MYTHS AND CONTROVERSIES IN HYPOGONADISM TREATMENT OF AGING MALES.

Low T is an independent risk factor for metabolic syndrome (MetS) and type 2 diabetes mellitus (T2DM) development; patients with these clinical conditions should be screened for hypogonadism. Testosterone replacement therapy (TRT) ameliorates libido, improves bone mass, improves insulin resistance, reduces fat mass and increases lean body mass with no change in body weight. There are no evidences that testosterone therapy increases the risk of prostate cancer but it is certain that testosterone stimulates growth of metastatic prostate cancer. TRT has an antiarrhythmic and a vasodilator effect, independent of the nitric oxide effect. Patients with heart failure have low levels of testosterone, and TRT improves exercise capacity. Men with low testosterone have risk for premature death. Cardiovascular adverse effects of testosterone therapy are under discussion. We need large prospective placebo-controlled randomized trials to determine definitively the cardiovascular risks of TRT.

ATYPICAL PRIMARY HYPERPARATHYROIDISM DUE TO HYPOVITAMINOSIS D.

Vitamin D deficiency is nowadays very common in the general population and also in patients with primary hyperparathyroidism. Hypovitaminosis D may modify the clinical features and the severity of primary hyperparathyroidism. We present the case of a 75-year-old woman with a 10 year history of nephrolithiasis and severe osteoporosis, with multiple fragility fractures. Her bone and kidney status required a more thorough metabolic assessment. Despite minimal changes in serum calcium and phosphate levels, parathyroid hormone (PTH) level was markedly elevated. Ultrasound and specific Sesta-MIBI scintigraphy diagnosed and localized a left parathyroid adenoma. Vitamin D assessment showed levels in the range of hypovitaminosis. Vitamin D deficiency may mask hypercalcemia despite high serum PTH levels, and does not seem to diminish but on the contrary increases the risk of kidney lithiasis, as well as the deleterious effects of hyperparathyroidism on bone.

Thyroid fine-needle biopsy: aspiration versus capillary.

UNLABELLED: Thyroid nodules are a common pathology of the thyroid gland. Thyroid fine-needle biopsy (FNB) is a technique used as the first step in the assessment of thyroid nodules. Some au- thors have demonstrated the superiority of nonaspiration compared with aspiration biopsy. AIM: The objective was to assess whether there are significant differences between the two thyroid biopsy techniques. MATERIAL AND METHODS: The study group comprised 309 patients with thyroid nodules admitted to the Endocrinology Clinic of the Iasi "St. Spiridon "Hospital between 2005 and 2008 in which fine-needle nonaspiration or aspiration biopsy was performed. The slides were read by one pathologist. The smears were stained using the May-Grunwald-Giemsa method (MGG). The quality of smears obtained by the two sampling techniques was evaluated by using the scoring system developed by Mair. RESULTS AND DISCUSSION: No differences in smear quality between the two sampling techniques in terms of blood contamination, amount of cellular material, degree of cellular degeneration, degree of cellular trauma, and preservation of appropriate architecture were found. CONCLUSION: The results of this study show that the sensitivity and specificity of both techniques allow their use as standard screening methods for thyroid nodular lesions.

Therapeutic particularities in amiodarone induced thyroid disorder in patients with underlying cardiac condition.

AIM: the analysis of therapeutic approach in patients with basic heart condition and amiodarone induced thyroid dysfunction--correlations with the evolution and prognosis. MATERIAL AND METHODS: The study included 215 patients, 90 men and 125 women aged between 35 and 87, with different cardiac pathologies hospitalized in the Cardiology Clinic between 2004-2014, who received amiodarone treatment, in most cases for prophylaxis of various arrhythmias, both supraventricular and ventricular. During the evolution, these patients have developed amiodarone-induced thyroid dysfunction (hypo- or hyper function). RESULTS AND DISCUSSION: The evaluation of thyroid function after starting treatment was performed in 187 patients (86.97%). Diagnosis of amiodarone-induced thyroid dysfunction was based on hormonal dosages of TSH, FT4 and FT3, endocrinological examination and thyroid ultrasound. Thyroid dysfunction treatment was initiated, depending on the situation, in all patients during the hospitalization. Treatment included anti thyroid drugs or hormones substitution and in some cases a minimal dose of prednisone. CONCLUSIONS: Thyroid dysfunction regardless of the type (with hypo- or hyper function) requires continuous changes of the cardiovascular treatment, and association, where appropriate, with thyroid dysfunction medication. In some cases the latter determines cardiovascular side effects, for instance corticotheraphy may become a factor of imbalance for the hemodynamic status of the patient (by fluid retention, increased blood pressure, hyper glycemia).

