FLI (OR 1.19; p = 0.010) in the unadjusted analysis. We found a negative association between free triiodothyronine levels and BARD (OR 0.70; p<0.01) and a positive association between free triiodothyronine levels and FLI (OR 1.48; p = 0.022). Concerning liver function, we found a positive association between total bilirubin and free thyroxine levels (ß = 0.18 [0.02 to 0.35]; p = 0.033) and a negative association between total bilirubin and free triiodothyronine levels (ß = -0.07 [-0.14 to -0.002]; p = 0.042). Conclusion: Higher levels of TSH and free triiodothyronine may be associated with a higher risk of NAFLD, particularly steatosis, in patients with morbid obesity.

Which Factors Are Associated with a Higher Prevalence of Anemia Following Bariatric Surgery? Results from a Retrospective Study Involving 1999 Patients.

INTRODUCTION: Anemia in obese patients is common and multifactorial and is also a complication of bariatric surgery. The aim of this study is to establish which variables are associated with a higher prevalence of post-bariatric surgery anemia. METHODS: Retrospective cohort study involving 1999 patients submitted to bariatric surgery with a follow-up period of 4 years. Anthropometric, laboratorial parameters and the presence of comorbidities were evaluated before surgery and during follow-up. Patients were divided into two groups, according to whether they developed anemia, or not. Groups were compared using independent sample T-tests or Chi-squared tests, as appropriate. Univariate binary logistic regression models were used to test the association between the diagnosis of anemia during follow-up and all the possible explanatory variables. Independent variables with an association with the outcome (p < 0.1) were included in multivariate binary logistic regression models, as well as possible confounders (age, BMI, and supplementation). RESULTS: Anemia was diagnosed in 24.4% of the patients. Females present a two-fold increased risk of developing anemia (OR 2.11, 95% CI 1.48-3.01, p < 0.001). Patients subjected to gastric sleeve and gastric band surgery present approximately half the risk of anemia when compared with gastric bypass surgery (RYGB) (OR 0.46, 95% CI 0.35-0.59, p < 0.001; OR 0.51, 95% CI 0.36-0.72, p < 0.001). None of the other variables evaluated showed association with the outcome. CONCLUSION: In our study, the only factors associated with an increased risk of developing anemia were female gender and RYBG surgery. Prospective studies evaluating the risk factors for anemia in patients undergoing bariatric surgery are needed.

The Impact of Bariatric Surgery on Hepatic Function and Predictors of Liver Steatosis and Fibrosis.

PURPOSE: To evaluate the variation in parameters of hepatic function and in the scores Fatty Liver Index (FLI; predictor of hepatic steatosis) and BARD (BMI, AST/ALT ratio and DM, predictor of hepatic fibrosis), 1 year after bariatric surgery. MATERIAL AND METHODS: This is a observational retrospective cohort study in patients with morbid obesity that underwent bariatric surgery in our centre. We used two linear regression models: (1) unadjusted and (2) adjusted for surgery type, sex, age, body mass index, diabetes, and dyslipidaemia. RESULTS: The included population (n = 1955) had an average age of 43.1 ± 10 years and 85.8% were female. Diabetes was present in 32.4% of the patients, 45.1% had dyslipidaemia, and 62.2% had hypertension. Twelve percent were submitted to gastric band, 29.6% to sleeve gastrectomy, and 58.4% to gastric bypass. We observed a relevant decrease in transaminases and gamma-glutamyltransferase, and an increase in alkaline phosphatase and total bilirubin. Both FLI and BARD markedly decrease 1 year after surgery (p < 0.01). Comparing the surgical procedures, sleeve gastrectomy was associated with a greater reduction of hepatic enzymes and of both FLI and BARD compared with gastric band. Comparing with gastric bypass, sleeve was associated with a greater reduction of transaminases and alkaline phosphatase, but a smaller reduction of FLI and BARD. CONCLUSION: Bariatric surgery is associated with a reduction of the hepatic enzymes and an improvement of FLI and BARD. It may represent an effective therapeutic approach for NAFLD.

Impact of Depression on Weight Variation after Bariatric Surgery: A Three-Year Observational Study.

