Surgical management of insulinomas at the Azerbaijan Medical University: a retrospective study of 21 cases over a 10-year period

Background/aim: This study represents the first report that evaluates the experience gathered from diagnosis, surgical treatment and outcome of insulinoma patients from Azerbaijan. Materials and methods: We retrospectively review of insulinoma patients for a 10-year period. Collected data included patient demographics, laboratory and imaging tests, detailed surgical reports, histopathological examination of resected specimens, and clinical follow-up. Results: Twenty-one insulinoma patients were identified. Male patients comprised 52.4%; mean age was 44 years. Mean time to diagnosis was 14 months; 61% patients had ≥3 medical referrals due to hypoglycemia-related symptoms. Diagnosis sensitivity of CT, MRI and US was 85%, 80%, and 55%, respectively. The mean glucose, insulin, C-peptide levels were 35.7 ± 9.5 mg/dL, 33.5 ± 21.9 µU/mL, and 3.74 ± 1.88 ng/mL, respectively. Pancreatic head and tail were the most frequent tumor locations; mean tumor size was 1.5 ± 0.7 cm. No statistical association was found between the tumor size and preoperative glucose, C-peptide and insulin levels. Distal pancreatectomy and enucleation were the most common surgical procedures. Local tumor recurrence rate was 14%. There was no mortality. Conclusions: To prevent delayed diagnoses, physicians should be familiar with the typical symptoms of these rare tumors.

Frequency of thyroid nodules and thyroid cancer in thyroidectomized patients with Graves' disease.

INTRODUCTION: Incidental thyroid cancers are frequently detected in patients operated on for Graves' disease (GD). There are no clear data about the incidence and risk factors of incidental thyroid cancer in operated GD patients. The aim of this study is to evaluate the risk of thyroid carcinoma in surgically treated GD patients. MATERIAL AND METHODS: The data of 121 GD patients who underwent total thyroidectomy in a single center between 2005 and 2015 were retrospectively evaluated. The diagnosis of thyroid cancer was based on pathological examination. RESULTS: Thyroid cancer was demonstrated in postoperative pathology specimens of 34 patients who were surgically treated for GD (28.1%). Preoperative thyroid ultrasonography (USG) revealed a nodular goiter in 62 (51.2%) patients. Nodules were not detected in the other 59 (48.8%) patients with GD. The frequency of thyroid cancer was significantly higher in patients with nodules (38% vs. 16%; p = 0.009). Thirty-two of the 34 cancer cases had papillary thyroid cancer (PTC), and the remaining 2 had follicular thyroid cancer (FTC). Of the 32 PTC patients, 28 were classical type, 2 patients had the follicular variant, 1 was the oncocytic variant, and 1 was a tall cell variant. CONCLUSIONS: The incidence of thyroid cancer was higher in patients who underwent surgery for GD. In addition to a careful physical examination in the follow-up of the patients with GD, ultrasonographic evaluation should be performed. Surgical treatment should not be delayed in patients with GD when indicated.

The Prognostic Roles of the Ki-67 Proliferation Index, P53 Expression, Mitotic Index, and Radiological Tumor Invasion in Pituitary Adenomas.

The fourth edition of the World Health Organization (WHO) classification of pituitary tumors recommended evaluation of tumor proliferation and invasion to identify aggressiveness. We aimed to assess the prognostic roles of the Ki-67 proliferation index, mitotic index, P53 expression, and cavernous sinus invasion in pituitary adenomas (PAs). Among the 601 patients who underwent transnasal/transsphenoidal adenomectomy from 2001 to 2016, 101 patients (16.8%) who had tumors with a high (≥ 3%) Ki-67 index (group A) and a control group consisting of 43 patients with a low (< 3%) Ki 67 index who were matched for age, gender, and tumor type were included. Mitotic index and P53 expressions were evaluated. Patient characteristics, histopathology reports, pre/postoperative magnetic resonance imaging (MRI), and follow-up data were assessed retrospectively. The frequency of macroadenomas and mean tumor size were greater in group A when compared to group B (67.4 vs. 94.1%, p< 0.01 and 25 ± 10.6 vs. 18 ± 11 mm, p< 0.01, respectively). Invasion to cavernous sinus was found in 53 (36.8%) patients and was more frequent in group A (p<0.01). The mean number of surgery was higher in group A than group B (p< 0.05). The mean follow-up period was 46.6 ± 34 months. The postoperative MRIs and follow-up data for at least 24 months were available in 117 patients. Recurrence risk was higher in group A than group B (p = 0.03). Tumors with high Ki-67 proliferation index were grouped as 3-5, 6-10, 11-15, and > 15%. The risk of recurrence was not different between groups of high Ki-67 index. The optimal cutoff point of the Ki-67 proliferation index that predicted recurrence was 2.5% with 84.6% sensitivity and 47.4% specificity. The cavernous sinus invasion on MRI was associated with recurrence (p = 0.03). Tumor size and recurrence risk were not associated with P53 expression. High P53 expression was related with cavernous sinus invasion (p = 0.03). The mitotic index was not associated with recurrence risk and tumor invasion. Recurrence risk was higher in tumors with ≥ 2 histopathological atypia criteria (p = 0.01). High Ki-67 index with a 2.5% cutoff point and cavernous sinus invasion on MRI are reliable markers for predicting recurrence in PAs. Recurrence risk is also higher in tumors with two histopathological aggressiveness criteria. Strict follow-up and more aggressive treatment approaches may be necessary for invasive-proliferative PAs.

Effects of tamoxifen on urinary incontinence: Case report and review of literature.

RATIONALE: Tamoxifen has been used in women with hormone receptor-positive breast cancer and has been shown to successfully reduce both recurrence and mortality. On the contrary, long-term use of tamoxifen has hormone-related urogenital side effects which decrease the quality of life of the patients. PATIENT CONCERNS: In this case report, we present a breast cancer patient receiving tamoxifen who developed urinary incontinence; we discuss the effects of tamoxifen on urinary incontinence, which decreases quality of life of the patients who were evaluated in our clinic. DIAGNOSES: Breast cancer, urinary incontinence. INTERVENTIONS: Temporarily discontinuing tamoxifen. OUTCOMES: Urinary incontinence resolved. LESSONS: Based on the case we reported and literature, estrogen can cause a dose-dependent increase in incontinence, but more preclinical and clinical studies of both estrogen and SERMs are needed to support this notion; given the fact that some small-scale clinical studies have not proven a direct relationship between tamoxifen and urinary incontinence. We suggest that clinicians faced with the issue should temporarily stop usage of the drug once the complaint of urinary incontinence arises.