RET/PTC rearrangement in papillary thyroid carcinoma arising in malignant struma ovarii with abdominal wall metastasis and cervical thyroid gland: a case report and review of the literature

BACKGROUND

Struma ovarii refers to rare mature cystic teratomas containing at least 50% of thyroid tissue, and malignant transformation is known to be even rarer. The synchronous development of malignant struma ovarii and cervical thyroid carcinoma are also scarce and poorly understood due to limited data about molecular features. Here, we present the first report of RET/PTC 1 rearrangement in synchronous metastatic malignant struma ovarii to the abdominal wall and cervical thyroid cancer.

CASE PRESENTATION

We described a 47-year-old multigravida woman with bilateral adnexal and lower abdominal wall masses detected during the evaluation of abnormal uterine bleeding. The patient underwent a hysterectomy, bilateral salpingo-oophorectomy, and surgical removal of abdominal wall mass. Then, the pathological evaluation revealed papillary thyroid carcinoma (PTC) within struma ovarii and metastatic PTC in the abdominal wall fibro adipose tissue. Further, cervical thyroid gland physical examination and ultrasound illustrated a nodule within the left lobe. Subsequently, a total thyroidectomy was performed, and a histological examination revealed PTC. Furthermore, all affected tissue, i.e., struma ovarii, abdominal wall metastasis, and cervical thyroid gland tested for BRAF and RAS mutations and RET/PTC 1 rearrangement. RET/PTC 1 rearrangement was identified among all three different sites. Finally, after six years of follow-up, the patient had no evidence of recurrence or distant metastasis.

CONCLUSIONS

In light of these findings, malignant struma ovarii might yield a clue to cervical thyroid carcinoma, and the molecular analysis could provide valuable information for understanding the underlying mechanism, tumor clinicopathological behaviors, and prognosis.

Change in blood pressure status defined by 2017 ACC/AHA hypertension guideline and risk of cardiovascular disease: results of over a decade of follow-up of the Iranian population

Background

Hypertension (HTN) is known to be the leading cause of cardiovascular disease (CVD) and mortality. We aimed to assess the impact of changes in 3 years in different blood pressure (BP) categories on incident CVD.

Methods

In this study, 3,685 Tehranians aged ≥30 years (42.2% men) free of prevalent CVD with BP level <140/90 mmHg and not on BP-lowering medications were enrolled. Participants were grouped according to baseline BP category using the 2017 ACC/AHA hypertension guideline definition: normal BP (<120/80 mmHg), elevated BP (120-129/<80), and stage 1 HTN (130-139 and/or 80-89). The hazard ratio of incident CVD by changes in the BP category was estimated after adjustment for traditional risk factors using Cox's proportional hazard model, with stable normotension as a reference.

Results

During a median follow-up of 11.7 years, 346 CVD events (men = 208) occurred. Compared to the reference group, among participants with normal BP at baseline, only those with BP rising to stage 1 HTN [1.47 (0.99-2.16)], and among those with stage 1 HTN at baseline, regression to elevated BP [1.80 (1.11-2.91)], remaining at stage 1 [1.80 (1.29-2.52)], and progression to stage 2 HTN [1.81 (1.25-2.61)] had a higher risk for CVD; however, regression to normal BP attenuated this risk [1.36 (0.88-2.12)]. Conversion from elevated BP to any other categories had no significant association with CVD risk.

Conclusions

Generally, prevalent stage 1 HTN (regardless of changing category) and incident stage 1 HTN were significantly associated with a higher risk of CVD; even regression to elevated BP did not attenuate the risk. Accordingly, these populations are potential candidates for antihypertensive management.

Metabolic effects of dopamine-agonists treatment among patients with prolactinomas

PURPOSE

To evaluate the effect of cabergoline treatment on metabolic parameters including the Triglyceride-glucose (TyG) index in newly diagnosed patients with prolactinoma.