INTRODUCTION: The association between obesity and depression has been repeatedly established. However, little is known about the impact that the diagnosis of depression before bariatric surgery (DDBS) may have on weight loss. OBJECTIVE: To evaluate the impact of DDBS on weight outcomes. METHODS: Retrospective study of patients submitted to BS. Patients with no weight, no current medication data, or those submitted to revision surgery were excluded. Patients were considered to have DDBS based on taking antidepressants prior to BS or if there was a medical history of past or current depression. Patients with and without a depression history were compared using independent t test. A multivariate logistic regression model was created to evaluate predictors of weight variation (variables included: age, sex, and type of surgery). RESULTS: A total of 616 patients did not have a history of depression and 230 had DDBS. There was a statistically significant difference in the BMI variation between groups. On average, individuals with DDBS lost 1.4 kg/m2 less than those without DDBS. In the multivariate analysis, the group with DDBS, compared with the group without DDBS, presented on average less -0.9 kg/m2 (95% CI -1.7 to -0.2, p = 0.018) BMI variation. CONCLUSION: DDBS is a predictor of lower weight loss after the surgical procedure. Even after adjusting for confounding variables such as age, sex, and BS type, this effect remains.

Cushing's syndrome: Consequences of late diagnosis after bariatric surgery.

Prior to bariatric surgery, endocrine causes of obesity must be excluded. The diagnosis of osteoporosis in a male requires the study of secondary causes of this condition. The diagnostic delay of Cushing's syndrome may have irreversible consequences.

Dopamine agonists in prolactinomas: when to withdraw?

Dopamine agonists (DAs) are well recognized as the first-line therapy for prolactinomas due to their efficacy in achieving tumoral shrinkage and normoprolactinemia. However, it remains to be established the best timing to withdraw DAs and in which patients this should be attempted. Studies in the 1980s, mainly using bromocriptine, started to defy the concept that DAs should be regarded as a lifelong therapy considering that sustained normoprolactinemia was attained in a small subset of patients after drug withdrawal. The introduction of the more effective agent cabergoline led to an increase in the percentages of remission. The most recent meta-analysis on the topic stated than remission rates after withdrawal can range from 15% in macroprolactinoma patients treated with bromocriptine to 41% in those with microprolactinomas previously treated with cabergoline. When more stringent criteria were applied before attempting withdrawal, sustained remission ensued in more than 50% of the individuals. Treatment duration for more than 24 months, the achievement of normoprolactinemia, marked reduction (≥ 50%) in tumoral size and DAs tapering till a low maintenance dose (e.g. cabergoline 0.5 mg/week) have been the most consistently identified predictors of success. In addition, a growing amount of evidence suggests that the post-pregnancy/breastfeeding period and menopause are reasonable timings to re-access the need for continuing DAs therapy. Considering that the achievement of sustained normoprolactinemia is still far from being universal after the withdrawal, even in highly selected cohorts, future larger prospective studies should continue to address this issue.

Variable Thresholds of Vitamin D Plasma Levels to Suppress PTH: the Effect of Weight and Bariatric Surgery.

BACKGROUND: Serum 25-hydroxyvitamin D [25(OH)D] and parathormone (PTH) have an inverse relation. The 25(OH)D threshold required to maximally suppress PTH has been used as a marker of optimal vitamin D status. Obesity is associated with lower serum levels of 25(OH)D and higher levels of PTH; however, the relation between these hormones in this setting is not well established. We aimed to assess the influence of excessive weight and weight loss after bariatric surgery on the relation between serum 25(OH)D and PTH. METHODS: Anthropometric and analytical parameters of phospho-calcium metabolism from 290 patients undergoing bariatric surgery were analyzed. The association between 25(OH)D and PTH before and 1 year after surgery was evaluated through Student's t test and simple and multivariable linear regression. RESULTS: At baseline, there was an inverse association between 25(OH)D and PTH plasma levels (ß = - 0.571; p = 0.001). The threshold for a significant increase of PTH at baseline was a 25(OH)D level of < 10 ng/mL (p < 0.001). At 1 year after surgery (n = 194), the association between the two variables was weaker (ß = - 0.291; p = 0.014). The 25(OH)D threshold for a significant increase in serum PTH levels was lower in patients who maintained obesity (n = 77) [25(OH)D 5 vs 10 ng/mL]. CONCLUSIONS: PTH suppression threshold observed in patients with morbid obesity before and after bariatric surgery is lower than that described for the general population, suggesting that the 25(OH)D plasma levels may not be representative of the body's vitamin D reserves. Other studies are required to demonstrate which optimal vitamin D levels need to be aimed for in obesity, in order to improve obese patients' bone health.

