LIVER TRANSPLANT FOR METASTATIC NEUROENDOCRINE TUMORS: A SINGLE-CENTER REPORT

ABSTRACT BACKGROUND: Neuroendocrine tumors are rare neoplasms of uncertain biological behavior. The liver is one of the most common sites of metastases, occurring in 50% of patients with metastatic disease. AIMS: To analyze a clinical series in liver transplant of patients with neuroendocrine tumors metastases. METHODS: A retrospective descriptive study, based on the review of medical records of patients undergoing liver transplants due to neuroendocrine tumor metastases in a single center in northeast Brazil, over a period of 20 years (January 2001 to December 2021). RESULTS: During the analyzed period, 2,000 liver transplants were performed, of which 11 were indicated for liver metastases caused by neuroendocrine tumors. The mean age at diagnosis was 45.09±14.36 years (26–66 years) and 72.7% of cases were females. The most common primary tumor site was in the gastrointestinal tract in 64% of cases. Even after detailed investigation, three patients had no primary tumor site identified (27%). Overall survival after transplantation at one month was 90%, at one year was 70%, and five year, 45.4%. Disease-free survival rate was 72.7% at one year and 36.3% at five years. CONCLUSIONS: Liver transplantation is a treatment modality with good overall survival and disease-free survival results in selected patients with unresectable liver metastases from neuroendocrine tumors. However, a rigorous selection of patients is necessary to obtain better results and the ideal time for transplant indication is still a controversial topic in the literature

Levothyroxine Replacement Improves Oxidative Status in Primary Hypothyroidism

Objective: Although hypothyroidism has been linked to oxidative stress, data regarding the relationship between thyroid hormone levels and oxidative stress is still inconsistent. This study was designed to evaluate the effect of levothyroxine replacement on oxidative stress in women with primary hypothyroidism.Design: A total of 25 female patients with primary hypothyroidism were included. Oxidative stress markers were measured before and after levothyroxine replacement treatment in all patients.Methods: Oxidative stress was evaluated through the measurement of oxidants (thiobarbituric acid reactive substances [TBARS] and nitrite/nitrate levels), and antioxidants (superoxide dismutase and catalase activity).Results: Antioxidant catalase activity (63.77 ± 23.8 vs. 50.12 ±12.75 atv/min; p = 0.03) was significantly increased and the levels of TBARS (3.02 ± 0.86 vs. 3.55 ± 0.87 μM; p = 0.03) were significantly decreased in the state of euthyroidism after levothyroxine replacement compared to the hypothyroidism before levothyroxine treatment. No significant change in neither nitrite/nitrate concentration (p = 0.18) nor in superoxide dismutase activity (p = 0.93) after L-T4 adjustment was found.Conclusions: Our data demonstrate that levothyroxine replacement improved oxidative status in patients with primary hypothyroidism, indexed by the significantly decreased levels of malonaldehyde (MDA) and increased catalase (CAT) activity

Dental status, salivary flow, and sociodemographic aspects in Sheehan Syndrome patients

Sheehan?s syndrome (SS) is one of the leading causes of hypopituitarism in developing countries. It occurs after postpartum necrosis of the pituitary gland, and it is considered a significant public health problem. This paper, apparently unpublished, aimed to perform an analysis on oral aspects in patients with SS. A cross-sectional study was performed with 23 women diagnosed with SS at the Division of Endocrinology and Diabetes (Walter Cantídio University Hospital, Fortaleza, Brazil). Data on sociodemographic, dental and salivary flow aspects were collected through a clinical approach and a panoramic radiograph request. The mean age was 64 ± 11.5 years old, with the sample consisting mainly of married women (56.5%), socioeconomic class C2 or D / E (78.2%) and years of education up to 8 years (69.5%). The presence of horizontal bone loss (p<0.001) and bilateral pneumatization of the maxillary sinus (p=0.015) were significant data. The mean number of absent teeth considering all subjects was 23.17±9.7, being statistically significant (p<0.001). In relation to age, the mean number of missing teeth was higher in individuals over 65 years old (p=0.048). Reduced salivary flow was observed in 78.3% of the patients. In a bivariate analysis, considering the outcome variables ?missing teeth? and ?reduced salivary flow?, it was observed that economic class (p< 0.001), family income (0.037) and maxillary sinus pneumatization (0.032) were statistically significant. In brief, patients with SS showed severe teeth loss, reduced salivary flow, and low educational status. This study addressed important aspects regarding oral findings in SS and highlighted the importance of researches in oral medicine

