Thyroid metastasis from small cell lung carcinoma: a case report and review of the literature.

INTRODUCTION: Small cell lung carcinoma frequently metastasizes to lymph nodes, liver, adrenal glands, bone, brain and pleura. Metastasis of small cell lung cancer to the thyroid gland is extremely rare. CASE PRESENTATION: A 55-year-old Turkish man presented with a mediastinal mass intermingled with mediastinal lymphadenopathy, measuring 11cm in total, and encasing superior vena cava and deviating his trachea, esophagus and vascular structures. He had superior vena cava syndrome. His thyroid appeared normal on computed tomography of his chest. A bronchoscopic biopsy showed small cell lung carcinoma. Chemotherapy with cisplatin and etoposide and external radiotherapy was given. Six months after the presentation, multiple brain metastases were detected on magnetic resonance imaging. Chemotherapy was changed to topotecan and cranial irradiation was performed. At the same time, a right thyroid nodule was detected on computed tomography of his chest and showed growth in size in the following 4 months. A palpable right thyroid nodule came to our attention at that time, the 10th month of presentation. Free thyroxine, free triiodothyronine, thyroid-stimulating hormone, antithyroglobulin and antithyroid peroxidase antibodies were within normal limits. Thyroid ultrasonography showed a right thyroid lobe 26.2×16.8×15.7mm hypoechoic solid nodule with irregular borders. Ultrasonography-guided thyroid fine-needle aspiration biopsy showed metastasis from small cell lung carcinoma. His cranial metastases worsened. He developed right cervical lymph node, hepatic, pancreatic and meningeal metastases and died 15 months after the initial presentation and 9 months after the detection of thyroid metastasis by computed tomography of his chest. Our case and two previously reported cases were male, 55-years old or older and had history of more than 40 pack-years of cigarette smoking. All had metastatic disease elsewhere, when the thyroid metastasis was diagnosed by fine-needle aspiration biopsy. All had poor survival, between 9 and 18 months, after thyroid metastasis was diagnosed. CONCLUSIONS: We conclude that in a patient with a known history of malignant disease, the finding of a new thyroid mass should be promptly evaluated with a thyroid fine-needle aspiration biopsy to search for metastatic disease. The clinical features of our and two previously reported cases were summarized.

Leptin levels and lipoprotein profiles in patients with cholelithiasis.

OBJECTIVE: To determine the relationships between serum leptin and levels of lipoprotein(a) [Lp(a)], apolipoprotein A-1 (ApoA-1) and apolipoprotein B (ApoB) in patients with cholelithiasis. METHODS: Patients with ultrasound-confirmed cholelithiasis and controls frequency-matched for age, sex, body mass index, fasting blood glucose and haemoglobin A1c levels were recruited. Fasting blood samples from all study participants were assayed for glucose, haemoglobin A1c, total cholesterol, high density lipoprotein-cholesterol (HDL-C) and triglyceride. Serum Lp(a), ApoA-1 and ApoB levels were measured using nephelometric assays; serum leptin was measured using an enzyme-linked immunosorbent assay. RESULTS: A total of 90 patients with cholelithiasis and 50 controls were included in the study. Serum levels of leptin, Lp(a), total cholesterol, triglyceride and ApoB were significantly increased, and levels of ApoA-1 and HDL-C were significantly decreased, in patients with cholelithiasis compared with controls. Serum leptin in patients with cholelithiasis were significantly positively correlated with Lp(a) and ApoB and negatively correlated with ApoA-1. CONCLUSIONS: Patients with cholelithiasis have higher leptin levels and an altered lipoprotein profile compared with controls, with increased leptin levels being associated with increased Lp(a) and ApoB levels, and decreased ApoA-1 levels, in those with cholelithiasis.

Short term effects of a low-carbohydrate diet in overweight and obese subjects with low HDL-C levels.