Jod-Basedow effect due to prolonged use of lugol solution-case report.

Graves' disease is the most common form of hyperthyroidism, accounting for 60-80% of all cases of thyrotoxicosis. If left untreated, it may lead to severe thyrotoxicosis with cardiovascular, ocular, psychiatric complication, and in extreme cases thyrotoxic crisis with a high mortality rate. We present the case of a 50-years-old woman diagnosed in another service with Graves' disease and treated for many years with antithyroid drugs (ATDs), admitted to our service for a relapse due to treatment discontinuation. The surgical treatment was planned and the preoperative preparation with Lugol solution was initiated. Due to a misunderstanding, the administration of iodine solution was extended for a period of about 30 days, thus generating the so-called Jod-Basedow effect, with the exacerbation of the manifestations of thyrotoxicosis and risk of thyroid storm. The patient received treatment with high ATDs doses, glucocorticoids, and beta-blockers, resulting in the progressive improvement of symptoms. She was discharged from hospital and given the risk of thyrotoxic crisis the surgery was postponed. After a month, the patient underwent thyroidectomy without preoperative preparation with iodine solution. The operative and postoperative courses were uneventful.

Retrosternal goiters.

UNLABELLED: The term of retrosternal or substernal goiter means that more than 50% of thyroid gland descends in the thorax. MATERIAL AND METHODS: There is a retrospective study on retrosternal and substernal goiter and its patological features among 2482 patients who underwent thyroidectomy between 2000 and 2010 in the First Surgery Clinic of Iasi. Retrosternal goiter was identified 54 patients (2.17%). All patients were refered to surgery from the Clinic of Endocrinology. RESULTS: Mean age at diagnosis was 55.3 +/- 3.58 years, and most cases were found in women (83.3%). The clinical pictures of retrosternal goiter was dominated by compressive disorders. Thyroid function abormalities were identified by hormonal assays performed on Endocrinology Clinic lasi in 15 cases (27.7%). The diagnosis of retrosternal goiter was suggested by clinical examination and confirmed by imagery: thorax X ray, ultrasonography, CT scan. The cervical approach was being safely performed. Only in 8 cases (14,8%), sternotomy was necessary. There was no mortality and morbidity was 5.5% (3 cases). The length of stay in the hospital was 4.3 days. We compared our recent data with a previous report on retrosternal and thoracic goiter treated in First Surgery Clinic of lasi during 1950 to 1979 and published in the journal "Chirurgia" in 1981. CONCLUSIONS: Retrosternal goiter is a particular form of thyroid surgical pathology presentation with declining incidence. Diagnosis and treatment of retrosternal goiter involve a multidisciplinary team. The endocrinologist has an important role in diagnosis and postoperative follow-up. Surgery is the treatment of choice for substernal goiters, but there are still some controversies on surgical approach, and complication rate. The cervical approach can be safely performed in almost all cases but when required, sternotomy should be performed without hesitation.

Familial syndromic papillary thyroid carcinoma report of two cases.

AIM: to describe two cases of familial papillary thyroid carcinoma. MATERIAL AND METHODS: patients were investigated by fine needle biopsy, MRI imaging and tumor biopsy, (first case) and histological examination of colonic and thyroid tumors (first case) and histological examination of thyroid tumor (second case). RESULTS AND DISCUSSION: case presentation: first case, 68 years old man had a colonic polyposis (attenuated form with only a few polyps) and a thyroid nodule. After hemicoleCtomy for a supposed colonic carcinoma with liver and lung metastases, histological examination revealed no malignant colonic disease. Two month later the diagnosis of invasive thyroid tumor with lymph node metastases was made, but only an open biopsy was done because tumor invasiveness demonstrated on MTI imaging. The biopsy identified a papillary thyroid carcinoma. Case 2: the son of the patient (30 years old) without known diseases was invited to be assessed for thyroid disease. Ultrasound examination discovered a large nodule with microcalcifications. Microscopic examination done after total thyroidectomy revealed a cribriform morular variant of papillary thyroid carcinoma, a variant that is known to be associated with FAP. Radioiodine ablation was made followed by suppressive thyroxine treatment. In the second case adenomatous polyposis was not found yet. In our knowledge these are the first cases of familial thyroid papillary carcinomas in our setting. Familial history allowed an earlier diagnosis and a good management of the disease in the second case. CONCLUSIONS: according to the literature and our first experience, screening for thyroid cancer must be done in all patients with FAP and in those with a FAP proband in the family.