METHODS

71 consecutive nondiabetic patients with prolactinoma were enrolled. Anthropometric and laboratory tests including TyG index were measured at baseline, 3 and 6 months visits. Treatment with cabergoline at the dose of 0.25 mg twice weekly was started and increased according to prolactin levels and continued for 6 months.

RESULTS

At the baseline examination, the mean (SD) age, body mass index (BMI), waist circumference (WC), systolic blood pressure (SBP), and diastolic blood pressure (DBP) of patients were 36.2 (10.5) years, 29.2 (5.0) kg/m², 98.2 (13.7) cm, 115.3 (13.3) mmHg, and 71.4 (8.1) mmHg, respectively. Forty-one (57.7%) of patients were women and 46 (64.8%) had microadenoma. Cabergoline treatment significantly improved anthropometric and metabolic measures including BMI, WC, fasting plasma glucose, triglycerides, total cholesterol, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, uric acid (only among women), TyG index, and hypogonadism. Blood pressure (both systolic and diastolic) levels remained steady except for a significant decrease in DBP after 6 months of treatment only among women. A declining trend in MetS prevalence was found from baseline to a 3-month evaluation in both genders which was statistically significant among men.

CONCLUSION

Short-term treatment with cabergoline can significantly improve cardiovascular risk factors except for blood pressure. Moreover, the TyG index as a surrogate marker of insulin resistance decreased significantly after the reduction of prolactin by treatment. Generally, results were similar among both genders.

Clinical features, risk factors and a prediction model for in-hospital mortality among diabetic patients infected with COVID-19: data from a referral centre in Iran

OBJECTIVES

The aim of this study was to identify risk factors of in-hospital mortality among diabetic patients infected with COVID-19.

STUDY DESIGN

This is a retrospective cohort study.

METHODS

Using logistic regression analysis, the independent association of potential prognostic factors and COVID-19 in-hospital mortality was investigated in three models. Model 1 included demographic data and patient history; model 2 consisted of model 1, plus vital signs and pulse oximetry measurements at hospital admission; and model 3 included model 2, plus laboratory test results at hospital admission. The odds ratios (ORs) and 95% confidence intervals (95% CIs) were reported for each predictor in the different models. Moreover, to examine the discriminatory powers of the models, a corrected area under the receiver-operating characteristic curve (AUC) was calculated.

RESULTS

Among 560 patients with diabetes (men = 291) who were hospitalised for COVID-19, the mean age of the study population was 61.8 (standard deviation [SD] 13.4) years. During a median length of hospitalisation of 6 days, 165 deaths (men = 93) were recorded. In model 1, age and a history of cognitive impairment were associated with higher mortality; however, taking statins, oral antidiabetic drugs and beta-blockers was associated with a lower risk of mortality (AUC = 0.76). In model 2, adding the data for respiratory rate (OR 1.07 [95% CI 1.00-1.14]) and oxygen saturation (OR 0.95 [95% CI 0.92-0.98]) slightly increased the AUC to 0.80. In model 3, the data for platelet count (OR 0.99 [95% CI 0.99-1.00]), lactate dehydrogenase (OR 1.002 [95% CI 1.001-1.003]), potassium (OR 2.02 [95% CI 1.33-3.08]) and fasting plasma glucose (OR 1.04 [95% CI 1.02-1.07]) significantly improved the discriminatory power of the model to AUC 0.86 (95% CI 0.83-0.90).

CONCLUSIONS

Among patients with type 2 diabetes, a combination of past medical and drug history and pulse oximetry data, with four non-expensive laboratory measures, was significantly associated with in-hospital COVID-19 mortality.

