Medullary Thyroid Carcinoma in Patients with Graves' Disease-A Case Series and Literature Review.

INTRODUCTION: Graves' disease (GD) is an autoimmune disorder affecting the thyroid gland, leading to systemic manifestations such as hyperthyroidism, Graves' orbitopathy, and pretibial myxedema. Contrary to previous beliefs that hyperthyroidism protects against thyroid cancer, recent studies reveal an increased incidence of thyroid malignancies in GD patients, particularly differentiated thyroid carcinomas and, in rare cases, medullary thyroid carcinoma (MTC). CASE SERIES: This case series presents three female GD patients diagnosed with MTC, highlighting the complexities of diagnosis and management. All patients exhibited thyroid nodules with suspicious ultrasonographic features, elevated plasma calcitonin levels, and required total thyroidectomy. Histological examination confirmed MTC. DISCUSSION: These cases underscore the importance of routine calcitonin screening in GD patients with thyroid nodules to facilitate early detection and improve prognosis. Our findings suggest that while the coexistence of GD and MTC is likely incidental, vigilant monitoring and comprehensive evaluation are crucial for timely intervention. CONCLUSIONS: This study advocates for integrating calcitonin testing into the standard diagnostic protocol for GD patients presenting with thyroid abnormalities.

Vitamin D-A New Therapeutic Target in the Management of Type 2 Diabetes Patients.

Background: Vitamin D is a fat-soluble vitamin that prevents cardiovascular diseases and diabetes mellitus (DM). The present research aimed to study the impact of 25-hydroxyvitamin D (25(OH)D) level on the health status of patients with type 2 DM (T2DM) hospitalized in the "Pius Brînzeu" Emergency Clinical County University Hospital in Timisoara, Romania. Methods: The study retrospectively included 160 patients with T2DM who were clinically and biologically evaluated during hospitalization. Results: 13.1% of patients had optimal, 23.1% insufficient, and 63.8% deficient 25(OH)D values. Patients with 25(OH)D deficiency presented poorer glycemic control and were older, with higher weight, but had altered renal function, anemia, and lower iron values. Also, patients with associated neoplasia, diabetic neuropathy, cardiovascular disease (CVD), dementia, and grade 3 arterial hypertension (HTN) had lower values of 25(OH)D. An age > 55 years (sensitivity 69.9, specificity 82.5, AUROC 0.786, p < 0.001) and an HbA1c > 7.7% (sensitivity 89.3, specificity 92.9, AUROC 0.938, p < 0.001) predict 25(OH)D deficiency in T2DM patients. Conclusions: Vitamin D influences almost every system and organ in the body, so it should be a routine test for all patients with DM to correct the deficiency and prevent other diseases and complications.

A rare form of hyperthyroidism leading to the diagnosis of acromegaly: A case report.

Acromegaly is a rare disease, usually caused by a pituitary tumor. It typically exhibits slow evolution and can result in numerous complications. In the present case report, the patient presented with hyperthyroidism associated with ophthalmopathy and right nodular goiter. The laboratory tests revealed persistent high levels of phosphorus without an apparent cause. After ruling out common pathologies associated with this finding, a focus was placed on the clinical aspects associated with acromegaly, a rare cause of hyperphosphatemia. Laboratory tests and MRI confirmed the diagnosis. The patient underwent transsphenoidal surgery, but the disease remained active, thus medical treatment was initiated, to a poor initial response. Associated with acromegaly, two distinct thyroid pathologies were diagnosed: Toxic adenoma and Graves' disease. This case highlights the challenges in diagnosing and managing a rare endocrine pathology.

Can Routine Laboratory Tests Be Suggestive in Determining Suspicions of Malignancy in the Case of Thyroid Nodules?