Bloqueio Atrioventricular Total Associado a Hipertireoidismo por Doença de Graves

Descrevemos o caso de uma paciente jovem, portadora de hipertireoidismo por doença de Graves, que durante admissao hospitalar desenvolveu quadro grave de instabilidade hemodinâmica, evoluindo com bloqueio atrioventricular total (BAVT) e necessidade de marcapasso provisório. Após introduçao de droga antitireoidiana e uso de corticóide, houve recuperaçao do grau de bloqueio com 36 horas. Um possível mecanismo, no estado de hipertireoidismo, seria o efeito direto do hormônio tireoidiano no sistema de conduçao ou a infiltraçao linfocitária na regiao do sistema de conduçao cardíaco, considerando a natureza auto-imune da doença de base. Esses mecanismos sao discutidos por nós e por outros autores na literatura

Bloqueio Atrioventricular Total Associado a Hipertireoidismo por Doença de Graves

Descrevemos o caso de uma paciente jovem, portadora de hipertireoidismo por doença de Graves, que durante admissao hospitalar desenvolveu quadro grave de instabilidade hemodinâmica, evoluindo com bloqueio atrioventricular total (BAVT) e necessidade de marcapasso provisório. Após introduçao de droga antitireoidiana e uso de corticóide, houve recuperaçao do grau de bloqueio com 36 horas. Um possível mecanismo, no estado de hipertireoidismo, seria o efeito direto do hormônio tireoidiano no sistema de conduçao ou a infiltraçao linfocitária na regiao do sistema de conduçao cardíaco, considerando a natureza auto-imune da doença de base. Esses mecanismos sao discutidos por nós e por outros autores na literatura

Oral health aspects in sporadic and familial primary hyperparathyroidism

Primary hyperparathyroidism (pHPT) is the third most common endocrinopathy, affecting 1-3% of postmenopausal women, with a total incidence of 21.6 cases per 100,000 people in the adult population. This study aimed to analyze the oral health and related a

Utilización de edulcorantes en Brasil : un abordaje a partir de una encuesta domiciliaria

O objetivo foi estimar a prevalência do uso de adoçantes pela população adulta brasileira e características dos usuários. Análise de dados da Pesquisa Nacional de Acesso, Utilização e Promoção do Uso Racional de Medicamentos (PNAUM, 2014), um inquérito nacional de base populacional. O desfecho de interesse foi o uso autorreferido de adoçantes entre brasileiros com 20 anos ou mais. As variáveis analisadas foram sexo, idade em anos completos, região do Brasil, escolaridade em anos completos e classificação econômica segundo o Critério Classificação Econômica Brasil da Associação Brasileira de Empresas de Pesquisa (ABEP). Os indicadores das condições de saúde foram: relato de doença crônica não transmissíveis (DCNT), número de DCNT e índice de massa corporal (IMC). A prevalência do uso de adoçantes na população adulta brasileira foi de 13,4% (IC95%: 12,5-14,3), sendo maior entre as pessoas do sexo feminino e no grupo com 60 anos ou mais, nas regiões Nordeste e Sudeste, entre pessoas da classe econômica A/B e entre indivíduos obesos. As pessoas com doenças crônicas (em especial diabetes) foram as que mostraram maior prevalência de uso de adoçantes, sendo o uso maior quanto maior o número de comorbidades relatadas. A prevalência de uso de adoçantes foi de 13,4% e mostrou-se associada a características sociodemográficas e de saúde.The objective was to estimate the prevalence of artificial sweetener use by the adult Brazilian population and users’ characteristics. Analysis of data from the Brazilian National Survey on Access, Utilization, and Promotion of Rational Use of Medicines (PNAUM, 2014), a nationwide population-based survey. The target outcome was self-reported use of sweeteners by Brazilians 20 years and older. The independent variables were sex, age, major geographic region of Brazil, schooling in complete years, and economic status according to the Brazilian Economic Classification Criterion of the Brazilian Association of Research Companies (ABEP). The health condition indicators were: self-reported noncommunicable diseases (NCDs), number of NCDs, and body mass index (BMI). Prevalence of sweetener use in the Brazilian adult population was 13.4% (95%CI: 12.5-14.3), and it was higher in females and in persons 60 years or older, in the Northeast and Southeast, among individuals from economic classes A and B, and among obese individuals. Persons with chronic diseases (especially diabetes) showed the highest prevalence of use of sweeteners, and their use increased with the number of reported comorbidities. Prevalence of use of artificial sweeteners was 13.4% and was associated with sociodemographic and health characteristics.El objetivo fue estimar la prevalencia del uso de edulcorantes por parte de la población adulta brasileña y las características de los usuarios. Análisis de datos de la Encuesta Nacional de Acceso, Utilización y Promoción del Uso Racional de Medicamentos (PNAUM, 2014), una encuesta nacional de base poblacional. El resultado de interés fue el uso autoinformado de edulcorantes entre brasileños con 20 años o más. Las variables analizadas fueron: sexo, edad (años completados), región de Brasil, escolaridad (años completados), así como la clasificación económica según el Criterio Clasificación Económica Brasil de la Asociación Brasileña de Empresas de Investigación (ABEP). Los indicadores de las condiciones de salud fueron: informe de enfermedades crónicas (DCNT), número de DCNT e índice de masa corporal (IMC). La prevalencia del uso de edulcorantes en la población adulta brasileña fue de un 13,4% (IC95%: 12,5-14,3), siendo mayor entre las personas de sexo femenino y en el grupo con 60 años o más, en las regiones Nordeste y Sudeste, entre personas de clase económica A/B y entre individuos obesos. Las personas con enfermedades crónicas (en especial diabetes) fueron las que mostraron una mayor prevalencia de uso de edulcorantes, siendo el uso mayor, cuanto mayor fuera el número de comorbilidades informadas. Conclusiones: la prevalencia de uso de edulcorantes fue de un 13,4% y se mostró asociada a características sociodemográficas y de salud