BACKGROUND: The aim of this study was to evaluate short-term effects of a low-carbohydrate diet in overweight and obese subjects with low HDL-C levels. METHODS: Overweight (BMI between 25-30 kg/m2) or obese (BMI over 30 kg/m2) subjects with low HDL-C levels (men with HDL-C <1.03, women <1.29 mmol/l) were invited to the study. A 1400 kcal 75-gram carbohydrate (CHO) diet was given to women and an 1800 kcal 100-gram CHO diet was given to men for four weeks. The distribution of daily energy of the prescribed diet was 21-22% from CHO, 26-29% from protein and 49-53% from fat. Subjects completed a three-day dietary intake record before each visit. Anthropometric indices, body fat ratio, blood lipids, glucose and insulin were measured. Baseline and week-four results were compared with a Wilcoxon signed ranks test. RESULTS: Twenty-five women and 18 men participated. Basal median LDL-C level of men was 3.11 and basal median LDL-C level of women was 3.00 mmol/l. After four weeks of a low-carbohydrate diet, the median energy intake decreased from 1901 to 1307 kcal/day, daily energy from carbohydrate from 55% to 33%, body weight from 87.7 to 83.0 kg and HDL-C increased from 0.83 to 0.96 mmol/l in men (p < 0.002, for all). After four weeks of a low-carbohydrate diet, the median energy intake tended to decrease (from 1463 to 1243 kcal, p = 0.052), daily energy from carbohydrate decreased from 53% to 30% (p < 0.001) and body weight decreased from 73.2 to 70.8 kg (p < 0.001) in women, but HDL-C did not significantly change (from 1.03 to 1.01 mmol/l, p = 0.165). There were significant decreases in body mass index, waist circumference, body fat ratio, systolic blood pressure, total cholesterol, triglyceride and insulin levels in all subjects. CONCLUSIONS: HDL-C levels increased significantly with energy restriction, carbohydrate restriction and weight loss in men. HDL-C levels didn't change in women in whom there was no significant energy restriction but a significant carbohydrate restriction and a relatively small but significant weight loss. Our results suggest that both energy and carbohydrate restriction should be considered in overweight and obese subjects with low HDL-C levels, especially when LDL-C levels are not elevated.

Optimal waist:height ratio cut-off point for cardiometabolic risk factors in Turkish adults.

OBJECTIVE: To identify the optimal waist:height ratio (WHtR) cut-off point that discriminates cardiometabolic risk factors in Turkish adults. DESIGN: Cross-sectional study. Hypertension, dyslipidaemia, diabetes, metabolic syndrome score >or=2 (presence of two or more metabolic syndrome components except for waist circumference) and at least one risk factor (diabetes, hypertension or dyslipidaemia) were categorical outcome variables. Receiver-operating characteristic (ROC) curves were prepared by plotting 1 - specificity on the x-axis and sensitivity on the y-axis. The WHtR value that had the highest Youden index was selected as the optimal cut-off point for each cardiometabolic risk factor (Youden index = sensitivity + specificity - 1). SETTING: Turkey, 2003. SUBJECTS: Adults (1121 women and 571 men) aged 18 years and over were examined. RESULTS: Analysis of ROC coordinate tables showed that the optimal cut-off value ranged between 0.55 and 0.60 and was almost equal between men and women. The sensitivities of the identified cut-offs were between 0.63 and 0.81, the specificities were between 0.42 and 0.71 and the accuracies were between 0.65 and 0.73, for men and women. The cut-off point of 0.59 was the most frequently identified value for discrimination of the studied cardiometabolic risk factors. Subjects classified as having WHtR >or= 0.59 had significantly higher age and sociodemographic multivariable-adjusted odds ratios for cardiometabolic risk factors than subjects with WHtR < 0.59, except for diabetes in men. CONCLUSIONS: We show that the optimal WHtR cut-off point to discriminate cardiometabolic risk factors is 0.59 in Turkish adults.

Cost-effectiveness comparison between palpation- and ultrasound-guided thyroid fine-needle aspiration biopsies.