Diagnosis, treatment, and survival analysis of adrenocortical carcinomas: a multicentric study.

INTRODUCTION: Current guidelines specify controversial areas in adrenocortical carcinomas (ACC), such as optimal follow-up time after remission and identification of prognostic markers. We aim to address these topics by analyzing four reference centers in our country. METHODS: Cross-sectional multicentric study of 69 patients (mean age: 51.7 ± 16.7 years-old; women, 72.5%). Kaplan-Meier survival curves and Cox regression analysis were used to calculate overall survival and its predictors. RESULTS: Thirty-eight individuals (55.0%) had hormonal autonomous production, and 40.6% of the patients presented with metastasis. Surgery was performed in 84.1% of them. Most of these patients (72.4%) were then assigned to adjuvant therapy, while 27.6% were actively surveilled. Among patients undergoing surgery, those who achieved transient remission presented a longer survival time (66 months) than those who never reached the disease-free status (21 months) (p = 0.021). One patient presented with recurrence more than 7 years after complete tumor resection. The lowest overall survival was observed in patients (n = 11) assigned to palliative care since diagnosis (9 months). Tumor stage was identified as the only independent predictor of survival in our cohort (p = 0.006). Five-year survival was 67% for tumors confined to the adrenal space (stage I/II), 56% for locally advanced disease (stage III), and 0% for metastatic disease (stage IV). CONCLUSION: This study reinforces the dismal prognosis of ACC, the need for long-term follow-up, and tumor stage as the most important survival predictor. Reviewing medical records in such rare conditions is an opportunity to identify insufficiencies and to improve medical care.

Long-Term Weight Loss and Metabolic Syndrome Remission after Bariatric Surgery: The Effect of Sex, Age, Metabolic Parameters and Surgical Technique - A 4-Year Follow-Up Study.

INTRODUCTION: Bariatric surgery is an effective treatment for morbid obesity and its metabolic related comorbidities. However, the literature reports inconsistent results regarding weight loss (WL) and the resolution of comorbidities associated with obesity. OBJECTIVE: We aim to evaluate long-term differences in WL between different surgical techniques and the impact of each surgical technique on metabolic parameters (type 2 diabetes mellitus [T2DM], dyslipidemia,hypertension, and metabolic syndrome). We also aim to evaluate the effect of baseline clinical characteristics in WL and in the evolution of metabolic syndrome (MetS) components. Our hypothesis is that different types of surgery have different effects on WL and the prevalence of comorbidities over time. METHODS: We retrospectively evaluated WL and metabolic parameter remission (T2DM, dyslipidemia, hypertension, and MetS) during 4 years in 1,837 morbidly obese patients (females, 85%; age, 42.5 ± 10.6 years; BMI, 44.0 ± 5.8) who underwent bariatric surgery (Roux-en-Y gastric bypass [RYGB], laparoscopic sleeve gastrectomy [LSG], and laparoscopic adjustable gastric band [LAGB]). RESULTS: The mean percentage of WL for RYGB, LSG, and LAGB was, respectively, 32.9 ± 8.7, 29.8 ± 9.8, and 16.2 ± 9.6 at 12 months and 30.6 ± 9.1, 22.7 ± 10.0, and 15.8 ± 10.8 at 48 months (p < 0.001), even after adjustment for baseline weight, BMI, age, and sex (p < 0.001). Women had more WL during the first 36 months (p = 0.013 and 0.007 at 12 and 36 months, respectively) and older patients had less WL compared to younger ones (p <0.001), except at 48 months. Patients with T2DM had less WL than those without diabetes after adjustment (sex, age, and surgical technique) during the same period. Patients with hypertension had less WL at 12 months (p = 0.009) and MetS at 24 months (p = 0.020) compared to those without these comorbidities. There was no significant difference regarding the presence of dyslipidemia in WL. The RYGB group showed better results for MetS resolution. CONCLUSION: During the 4-year follow-up, RYGB was the surgical procedure that caused the highest WL and MetS resolution.