Background and objectives: Thyroid nodules are a common finding in clinical practice and can be either benign or malignant. The aim of this study was to compare laboratory parameters between patients with malignant thyroid nodules and those with benign thyroid nodules. Materials and methods: A total of 845 patients were included, with 251 in the study group (malignant thyroid nodules) and 594 in the control group (benign thyroid nodules). Results: Our results show that there were statistically significant differences in several laboratory parameters, including FT3, FT4, ESR, fibrinogen, WBC, and lymphocyte percentage, between the two patient groups (p < 0.05). Conclusions: These findings suggest that certain laboratory parameters may be useful in differentiating between benign and malignant thyroid nodules and could aid in the diagnosis and treatment of thyroid cancer. However, further diagnostic tests such as fine-needle aspiration biopsy and imaging studies are typically required for an accurate diagnosis. Routine laboratory tests prove most effective when combined with other diagnostic methods to identify thyroid cancer. Although not conclusive on their own, these tests significantly suggest and guide physicians to suspect malignancy in thyroid nodules. This affirmative answer to our question, "Can routine laboratory tests be suggestive in determining suspicions of malignancy in the case of thyroid nodules?" aligns with the results of our study.

The Experience of a Single Tertiary Center Regarding Benign and Malignant Tumors in Acromegalic Patients.

Background and Objectives: Acromegaly is a rare disease associated with increased levels of growth hormones (GHs) that stimulates the hepatic production of insulin growth factor-1 (IGF-1). Increased secretion of both GH and IGF-1 activates pathways, such as Janus kinase 2/signal transducer and activator of transcription 5 (JAK2/STAT5), and mitogen-activated protein kinase (MAPK), involved in the development of tumors. Materials and Methods: Given the disputed nature of the topic, we decided to study the prevalence of benign and malignant tumors in our cohort of acromegalic patients. In addition, we aimed to identify risk factors or laboratory parameters associated with the occurrence of tumors in these patients. Results: The study group included 34 patients (9 men (25.7%) and 25 women (74.3%)). No clear relationship between the levels of IGF-1 or GH and tumor development could be demonstrated, but certain risk factors, such as diabetes mellitus (DM) and obesity, were more frequent in patients with tumors. In total, 34 benign tumoral proliferations were identified, the most common being multinodular goiter. Malignant tumors were present only in women (14.70%) and the most frequent type was thyroid carcinoma. Conclusions: DM and obesity might be associated with tumoral proliferation in patients with acromegaly, and findings also present in the general population. In our study we did not find a direct link between acromegaly and tumoral proliferations.

Collision tumor of the thyroid - a challenge during the COVID-19 pandemic.

Some of the patients with anaplastic thyroid carcinomas have a coexistent differentiated thyroid cancer, sustaining the hypothesis that this cancer may develop from more differentiated tumors. We describe a case with a collision tumor of the thyroid, defined as a neoplastic lesion composed of two distinct cell populations, with distinct borders. The patient presented during the COVID-19 pandemic with dysphonia, dyspnea, multinodular goiter and a painless, rapidly enlarging, left cervical swelling. She had been first time diagnosed with left nodular goiter in 2007, with an indication for surgery, which she declined. After partial excision of the left latero-cervical adenopathy, the pathological analysis showed massive lymph node metastasis from anaplastic thyroid cancer. A total thyroidectomy was done; the postoperative pathological exam identified a papillary thyroid microcarcinoma in the right lobe and an anaplastic thyroid cancer in the left lobe. Postoperatively, levothyroxine treatment was started and the patient was referred to radiotherapy. This case highlights the importance of urgent management of some cases with compressive multinodular goiter, even during the COVID-19 pandemic.

2D-Shear Wave Elastography in the Evaluation of Parathyroid Lesions in Patients with Hyperparathyroidism.

BACKGROUND AND AIMS: 2D-shear wave elastography (2D-SWE) is a relatively new elastographic technique. The aim of the present study is to determine the values of the elasticity indexes (EI) measured by 2D-SWE in parathyroid benign lesions (adenomas or hyperplasia) and to establish if this investigation is helpful for the preoperative identification of the parathyroid adenoma. MATERIAL AND METHODS: The study groups were represented by 22 patients with primary or tertiary hyperparathyroidism, diagnosed by specific tests, and 43 healthy controls, in whom the thyroid parenchyma was evaluated, in order to compare the EI of the thyroid tissue with those of the parathyroid lesions. RESULTS: The mean EI measured by 2D-SWE in the parathyroid lesions was 10.2 ± 4.9 kPa, significantly lower than that of the normal thyroid parenchyma (19.5 ± 7.6 kPa; p = 0.007), indicating soft tissue. For a cutoff value of 12.5 kPa, the EI assessed by 2D-SWE had a sensitivity of 93% and a specificity of 86% (AUC = 0.949; p < 0.001) for predicting parathyroid lesions. CONCLUSION: A value lower than 12.5 kPa for the mean EI measured by 2D-SWE can be used to confirm that the lesion/nodule is a parathyroid adenoma.