ExpressÃo dos genes GNAS e BTG2 e de um painel de microRNAs em somatotrofinomas esporÃdicos com e sem mutaÃÃo no gene GNAS

IntroduÃÃo: MutaÃÃes nos genes GNAS e AIP estÃo presentes em 35% e 3%, respectivamente, dos somatotrofinomas esporÃdicos. Recentemente, observa-se importÃncia biolÃgica crescente dos microRNAs (miRNAs) na tumorigÃnese hipofisÃria. Entretanto, mecanismos moleculares envolvidos na patogÃnese de 60% desses tumores permanecem nÃo elucidados. Objetivos: Identificar a prevalÃncia de mutaÃÃes nos genes GNAS e AIP em um grupo de somatotrofinomas esporÃdicos. Comparar parÃmetros clÃnicos e bioquÃmicos ao diagnÃstico como idade, tamanho tumoral e agressividade (escore Hardy), hormÃnio do crescimento (GH), prolactina (PRL) e Fator de Crescimento Insulin-Like I (IGF-1) e resposta as terapÃuticas entre os grupos com (gsp+) e sem (gsp-) mutaÃÃo no GNAS. Analisar a expressÃo dos genes GNAS e BTG2 e miRNAs entre somatotrofinomas e hipÃfises normais (HN) e a associaÃÃo entre a expressÃo com agressividade, a resposta à cirurgia e a todas as terapÃuticas adjuvantes disponÃveis. Material e MÃtodos: 26 pacientes com diagnÃstico de acromegalia. Tamanho tumoral foi avaliado por RNM/CT e o grau de invasibilidade pelo escore de Hardy (I a IV). GH basal &#8804;2.5&#956;g/L ou nadir de GH apÃs o GTT&#8804;1&#956;g/L e IGF-1 normal para idade e sexo foram utilizados como critÃrio de cura apÃs cirurgia transesfenoidal (CTE). Como controle com o anÃlogo da somatostatina (AS), adotamos a normalizaÃÃo dos nÃveis de IGF-1 para idade e sexo. As amostras tumorais (n=26) foram obtidas durante a CTE, realizado histopatolÃgico e armazenadas a -70 ÂC, para estudos moleculares. HN (07) foram obtidas durante autÃpsias. RNA e DNA total foram extraÃdos pelo TRIzolÂ. Os cÃdons 201 e 227 do gene GNAS e o AIP completo foram sequenciados. ExpressÃo relativa dos genes GNAS e BTG2 e dos miRNAs let-7a, miR-16a, miR-21, miR-141, miR-143, miR-15a, miR-145, miR-23a, miR-23b e miR-24-2 foi avaliada por qPCR (sondas TaqMan), pelo mÃtodo 2-&#916;&#916;Ct. Resultados: A frequÃncia de mutaÃÃes no GNAS foi de 35% e no AIP 3,8%. NÃo houve diferenÃa entre as mÃdias de idade (39,0Â11,5 vs 43,6Â9,0 anos; p=0,32), nas concentraÃÃes plasmÃticas basais de GH (62,4Â128,1 vs 39,9Â48,3Âg/L; p=0,39), IGF-1 (435,5Â230,8 vs 556,9 238,3 %ULNR; p=0,32), PRL (25,7Â29,8 vs 30,9Â32,8 ng/L; p=0,69) e agressividade tumoral entre os gsp+ e gsp-(p=1,00). Ao analisar o uso do AS como terapÃutica adjuvante à CTE, observamos que 04/05 (80%) dos indivÃduos com somatotrofinoma gsp+ obtiveram controle da doenÃa, enquanto que no grupo gsp- 02/06 (33%) obtiveram controle (p=0,08). Quando associamos ao AS, os agonistas dopaminÃrgicos e/ou radioterapia externa, observamos que 05/05 (100%) dos pacientes gsp+ tiveram critÃrio de controle da doenÃa, contra (04/09) 44% no grupo gsp- (p=0,09). NÃo houve diferenÃa na expressÃo de GNAS entre os somatotrofinomas e as HN (1,07Â0,55 vs 0,98Â0,28; p=0,97), e entre os gsp+ e gsp- (1,04Â0,59 vs 