Radiation-Free myeloablative allogeneic hematopoietic stem cell transplantation for adult acute lymphoblastic leukemia: A comparison of outcomes between patients with and without central nervous system involvement

For patients with acute lymphoblastic leukemia (ALL) undergoing allogeneic hematopoietic stem cell transplantation (allo-HSCT), total body irradiation (TBI) has been particularly advocated as a part of the conditioning regimen in case of extramedullary involvement in sanctuary sites such as the central nervous system (CNS), to ensure greater tissue penetration. In resource-limited countries lacking TBI facilities; however, ALL patients undergo radiation-free myeloablative conditioning, though its impacts on post-HSCT outcomes of the patients with pre-HSCT CNS involvement have not been analyzed. In this 14-year series of 278 adult (> 18 y) ALL patients undergoing TBI-free busulfan/cyclophosphamide conditioning allo-HSCT, we found that the long-term probabilities of overall survival, disease free survival, relapse and non-relapse mortality were not significantly different between CNS-involved and CNS-spared patients. Moreover, there was no statistically significant difference in the incidence of post-HSCT CNS relapse between CNS-involved and CNS-spared patients. Pre-HSCT cranial radiation therapy (CRT) showed no significant preventive effect on the likelihood of post-HSCT CNS relapse. Through multivariable regression analysis, grade III-IV acute graft-versus-host disease (GvHD), extensive chronic GvHD and post-HSCT relapse were ascertained as independent determinants of mortality (Adj.R² = 53.9 %, F_(12,265) = 28.1, P < 0.001), while other parameters including Philadelphia translocation, pre-HSCT CNS involvement and CRT were found to have no independent effect. Although this study was not an attempt to compare TBI-based vs. non-TBI conditioning, the TBI-free myeloablative allo-HSCT was shown to be feasible and an option for adult ALL patients with CNS involvement, considering the comparable outcomes between patients with and without CNS involvement.

Usefulness of prolactin measurement in inferior petrosal sinus sampling with desmopressin for Cushing's syndrome

Background: Bilateral inferior petrosal sinus sampling (IPSS) is used to distinguish pituitary from ectopic adrenocorticotropin (ACTH) excess in patients with ACTH-dependent Cushing's syndrome. Our objective was to examine the utility of prolactin measurement during IPSS with desmopressin (DDAVP) stimulation in localization of the source of ACTH excess.Method: Retrospective review of 20 patients with ACTH-dependent Cushing's syndrome who underwent IPSS with DDAVP stimulation. Baseline, DDAVP-stimulated, and prolactin-normalized ACTH IPS:P (inferior petrosal sinus to peripheral) ratios were calculated. Cut-off values for each test were obtained from receiver-operating characteristic (ROC) curve analysis.Results: Fifteen patients had Cushing disease (CD), and five were diagnosed with ectopic ACTH syndrome (EAS). For the baseline ACTH IPS:P ratio of ≥2, the diagnostic sensitivity (80%), specificity (100%), positive predictive value (PPV) (100%) and negative predictive value (NPV) (62.5%) were calculated. These values for DDAVP-stimulated IPS:P ACTH ratio ≥ 3, were 86.7%, 100%, 100% and 71.4%, respectively. The corresponding value for the prolactin-normalized ACTH IPS:P ratio ≥ 0.8 were 86.6%, 80%, 92.8% and 66.7%. The cut-off value for the baseline, DDAVP-stimulated and prolactin-normalized ACTH IPS:P ratios were 1.76, 3.9, and 0.33, respectively.Conclusion: Prolactin-normalized ACTH IPS:P ratio measurement showed comparable sensitivity and less specificity than baseline/DDAVP-stimulated IPS/P ACTH ratios. Moreover, when baseline and stimulated IPS/P ACTH tests were discordant, prolactin-normalized ACTH IPS: P ratio correctly localized the source of ACTH excess. The sensitivity of the test increased, applying a prolactin-normalized ACTH IPS: P ratio ≥0.33.

Change in glucose intolerance status and risk of incident cardiovascular disease: Tehran Lipid and Glucose Study

Background

To assess the impact of changes in different glucose tolerance states on risk of incident cardiovascular disease (CVD)/coronary heart disease (CHD).

Methods

A total of 4094 Iranians (43.9% men) aged ≥ 30 years, without diabetes and CVD at enrolment were included. The following categories were defined both at baseline visit and 3 years later (second visit): normal fasting glucose (NFG), normal glucose tolerance (NGT), NFG and NGT (NFG/NGT), impaired fasting glucose (IFG), impaired glucose tolerance (IGT) and IFG and/or IGT (IFG/IGT). Changes in the categories, i.e. regression to normoglycemia, remaining in previous status and progression to diabetes were assessed. We used Cox’s proportional hazard models adjusted for traditional risk factors and their changes, to estimate the hazard ratio (HR) with 95% confidence interval (CI) of different changing categories for incident CVD/CHD.