Ectopic Cushing's Syndrome Unveiling a Metastatic Parotid Carcinoma.

INTRODUCTION: Adrenocorticotropic hormone (ACTH) ectopic production is a rare cause of Cushing syndrome (CS). The most commonly associated tumours are small-cell lung carcinoma along with bronchial and thymic carcinoids. To date, only 5 cases have been published in the literature featuring ectopic ACTH secretion from metastatic acinic cell carcinoma (ACC) of the parotid gland. We hereby describe a very uncommon case of ectopic CS (ECS) unveiling a metastatic parotid ACC. CASE PRESENTATION: A 46-year-old man with hypertension and dyslipidemia diagnosed 4-months before, as well as new-onset diabetes mellitus unveiled 1-month earlier, was referred to emergency department for hypokalemia. Hormonal study and dynamic biochemical tests performed indicated ECS. Imaging and cytological findings pointed toward a likely primary right parotid malignancy with liver metastases. Somatostatin receptor scintigraphy has shown an increased uptake in the parotid gland and mild expression in liver metastasis. The patient underwent right parotidectomy, and histopathologic examination confirmed ACC. Meanwhile, hypercortisolism was managed with metyrapone, ketoconazole, and lanreotide. Despite chemotherapy onset, a rapid disease progression and clinical course deterioration was observed. CONCLUSION: The present report highlights a rare ECS, exposing a metastatic parotid ACC, with an aggressive and challenging clinical course, representing the first case whose diagnosis of ECS came prior to ACC.

Metformin in overweight and obese women with gestational diabetes: a propensity score-matched study.

PURPOSE: Obesity and gestational diabetes mellitus (GDM) have an independent negative impact in pregnancy outcomes. Excessive gestational weight gain (GWG) represents an additional high-risk condition for adverse outcomes. The aims of this study were to evaluate the potential effect of metformin in GWG in overweight or obese women with GDM, to report our experience and to assess metformin's safety in this population. METHODS: Retrospective observational cohort study involving pregnant women with GDM and pregestational overweight or obesity. Demographic, anthropometric, glycemic control data, obstetric, fetal and neonatal outcomes were evaluated. The sample was divided into two groups according to metformin treatment. A propensity score-matched analysis was performed using age, initial body mass index (BMI), trimester at GDM diagnosis and previous history of GDM or macrosomia as covariates. RESULTS: Of the 457 enrolled in the study, 177 (38.7%) were treated with metformin. Two groups of 130 well matched patients were balanced regarding baseline characteristics. Women in metformin group had significantly less excessive GWG (29.23% vs. 42.31%, OR 0.56, 95% CI 0.34-0.94, p = 0.028) and more adequate GWG (36.92% vs. 23.08%, OR 1.95, 95% CI 1.14-3.35, p = 0.015). No significant differences were found between both groups regarding glycemic control, rate of insulinization, and obstetric, fetal, and neonatal outcomes. CONCLUSIONS: This study highlights metformin as an important and safe tool to prevent excessive GWG and promote adequate GWG in overweight or obese women with GDM, regardless of age, BMI, timing of GDM diagnosis, previous history of GDM or macrosomia.

Long-term diabetes outcomes after bariatric surgery-managing medication withdrawl.