BACKGROUND: The aim of this study is to perform a cost-effectiveness comparison between palpation-guided thyroid fine-needle aspiration biopsies (P-FNA) and ultrasound-guided thyroid FNA biopsies (USG-FNA). METHODS: Each nodule was considered as a case. Diagnostic steps were history and physical examination, TSH measurement, Tc99m thyroid scintigraphy for nodules with a low TSH level, initial P-FNA versus initial USG-FNA, repeat USG-FNA for nodules with initial inadequate P-FNA or USG-FNA, hemithyroidectomy for inadequate repeat USG-FNA. American Thyroid Association thyroid nodule management guidelines were simulated in estimating the cost of P-FNA strategy. American Association of Clinical Endocrinologists guidelines were simulated for USG-FNA strategy. Total costs were estimated by adding the cost of each diagnostic step to reach a diagnosis for 100 nodules. Strategy cost was found by dividing the total cost to 100. Incremental cost-effectiveness ratio (ICER) was calculated by dividing the difference between strategy cost of USG-FNA and P-FNA to the difference between accuracy of USG-FNA and P-FNA. A positive ICER indicates more and a negative ICER indicates less expense to achieve one more additional accurate diagnosis of thyroid cancer for USG-FNA. RESULTS: Seventy-eight P-FNAs and 190 USG-FNAs were performed between April 2003 and May 2008. There were no differences in age, gender, thyroid function, frequency of multinodular goiter, nodule location and diameter (median nodule diameter: 18.4 mm in P-FNA and 17.0 mm in USG-FNA) between groups. Cytology results in P-FNA versus USG-FNA groups were as follows: benign 49% versus 62% (p = 0.04), inadequate 42% versus 29% (p = 0.03), malignant 3% (p = 1.00) and indeterminate 6% (p = 0.78) for both. Eleven nodules from P-FNA and 18 from USG-FNA group underwent surgery. The accuracy of P-FNA was 0.64 and USG-FNA 0.72. Unit cost of P-FNA was 148 Euros and USG-FNA 226 Euros. The cost of P-FNA strategy was 534 Euros and USG-FNA strategy 523 Euros. Strategy cost includes the expense of repeat USG-FNA for initial inadequate FNAs and surgery for repeat inadequate USG-FNAs. ICER was -138 Euros. CONCLUSION: Universal application of USG-FNA for all thyroid nodules is cost-effective and saves 138 Euros per additional accurate diagnosis of benign versus malignant thyroid nodular disease. TRIAL REGISTRATION: ClinicalTrials.gov, NCT00571090.

Comparison between Turkish Cardiovascular Risk Platform and United States National Cholesterol Education Program Adult Treatment Panel III definitions of the metabolic syndrome in Turkish adults.

The Turkish Cardiovascular Risk Platform (TCRP) calls for the diagnosis of the metabolic syndrome (MS) if insulin resistance, impaired fasting glucose, impaired glucose tolerance, or diabetes mellitus and >or=2 other established criteria are present. TCRP defines insulin resistance as a homeostasis model assessment >2.7. The aim of this cross-sectional study was to compare TCRP guidelines with the United States National Cholesterol Education Program Adult Treatment Panel III (NCEP) definition of MS in Turkish adults (N=1690). The age- and sex-adjusted prevalence of MS was 25% with the TCRP and 40% for the NCEP definition. Patients with MS identified by the NCEP definition but not by the TCRP definition had lower body mass index and less insulin resistance, but had a similarly adverse cardiovascular risk factor profile to those with TCRP-identified MS, with high blood pressure, waist circumference, triglycerides, and total cholesterol/high-density lipoprotein cholesterol ratio. Other national health organizations should avoid using homeostasis model assessment as a prerequisite for diagnosing MS. Modification of the NCEP definition would be more appropriate for ethnic groups with different body sizes.

Anthropometric indices and their relationship with cardiometabolic risk factors in a sample of Turkish adults.

OBJECTIVE: To identify the best anthropometric index that predicts cardiometabolic risk factors.Design and settingCross-sectional study in Turkey, in 2003. SUBJECTS: Turkish men and women aged 18 years and over (n 1692) were examined. Body weight, height, waist and hip circumferences, blood pressure, total cholesterol, HDL cholesterol, TAG, glucose and insulin were measured. Metabolic syndrome score was calculated as the sum of modified National Cholesterol Education Program Adult Treatment Panel III criteria, excluding waist circumference. Insulin resistance was estimated by homeostasis model assessment (HOMA-IR). RESULTS: BMI, waist:hip ratio (WHpR), waist:height ratio (WHtR), waist circumference (WC) and hip circumference (HC) were significantly correlated with each other. Partial correlation coefficients between systolic blood pressure, HDL cholesterol, TAG levels or HOMA-IR and BMI, WC or WHtR were similar and higher than correlation coefficients of WHpR and HC. The association of anthropometric indices with metabolic syndrome score and Framingham risk score was highest for WHtR. Areas under the receiver-operating characteristic curves showed that WHtR was the best anthropometric index that discriminated between the presence and absence of hypertension, diabetes and metabolic syndrome, whereas WHpR was better for dyslipidaemia. CONCLUSIONS: WHtR was the best anthropometric index for predicting most cardiometabolic risk factors. WC and BMI ranked second for their predictive capability of cardiometabolic risk, followed by WHpR and HC.

Comparison of palpation-versus ultrasound-guided fine-needle aspiration biopsies in the evaluation of thyroid nodules.