The absence of CD56 expression can differentiate papillary thyroid carcinoma from other thyroid lesions.

CONTEXT: The neural cell adhesion molecule CD56 is an antigen important for the differentiation of the follicular epithelium. Recent studies have reported low or absent expression of CD56 in papillary thyroid carcinoma (PTC) and its presence in normal thyroid tissue, benign thyroid lesions, and most follicular non-PTC tumors. AIM: We wish to estimate the value of CD56 in the differentiation of PTC (including follicular variant-PTC [FV-PTC]) from other nontumoral lesions and follicular thyroid neoplasias. SETTINGS AND DESIGN: This was a retrospective, case-control study. SUBJECTS AND METHODS: We analyzed the expression of CD56 in normal thyroid follicular tissue, 15 nonneoplastic thyroid lesions (nodular hyperplasia, Graves' disease, and chronic lymphocytic thyroiditis/Hashimoto), and 38 thyroid follicular cell neoplasms (25 cases of PTC). The immunohistochemical reactions were performed on sections stained with anti-CD56 antibody. STATISTICAL ANALYSIS USED: We used the Chi-square test, values of P< 0.05 being considered statistically significant. Risk analysis was applied on these studied groups, by calculating the odds ratio (OR) value. RESULTS: Our results indicated that CD56 immunoexpression had differentiated PTC from benign nonneoplastic lesions (P = 0.002), as well as from follicular neoplasias (P = 0.046). There were no significant differences regarding CD56 expression between FV-PTC and classical PTC (P = 0.436). The immunoexpression of CD56 has differentiated PTC from other thyroid non-PTC lesions (P < 0.001), with 26.4 OR value. CONCLUSIONS: CD56 has been proved to be a useful marker in the diagnosis of PTC, including FV-PTC. Its absence can help differentiate FV-PTC from other thyroid nodules with follicular patterns.

Real-time shear wave elastography may predict autoimmune thyroid disease.

OBJECTIVE: To evaluate and compare the values of the elasticity index as measured by shear wave elastography in healthy subjects and in patients with autoimmune thyroid disease, in order to establish if this investigation can predict the occurrence of autoimmune thyroid disease. METHODS: A total of 104 cases were included in the study group: 91 women (87.5%), out of which 52 (50%) with autoimmune thyroid disease diagnosed by specific tests and 52 (50%) healthy volunteers, matched for age and gender. For all the subjects, three measurements were performed on each thyroid lobe and a mean value was calculated. The data were expressed in kPa. The investigation was performed with an Aixplorer system (SuperSonic Imagine, France), using a linear high-resolution 15-4 MHz transducer. RESULTS: The mean value for the elasticity index was similar in the right and the left thyroid lobes, both in normal subjects and in patients with autoimmune thyroid disease: 19.6 ± 6.6 vs. 19.5 ± 6.8 kPa, p = 0.92, and 26.6 ± 10.0 vs. 25.8 ± 11.7 kPa, p = 0.71, respectively. This parameter was significantly higher in patients with autoimmune thyroid disease than in controls (p < 0.001). For a cut-off value of 22.3 kPa, which resulted in the highest sum of sensitivity and specificity, the elasticity index assessed by shear wave elastography had a sensitivity of 59.6% and a specificity of 76.9% (AUROC = 0.71; p < 0.001) for predicting the presence of autoimmune thyroid disease. CONCLUSION: Quantitative elasticity index measured by shear wave elastography was significantly higher in autoimmune thyroid disease than in normal thyroid parenchyma and may predict the presence of autoimmune thyroid disease.