Epidemiology and histology of malignant thyroid nodules in North East Region of Romania (Moldavia) before and after alimentary salt universal iodination.

UNLABELLED: Research on the relationship between iodine exposure and thyroid cancer risk is limited and the findings are inconclusive. OBJECTIVES: Given this molecular data on iodine we decided to evaluate the changes of incidence and histology of thyroid cancer in the North-Eastern region of Romania (Moldavia) after the government decision from 2004 that introduced the universal iodination of alimentary salt. After this decision values of urinary iodine increased from 50 microg/L (2001-2002) to 117 microg/L (2006 -2008). MATERIAL AND METHODS: We compared the incidence and the histology of thyroid cancer in residents living in an area known as a mild endemic goiter region (Moldavia-Romania) between 2001-2004 with the incidence and the histology of thyroid cancer between 2005-2008 in the same region after the introduction of universal iodization of alimentary salt. RESULTS: The number of papillary cancers increased from 125 cases (2001-2004) to 276 cases (2005-2008). The number of follicular cancer decreased from 52 cases (2001-2004) to 27 cases (2005-2008). The ratio between papillary and follicular cancers increased from 4.80 / 1 (2001-2004) at 10.61 / 1 (2005-2008). The number of medullar thyroid carcinoma increased from six cases (2001-2004) to 24 cases (2005-2008). Thyroid anaplastic carcinomas number increased from 7 cases (2001-2004) to 12 cases (2005-2008). The total number of thyroid cancer has increased dramatically after the introduction of universal iodination of alimentary salt with 178% compared to 2001-2004 (from 190 cases in 2001-2004 to 339 cases in 2005-2008), despite the fact that the number thyroidectomies decreased from 1734 (2001-2004) to 1449 (2005-2008). CONCLUSION: After the introduction the universal iodination of alimentary salt starting from 2004 the total number of thyroid cancers increased comparative with the period before universal iodination of alimentary salt.

[Clinical profile of thyroid nodules in Iasi, Department of Endocrinology, St. Spiridon Hospital, between 2005-2009]. / Profilul clinic al nodulilor tiroidieni in Clinica de Endocrinologie a spitalului "Sf. Spiridon" Iasi in perioada 2005-2009.

UNLABELLED: Thyroid nodules are common, with up to 50% of the adult population having palpable nodules. With the use of ultrasound, up to 10 times more nodules are likely to be detected. Given this we decided to evaluate by retrospective study the incidence of thyroid nodule in the North-Eastern Region of Romania (Moldavia) between 2005-2009. MATERIAL AND METHOD: We reviewed the records of patients admitted in the Department of Endocrinology, St. Spiridon Hospital Iasi between 1.01.2005-31.12. 2009 (4712 patients) and with selected the cases with nodular goiter. RESULTS: A total of 3105 cases of nodular goiter were identified. The women were most affected and highest prevalence was noticed for the patients with ages between 51-60 years. Most of the nodules were found in the right thyroidian lobe and the majority of the patients were euthyroid . The peak of incidence of nodular hyperthyroidism was different from that of diffuse hyperthyroidism. CONCLUSIONS: Thyroid nodules are the most common endocrine problem and the increasingly frequent detection of nonpalpable thyroid nodules in asymptomatic patients requires new approaches for their management.

[Brown tumors of upper and lower jaws in Recklinghausen neurofibromatosis. A case report]. / Tumori brune ale maxilarului si mandibulei in neurofibromatoza Recklinghausen. Observatii pe marginea unui caz.

We report the case of a 41-year-old patient who presented multiple cafe au lait spots and exophytic tumors of the upper jaw, causing facial asymmetry and masticatory impairment. Physical examination and paraclinical investigations established the diagnosis of NF1 (type 1 neurofibromatosis) associated with brown tumors in jaws and left nasal bone, caused by a primary hyperparathyroidism (Oxyphilic adenoma). The parathyroidectomy determines brown tumors regression and sclerosis with no dependence on their localization.