BACKGROUND: The aim of this study was to compare the results of palpation-versus ultrasound-guided thyroid fine-needle aspiration (FNA) biopsies. FINDINGS: Clinical data, cytology and histopathology results were retrospectively analyzed on all patients who underwent thyroid FNA biopsy in our outpatient endocrinology clinic between January 1998 and April 2003. The same investigators performed all thyroid FNAs (ASC) and cytological evaluations (KP). Subjects in the ultrasound-guided group were older, otherwise there were no differences in baseline characteristics (gender, thyroid function, the frequency of multinodular goiter, nodule diameter and nodule location) between groups. Cytology results in nodules aspirated by palpation (n = 202) versus ultrasound guidance (n = 184) were as follows: malignant 2.0% versus 2.7% (p = 0.74), benign 69.8% versus 79.9% (p = 0.02), indeterminate 1.0% versus 4.9% (p = 0.02), inadequate 27.2% versus 12.5% (p < 0.01). Malignant results were compared with Fisher's exact test. Other cytology categories were compared with chi-square test. Eighteen patients from the palpation- and 23 from ultrasound-guided group underwent surgery. In the palpation-guided group, the sensitivity of FNA was 100%, specificity 94%, positive predictive value 67% and negative predictive value 100%. In the ultrasound-guided group, the sensitivity of FNA was 100%, specificity 80%, positive predictive value 73% and negative predictive value 100%. CONCLUSION: We demonstrate that ultrasound guidance for thyroid FNA significantly decreases inadequate for evaluation category. We also confirm the high sensitivity and specificity of thyroid FNA biopsy in the diagnosis of thyroid cancer. Where available, we recommend universal application of ultrasound guidance for thyroid FNA biopsy as a standard component of this diagnostic technique.

Analysis of agreement among definitions of metabolic syndrome in nondiabetic Turkish adults: a methodological study.

BACKGROUND: We aimed to explore the agreement among World Health Organization (WHO), European Group for the Study of Insulin Resistance (EGIR), National Cholesterol Education Program (NCEP), American College of Endocrinology (ACE), and International Diabetes Federation (IDF) definitions of the metabolic syndrome. METHODS: 1568 subjects (532 men, 1036 women, mean age 45 and standard deviation (SD) 13 years) were evaluated in this cross-sectional, methodological study. Cardiometabolic risk factors were determined. Insulin sensitivity was calculated by HOMA-IR. Agreement among definitions was determined by the kappa statistic. ANOVA and post hoc Tukey's test were used to compare multiple groups. RESULTS: The agreement between WHO and EGIR definitions was very good (kappa: 0.83). The agreement between NCEP, ACE, and IDF definitions was substantial to very good (kappa: 0.77-0.84). The agreement between NCEP or ACE or IDF and WHO or EGIR definitions was fair (kappa: 0.32-0.37). The age and sex adjusted prevalence of metabolic syndrome was 38% by NCEP, 42% by ACE and IDF, 20% by EGIR and 19% by WHO definition. The evaluated definitions were dichotomized after analysis of design, agreement and prevalence: insulin measurement requiring definitions (WHO and EGIR) and definitions not requiring insulin measurement (NCEP, ACE, IDF). One definition was selected from each set for comparison. WHO-defined subjects were more insulin resistant than subjects without the metabolic syndrome (mean and SD for log HOMA-IR, 0.53 +/- 0.14 vs. 0.07 +/- 0.23, respectively, p < 0.05) and had higher Framingham risk scores (mean and SD, 2.99 +/- 4.64% vs. 1.10 +/- 1.87%, respectively, p < 0.05). The additional subjects identified by IDF definition, but not by WHO definition also had more insulin resistance and higher Framingham risk scores than subjects without the metabolic syndrome (mean and SD, log HOMA-IR 0.18 +/- 0.18 vs. 0.07 +/- 0.23, p < 0.05 and Framingham risk score 2.93 +/- 4.54% vs. 1.10 +/- 1.87%, p < 0.05). The IDF-identified additional subjects had similar Framingham risk scores as WHO-identified subjects (p > 0.05), but lower log HOMA-IR values (p < 0.05). CONCLUSION: The metabolic syndrome definitions that do not require measurement of insulin levels (NCEP, ACE and IDF) identify twice more patients with insulin resistance and increased Framingham risk scores and are more useful than the definitions that require measurement of insulin levels (WHO and EGIR).