Some clinical aspects in chronic autoimmune thyroiditis associated with thyroid differentiated cancer.

BACKGROUND: The coexistence of Hashimoto's thyroiditis (HT) with differentiated thyroid cancer (DTC) was reported with a heterogeneous incidence. The wide distribution of this association may be related to differences in the level of morphological examination, autoimmunity used criteria, patient selection, surgical indication, genetic background, geographical and environmental factors.Some consider the coexistence of these two entities a coincidental one, others suspecting a causative link between these conditions. METHODS: This retrospective paper included 216 patients with HT, issued from an iodine-replete area. 21 cases of nodular HT were investigated by means of: thyroid functional tests (TFT), immunological determinations, thyroid ultrasonography (US) and cytological analysis.ALL CASES WERE OPERATED BECAUSE OF DIFFERENT REASONS: compressive symptoms and signs, suspicious sonographic features and certain cytological smears (malignant, indeterminate and non-diagnostic). RESULTS: The morphologic investigation revealed 9 patients with DTC and 12 cases with benign thyroid disease (BTD).None of the US analyzed characteristics provided sufficient accuracy for the diagnosis of DTC in cases with HT. The preoperative cytological examination by means of fine-needle-aspiration biopsy (FNAB) showed a better sensitivity and specificity vs. US criteria. CONCLUSION: The coexistence of HT with DTC represents a clinical reality with yet unknown significance. The difficulty of diagnosis imposes the corroboration of different types of investigations. The best diagnostic accuracy seems to be offered by thyroid US and thyroid cytological investigation.

Evaluation of proliferation potential in thyroid normo-/hypofunctioning and hyperfunctioning nodules.

INTRODUCTION: Thyroid follicular adenomas (FA) and adenomatous thyroid nodules (AN) - lesions that are frequently found in areas with iodine deficiency, can be normo-/hypofunctioning (scintigraphically cold - SCN) or hyperfunctioning (scintigraphically hot - SHN) nodules. AIM: Evaluation of proliferation potential in thyroid nodules on tissue samples obtained at surgery from euthyroid patients clinically diagnosed with SCN and from patients with thyroid hyperfunction and SHN. MATERIALS AND METHODS: We investigated the proliferation activity estimated by assessing PCNA and Ki-67 proliferation markers in 20 SCN (eight FA and 12 AN) and 16 toxic nodules (six hyperfunctioning FA and 10 toxic multinodular goiters), on formalin-fixed and paraffin-embedded tissue samples, 4-5 µm thick; we used the immunohistochemical technique in LSAB system (DAB visualization) with anti-PCNA (PC10) and anti-Ki-67 (MIB-1) monoclonal antibodies. For each case, we calculated the proliferation index PI-PCNA and PI-Ki-67. The dates were statistically evaluated using the t-unpaired test. RESULTS: We observed a higher PI-PCNA in thyroid nodules than in the normal surrounding thyroid tissue, with statistically significant values for FA (14.3% vs. 3.8%; p<0.029) and also for AN (8.36% vs. 1.24%; p<0.001). The mean PI-Ki-67 in nodules vs. surrounding thyroid tissue was 1.64% vs. 1.10% in FA (p<0.35) and 1.07% vs. 0.51% in AN (p>0.05). We also noted: (1) significantly higher PI-PCNA values (p < 0.01) in FA (14.03%) than in AN (8.36%), as compared to statistically insignificant values for Ki-67 (1.64% vs. 1.07%; p>0.05); (2) increased proliferation rate (p<0.01) in thyroid nodules with aspects of lymphocytic thyroiditis (LT) (PI-Ki-67 was 1.21%) as compared to nodules without LT (PI-Ki-67 was 0.12%); (3) a mean PI-PCNA of 8.5% and PI-Ki-67 of 4.61% in toxic thyroid nodules (TTN) vs. 3.01% and 1.5% in normal surrounding thyroid, respectively. CONCLUSIONS: The clinical expression of SCN is the consequence of increased thyrocyte proliferation in the nodules; the increased proliferative potential of TTN thyrocytes is a common feature of nodules, independent of their histopathological characteristics.