Results

During a median follow-up of 12.42 years, 428 subjects (men = 265) experienced CVD. Considering persistent NFG/NGT as reference, participants who shifted from NFG/NGT to IFG/IGT showed a lower hazard of CVD in the fully adjusted model, HR 0.72 [95% CI 0.52–0.996, P = 0.048]. Moreover, subjects who shifted from IFG, IGT and IFG/IGT to diabetes had an increased risk of CVD/CHD. The risk however, was only statistically significant for those with IFG/IGT, 1.61 [(1.03–2.51), P = 0.04] for CVD and 1.75 [(1.10–2.78), P = 0.02] for CHD; considering IFG/IGT at both visits as reference. Furthermore, those who regressed from IFG/IGT to normoglycemia were at the same risk as those remained in IFG/IGT state, 1.12 [(0.79–1.60), P = 0.52] for CVD and 1.04 [(0.70–1.53), P = 0.85] for CHD. Among a subgroup of population with insulin data (n = 803) those with insulin resistance (IR) that converted to diabetes showed a higher risk for CVD, 3.68 [(1.49–9.06), P = 0.01] and CHD, 2.76 [(1.00–7.60), P = 0.05] events in the fully adjusted model.

Conclusions

Among participants with IFG, IGT or IFG/IGT at baseline, only those who developed diabetes had a higher risk of developing CVD/CHD. Persistent IFG/IGT was not associated with higher risk, compared with those reverted to normoglycemia. Moreover, subjects who converted from NFG/NGT to incident IFG/IGT showed a signal for lower risk of CVD/CHD.

Gestational diabetes mellitus in mothers and long term cardiovascular disease in both parents: Results of over a decade follow-up of the Iranian population

BACKGROUND AND AIMS

We aimed at evaluating whether the presence of gestational diabetes mellitus (GDM) in mothers is associated with increased risk of incident cardiovascular disease (CVD) in both mothers and fathers.

METHODS

In this population-based study, 4308 Iranian women, aged 18-64 years, with at least 1 live-birth delivery, and free of CVD at baseline, were followed. Corresponding spouses were identified in 2547 cases. The association between history of GDM and incident CVD was assessed using multivariate Cox's proportional hazard in 3 models: model 1, unadjusted; model 2, adjusted for age, body mass index, smoking (for men), maternal parity, miscarriage, physical activity, hypertension and hypercholesterolemia, and model 3, further adjusted for diabetes mellitus.

RESULTS

After a median follow-up of 14.1 years, 314 mothers and 424 fathers experienced CVD. Women with history of GDM had an adjusted hazard ratio (HR), 95% CI of 1.85 (1.38-2.48) and 1.29 (0.96-1.75) for CVD in models 1 and 2, respectively. Furthermore, an independent association with CVD was observed in fathers with an adjusted HR of 1.35 (1.02-1.79) in the confounder adjusted model and even after further controlling for diabetes [1.36 (1.03-1.80)]. Moreover, all traditional risk factors, excluding BMI, showed an independent risk for CVD in both genders.

CONCLUSIONS

Women with prior GDM showed an increased risk of CVD that was not independent of important CVD risk factors. However, among men, spousal history of GDM was an independent risk factor for incident CVD, even after considering important traditional risk factors, including diabetes.

Sex specific impact of different obesity phenotypes on the risk of incident hypertension: Tehran lipid and glucose study

Background

To investigate the association between different obesity phenotypes and the risk of incident hypertension among both genders.