[Thyroid ultrasonography. Interobserver and intraobserver variations]. / Ecografia tiroidiana. Variatii interobservator si intraobservator.

UNLABELLED: Thyroid ultrasonography is a simple diagnostic method for assessing the prevalence of goitre in children, parameter useful in the estimation of iodine supply. The normal limits recommended by WHO and ICCIDD (following the ThyroMobil study) have been debated by studies which found smaller values, even in regions included in the ThyroMobil study. AIM: To assess the importance of the inter- and intra-observer differences in the determination of thyroid volume in children. MATERIAL AND METHODS: Thyroid volume in 30 children was estimated using the rotating ellipsoid formula by 3 different observers. One of them determined twice the volume in 25 children. RESULTS: Mean interobserver variations were 9.51 +/- 8.8%. More important differences were between observer 1 and 3. The differences between every diameter were between 12 and 16%, more important for the longitudinal one. The intraobserver differences were 6.29 +/- 6.12%. We did not find a relation between the value of the thyroid volume and the interobserver (r2 = 0.13, p > 0.05) or intraobserver (r2 = 0.15, p > 0.05) differences. CONCLUSIONS: Interobserver variation may be important, and can partially explain the disagreements on thyroid volume in children. Intraobserver differences, although present, are less calculated. It is important to establish standards for each geographical area and, as much as possible, by the same person. In order to obtain comparable data the techniques of the ultrasound volume evaluation should be harmonized.

[The role of fine needle aspiration biopsy in differentiated thyroid carcinoma]. / Utilitatea punctiei cu ac fin in carcinoamele tiroidiene bine diferentiate.

UNLABELLED: Fine needle aspiration biopsy (FNAB) in evaluation of nodular goiter generated a true revolution. It is generally assumed that the use of FNAB reduces the number of surgical procedures by 50%, while doubles the proportion of carcinoma in surgically treated patients. The aim of the study was to demonstrate the utility of FNAB in preoperative diagnosis of thyroid carcinoma. MATERIAL AND METHOD: We have investigated 3240 patients with nodular goiter by FNAB (MGG stain and morphometrical analysis), followed by morphological examination in those who underwent surgery. RESULTS: Globally, FNAB had a good sensitivity (77%) and specificity (95%), which made an accuracy of 92%, proving its diagnostic value. In follicular carcinoma (FC), where the cytological diagnostic cannot be certain, morphometry helped the diagnostic: mean cells diameter was significantly higher (p < 0.001) in FC (9.5 mm) vs. thyroid adenoma (8.6 mm). CONCLUSION: With good statistical value, FNAB remain a useful preoperative diagnostic method.

[Differentiated thyroid cancer--staging and prognostic systems]. / Cancerul tiroidian diferentiat stadializare si sisteme de scor prognostic.

Differentiated thyroid cancer (DTC), including papillary and follicular carcinoma with histological variants, has an excellent prognosis; nevertheless a subset of these tumours is clinically aggressive and, in some patients, fatal. Treatment of DTC remains controversial, regarding the extent of primary surgical resection, the need for lymph node dissection and the role of postoperative radioactive iodine ablation. In addition to the widely accepted TNM classification, recognition of significant risk factors and developing of staging systems, such as AMES, AGES, MACIS, MSKCC and NTCTCS, has helped to identify the patients with a potential aggressive course of the disease and high risk of recurrence. This has allowed the development of a rational and selective approach to therapy, thus, avoiding excessive treatment and subsequent morbidity without compromising the oncological outcome.

[Differentiated thyroid cancer--peculiar morphological and clinical forms]. / Cancerul tiroidian diferentiat forme anatomoclinice particulare.

The most common clinical presentation of differentiated thyroid cancer (DTC), consisting of papillary and follicular adenocarcinoma (with their histological variants), is the solitary thyroid nodule. A review of the literature is performed in order to describe particular forms of DTC, in terms of incidence, diagnosis and treatment: occult carcinoma, carcinoma on aberrant thyroid tissue, "functional" thyroid carcinoma and familial non-medullary carcinoma. A particular interest is shown to the coexistence of malignancy with benign thyroid diseases, such as goiter, hyperthyroidism and Hashimoto's thyroiditis, as well as parathyroid adenoma. In conclusion, the authors emphasize that the association of carcinoma with benign thyroid conditions is not rare and it substantiate an aggressive approach in regard to diagnosis and treatment, increasing the indication for surgery and, moreover, for total thyroidectomy.