BACKGROUND/OBJECTIVES: Bariatric surgery leads to type 2 diabetes mellitus (T2DM) remission, but recurrence can ensue afterwards. However, literature provides heterogenous remission/recurrence criteria and there is no consensus on long-term T2DM management after surgery. We aim to assess T2DM remission/recurrence rates using standardized criteria and to identify relapse predictors. We also intend to analyze the management of residual T2DM and the impact of maintaining/withdrawing metformin in avoiding future relapse. SUBJECTS/METHODS: We investigated a cohort of 110 obese patients with T2DM who underwent bariatric surgery and were followed for 5 years (Y0-Y5). Patients who ever attained remission were accounted for cumulate remission, while prevalent remission was considered for individuals who were on remission in a specific visit. RESULTS: A complete prevalent remission of 47.3% was reached at Y1 and it remained stable till Y5 (46.4-48.2%). Complete cumulative rate was of 57.3% at Y5. Five-year T2DM recurrence rate was 15.9% and it was associated with higher pre-operative HbA1c levels (ß = 1.06; p < 0.05) and a milder excess body weight loss (EBWL) (ß = 0.49; p < 0.05). Glucose-lowering agents were fully stopped in 51.4% of the patients till Y1 and in 16.2% of them afterwards. Medication withdrawal was mainly attempted in patients with a lower baseline HbA1c (ß = 0.54; p < 0.01) and higher first-year EBWL (ß = 1.04; p < 0.01). Patients that kept metformin after reaching a HbA1c in the complete remission range (<6.0%) did not have greater odds of avoiding relapse in the next visit (OR = 0.33; p = 0.08). CONCLUSIONS: Baseline HbA1c and EBWL were the main variables driving both T2DM relapse after bariatric surgery and the attempt to withdrawal anti-diabetic medication. In our population keeping metformin once an HbA1c < 6.0% is achieved did not seem to diminish relapse but further studies on this matter are needed.

Pituitary incidentalomas in paediatric age are different from those described in adulthood.

PURPOSE: Guidelines on pituitary incidentalomas evaluation and management are limited to adults since there are no data on this matter in the paediatric population. We aim to analyse the morphologic characteristics, hormonal profile and follow-up of these lesions in children. METHODS: We have searched for pituitary incidentalomas in the neuroimaging reports and electronic medical records of the Paediatric Endocrinology Clinic of our centre. Patients with 18 years-old or less were included. RESULTS: Forty-one incidentalomas were identified, 25 of them (62.4%) in females. The mean age at diagnosis was 12.0 ± 4.96 years-old. Headaches were the main reason that led to image acquisition (51.2%) and MRI was the imaging method that detected the majority of the incidentalomas (70.7%). The most prevalent lesion was pituitary hypertrophy (29.3%), which was mainly diagnosed in female adolescents (91.7%), followed by arachnoid cysts (17.1%), pituitary adenomas (14.6%) and Rathke's cleft cysts (12.2%). Most patients (90.2%) did not present clinical or laboratorial findings of hypopituitarism or hormonal hypersecretion. Four patients presented endocrine dysfunction: three had growth hormone deficiency and one had a central precocious puberty. Twenty-three patients (56.1%) underwent imagiological revaluation during a median follow-up time of 24.6 months (interquartile range 5.07). None of them presented dimensional progression. CONCLUSIONS: To the best of our knowledge, this is the first series of pituitary incidentalomas in pediatric age. Comparing our series with those conducted in adults, we have observed a higher preponderance of pituitary hypertrophy over adenomas, a lower prevalence of hormonal hyper/hyposecretion and lower risk of dimensional progression during follow-up.

68Ga-DOTANOC and 18F-FDG PET/CT in metastatic medullary thyroid carcinoma: novel correlations with tumoral biomarkers.

OBJECTIVE: Metastatic disease is common in medullary thyroid carcinoma (MTC) and it is usually detected by raising calcitonin and carcinoembryonic antigen (CEA) levels. Nuclear medicine imaging has an important role in lesion identification/characterisation. We aim to compare 68Ga-DOTANOC PET/CT and 18F-FDG PET/CT performance and to explore the correlations between tumoral markers and functional imaging. METHODS: This a retrospective cross-sectional study including 13 patients with MTC and high calcitonin/CEA levels that underwent both 68Ga-DOTANOC PET/CT and 18F-FDG PET/CT. RESULTS: 68Ga-DOTANOC PET/CT identified MTC metastases in 2twopatients that were 18F-FDG-negative (sensitivity of 69.2% vs. 53.9%, respectively). 68Ga-DOTANOC PET/CT also detected a higher number of lesions than 18F-FDG PET/CT in seven patients, with only one patient showing the opposite pattern. Both differences lacked statistical significance (p = 0.50 and p = 0.86, respectively) but 68Ga-DOTANOC PET/CT better performance allowed changes in patients' management. 68Ga-positive/18F-FDG-negative patients were the ones with the lowest calcitonin doubling time and presented a CEA doubling time >24 months, while the patient with more 18F-FDG-positive lesions was the one with the highest CEA/calcitonin ratio. The number of lesions found in 68Ga-DOTANOC PET/CT were correlated with calcitonin levels (r = 0.73; p < 0.01) but not with CEA ones (r = 0.42; p = 0.15). The number of 18F-FDG hypermetabolic focus were correlated with CEA levels (r = 0.60; p < 0.05) but not with calcitonin (r = 0.48; p = 0.09). CONCLUSIONS: This is the first study to describe a positive correlation between 68Ga-positive lesions and calcitonin levels and between 18F-FDG-positivity and CEA levels. Tumoral markers pattern in metastatic MTC could help clinicians to decide which exam to perform first.