Methods

The study population included 3659 Iranians (men = 1540), aged ≥20 years free of hypertension at baseline. Participants were classified into six categories of body mass index (BMI)-metabolic health status, in which unhealthy metabolic status was defined based on the presence of > 1 component of metabolic syndrome (MetS) using the joint interim statement (JIS) criteria or the presence of insulin resistance (IR). The association between different obesity phenotypes and incident hypertension was assessed using multivariate Cox's proportional hazard models adjusted for age, current smoking, low physical activity, diabetes mellitus, family history of premature cardiovascular disease, estimated glomerular filtration rate, phase of recruitment, BMI and systolic blood pressure, considering metabolically healthy normal weight group as the reference.

Results

After a median follow-up of 11.6 years 1122 participants (men = 493) experienced hypertension. Using JIS criteria, a significant higher risk of hypertension was observed among metabolically healthy obese and well as metabolically unhealthy groups among men in the age adjusted model; however, a significant higher risk in the fully adjusted model was seen among women in the metabolically healthy obese [hazard ratio (HR) 95% confidence interval (CI) 1.96(1.16-3.32)] as well as metabolically unhealthy normal weight [1.98(1.37-2.86)], overweight [2.08(1.49-2.90)] and obese [2.06(1.27-3.30)] groups. Using insulin sensitive normal weight group as the reference, among men, being overweight or obese with and without IR was significant predictors of incident hypertension in the age adjusted model; however, among women, insulin resistant overweight [1.46(1.06-2.02)] and obese groups, [1.63(1.01-2.62)] showed significant risk in the fully adjusted model.

Conclusion

We concluded that first, there was significant difference between genders in the associations between obesity phenotypes and incident hypertension. Second, in general, metabolic status defined by MetS components as compared to IR could do better in identifying high risk women for hypertension. Third, women populations who are metabolically healthy obese using MetS definition or those with either > 1 component of metabolic syndrome or overweight/obese ones with IR should be prioritized for implementing urgent preventive strategies against hypertension focusing on lifestyle changes.

Serum alkaline phosphatase and the risk of coronary heart disease, stroke and all-cause mortality: Tehran Lipid and Glucose Study

OBJECTIVES

To investigate the association of alkaline phosphatase (ALP) levels with the risk of the composite end point of cardiovascular disease (CVD), and all-cause mortality as well as each of them separately.

DESIGN

Prospective cohort study.

SETTING

Within the framework of the Tehran Lipid and Glucose Study (TLGS) cohort, participants were followed from baseline examination (1999-2001) until March 2014.

PARTICIPANTS

A total of 2578 participants, aged ≥30 years free of prevalent CVD at baseline examination.

PRIMARY OUTCOME

The main outcome measures were composite end point of coronary heart disease (CHD), stroke, all-cause mortality and each per se.

RESULTS

During a median follow-up of 11.3 years, 369, 68, 420, 170 and 495 participants experienced CHD, stroke, CVD, all-cause mortality and the composite outcome, respectively. In the multivariable Cox regression models, the adjusted HRs (95% CI) for mentioned events per one SD increase in ALP level after full adjustment were 1.11 (1.01 to 1.22), 1.20 (0.97 to 1.49, p=0.058), 1.10 (1.01 to 1.21), 1.16 (1.01 to 1.33) and 1.11 (1.02 to 1.21), respectively. Furthermore, participants with ALP levels in the highest tertile had significant adjusted HRs (95% CI) for stroke (1.88 (1.00 to 3.61)), CVD (1.30 (1.01 to 1.68)) and composite outcome (1.27 (1.00 to 1.61)). The cut-off value of ALP ≥199 IU/L for predicting composite outcome was derived using Youden's index, based on which this cut-off point was associated with significant risk of 80%, 26%, 43% and 26% for incident stroke, CVD, all-cause mortality and composite outcome. Additionally, no improvement was seen in the predictive ability of traditional risk factors models after adding ALP values, considering the levels of Akaike information criterion, C-index and Net Reclassification Index.

CONCLUSION

Independent associations between ALP levels and the risks of CVD and mortality events were shown, despite the fact that adding the data of ALP to known risk factors did not improve the prediction of these events.