Comparative Effectiveness of Different Bariatric Procedures in Super Morbid Obesity.

BACKGROUND: Super obesity (BMI ≥ 50 kg/m2) is associated with significant morbidity and mortality. The best procedure to treat super obesity is not completely established. Our aim was to compare the effectiveness of bariatric procedures (adjustable gastric band [AGB], Roux-en-Y gastric bypass [RYGB], sleeve gastrectomy [SG]) in super obesity. METHODS: Retrospective observational study of super obese patients who underwent bariatric surgery. Data was assessed preoperatively and in the 1st and 2nd years of follow-up. RESULTS: We evaluated 213 individuals, 77.9% female, age of 43.38 ± 11.49 years, and preoperative BMI of 54.53 ± 4.54 kg/m2; 19 submitted to AGB, 127 to RYGB, and 67 to SG. In the pre-surgical assessment, there were no significant differences in age, anthropometric parameters, blood pressure, glycemic profile, and lipid profile between the three surgical groups. The percentage of excess weight loss (%EWL) in the 1st year was 67.58% in RYGB, 58.74% in SG, and 38.71% in AGB (p < 0.001), and the percentage of total weight loss (%TWL) was 36.29%, 31.59%, and 21.07%, respectively (p < 0.001). Two years after surgery (n = 147; follow-up rate of 69%), the %EWL and %TWL were significantly higher in the RYGB group (p < 0.001). RYGB had a higher success rate (%EWL ≥ 50% and %TWL ≥ 20%) in both years of follow-up (p < 0.001). In multiple linear regression, after adjusting for other covariates, RYGB was the only strong predictive factor of %EWL and %TWL (p < 0.001). CONCLUSION: RYGB proved to be more effective in super obesity. The beneficial effects in weight loss were evident both 1 and 2 years after the procedure, regardless of pre-surgical anthropometric characteristics.

Prolactin-Producing Pituitary Carcinoma, Hypopituitarism, and Graves' Disease-Report of a Challenging Case and Literature Review.

INTRODUCTION: The diagnosis of pituitary carcinoma is very rare, requires the evidence of metastatic disease, and has a poor overall survival. Malignant prolactinoma frequently requires dopamine agonist therapy, pituitary surgery, radiotherapy, and even chemotherapy. CASE DESCRIPTION: A 19-year-old female presented with galactorrhea, primary amenorrhea, and left hemianopsia. Complementary study detected hyperprolactinemia and a pituitary macroadenoma with cavernous sinus invasion and suprasellar growth. She was treated with cabergoline and bromocriptine without clinical or analytical improvement. Resection of the pituitary lesion was programmed and a non-contiguous lesion of the nasal mucosa was detected during the approach. This metastasis led to the diagnosis of prolactin-producing pituitary carcinoma. After partial resection, the patient was submitted to radiotherapy for residual disease with persistent symptoms. She developed growth hormone deficiency, central hypothyroidism, hypogonadism, and permanent diabetes insipidus. Six years later she was admitted for the suspicion of secondary adrenal insufficiency and thyrotoxicosis. Physical findings, laboratory data, thyroid ultrasound, and scintigraphy achieved the diagnosis of Graves' disease and hypocortisolism. She was treated with hydrocortisone and methimazole, but central hypothyroidism recurred after antithyroid drug withdrawal. Nine years after the diagnosis of a pituitary carcinoma, she maintains treatment with bromocriptine, has a locally stable disease, with no metastases. CONCLUSION: This report highlights an unusual presentation of a prolactin-producing pituitary carcinoma in a young female. The patient had multiple hormone deficiencies due to a pituitary lesion and treatments. The posterior development of hyperthyroidism and adrenal insufficiency brought an additional difficulty to the approach.