Different Weight Histories and Risk of Incident Coronary Heart Disease and Stroke: Tehran Lipid and Glucose Study

Background

This study aimed to determine the association between different weight histories, including cumulative excess weight, cumulative excess waist circumference (WC), duration of general and central adiposity, current and maximum body mass index, and current and maximum WC, and incident coronary heart disease (CHD) and stroke.

Methods and Results

The study population consisted of 4398 adults aged ≥40 years without CHD or stroke at baseline. Associations between different weight histories and CHD and stroke were determined by multivariable time‐varying Cox regression models after adjustment for age, sex, and time‐varying confounders. Further adjustment was also done for mediators (eg, diabetes mellitus, hypercholesterolemia, and hypertension). During median follow‐up of 13.9 years, 718 incident CHD and 158 stroke events were documented. Multivariable adjusted hazard ratios (HRs) were calculated in the sex and confounder adjusted model for CHD per 1‐SD increase in cumulative excess weight (HR: 1.02; 95% confidence interval [CI], 0.96–1.07), cumulative excess WC (HR: 1.14; 95% CI, 1.04–1.24), duration of general adiposity (HR: 1.00; 95% CI, 0.92–1.08), duration of central adiposity (HR: 1.01; 95% CI, 0.93–1.09), current body mass index (HR: 1.03; 95% CI, 0.99–1.07), current WC (HR: 1.21; 95% CI, 1.11–1.32), maximum body mass index (HR: 1.01; 95% CI, 0.95–1.07), and maximum WC (HR: 1.17; 95% CI, 1.07–1.28). After further adjustment for mediators, current and maximum WC still showed a significant risk (HR: 1.13 [95% CI, 1.03–1.23] and 1.09 [95% CI, 1.00–1.20], respectively). Moreover, in the sex and confounder adjusted model, cumulative excess WC and maximum WC were associated with higher risk of stroke (hazard ratio: 1.21 [95% CI, 0.99–1.48] and 1.25 [95% CI, 1.02–1.55], respectively).

Conclusions

Exposure to cumulative excess weight and cumulative excess WC confers little additional risk beyond their current and maximum values. Even current and maximum WC were associated with incident CHD in the presence of obesity mediators, and the latter was a significant predictor of stroke in the presence of confounders.

Mucocutaneous manifestations and nail changes in patients with end-stage renal disease on hemodialysis

Mucocutaneous manifestations are common among patients on hemodialysis (HD). This study was undertaken to determine the prevalence of mucocutaneous manifestations in patients with end-stage renal disease (ESRD) who are on HD. In this cross-sectional, descriptive and analytic study conducted in 2009, 100 patients on HD at the Five Azar Hospital in Gorgan city were randomly selected. All the patients underwent detailed examination by a dermatologist to look for lesions in the skin, hair, nail and mucous membranes; if felt necessary, biopsy was obtained from the lesions. The findings were statistically analyzed using SPSS-13 software. For evaluation of normality of distribution, Kolmogorov-Smirnov was used, for quantitative variables Mann-Whitney and T-test (abnormal distribution) were used and for qualitative variables, Chi-2 and Fisher were used. In this study, P-value less than 0.05 was considered significant. Fifty-one males and 49 females were enrolled. The mean age was 49 ± 12 years. Diabetes was the most common cause of ESRD. In 95% of the patients, at least one mucocutaneous manifestation was present. Xerosis (78.3%) was the most common lesion, followed by pruritus (39.1%), lentigo (34.8%), skin discoloration (32.6%), leukonychia (32%) and thinning of the nail bed (24%). Xerosis, scaling, lentigo, folliculitis, idiopathic guttate hypopigmentation, leukonychia and half and half nail were associated with age. A significant relationship was seen between duration on dialysis and skin discoloration and leukonychia. Clubbing had a significant association with calcium-phosphorus product (Ca × P). There was a significant association between serum ferritin level and pruritus and tinea versicolor lesions. Our study shows that mucocutaneous manifestations are common among patients with ESRD. Identification of these manifestations and their association with causative factors are useful for preventing the lesions.