1,10Â0,55; p=0,97, respectivamente). Os tumores Hardy I / II apresentaram maior expressÃo do GNAS do que os tumores classificados como III / IV (p=0,02). NÃo houve associaÃÃo entre a expressÃo do GNAS e o controle da doenÃa com cirurgia isolada ou com o uso de todas as terapÃuticas adjuvantes. Observamos hipoexpressÃo do BTG2 e dos miR-16a e miR-141 em somatotrofinomas quando foram comparados com as HN (p=0,002, fold=-6,63; p=0,01, fold=-10,00; p=0,0003, fold=-50,00, respectivamente) sem diferenÃas entre os gsp+ e gsp-. Houve hiperexpressÃo do miR-21 (p=0,02;fold=10,18) em somatotrofinomas (20,16Â18,48) quando comparado com as HN (2,52 Â3,56), sem diferenÃa entre os gsp + e gsp-. NÃo houve diferenÃa na expressÃo entre os grupos gsp+ e gsp- para os miRNAs let-7a, miR-21, miR-143, miR-15a, miR-23a e miR-24-2. Entretanto, miR-145 e miR-23b foram mais hipoexpressos no grupo gsp+ quando comparados ao gsp- (p=0,03, fold=-4,83 e p=0,02, fold=-2,77, respectivamente). NÃo houve associaÃÃo entre a expressÃo do BTG2 e o painel de miRNAs com agressividade e com o controle da doenÃa. ConclusÃo: Na presente sÃrie de somatotrofinomas, assumidos como esporÃdicos, a frequÃncia de mutaÃÃes nos genes GNAS (35%) e AIP (3,8%) foram semelhantes aos relatados na literatura. NÃo houve diferenÃas nas caracterÃsticas clÃnicas e bioquÃmicas, agressividade, resposta Ãs terapÃuticas, e na expressÃo diferencial do GNAS entre os pacientes com tumores gsp+ e gsp-. HipoexpressÃo de BTG2 (gene supressor tumoral relacionado Ãs vias de sinalizaÃÃo do p53 e do Rb), baixa expressÃo de miRNAs (supressores tumorais) e alta expressÃo de oncomirs em somatotrofinomas sugerem um papel desses na tumorigÃnese somatotrÃfica.Introduction: Mutations in GNAS and AIP genes are present in 35% and 3%, respectively, of the sporadic somatotropinomas. Recently, increased biological importance of microRNAs (miRNAs) has been observed in pituitary tumorigenesis. However, the molecular mechanisms involved in the pathogenesis of 60% of these tumors remain to be elucidated. Objectives: To identify the prevalence of mutations in GNAS and AIP genes in a series of sporadic somatotropinomas. Compare clinical, bioquimical parametrer at diagnosis as age, tumor size and theirs aggressiveness, pre-operative growth hormone (GH), prolactin (PRL) and insulin-like growth factor-I (IGF-1) levels and treatment responsiveness between somatotropinomas with (gsp+) and without (gsp-) GNAS mutation.To analyze the expression of GNAS and BTG2 genes and a panel of miRNAs between somatotrofinomas and normal pituitaries (NP) and the association between the expression of these genes and miRNAs with aggressiveness, as well as disease control with surgery or control with all adjuvant therapeutic approaches. Material and Methods: 26 patients with acromegaly. GH basal &#8804;2.5&#956;g/L or nadir after OGTT &#8804;1&#956;g/L and normal IGF-I matched for age and sex were used as diagnosis and for cure criteria after transsphenoidal surgery (TS). As control after somatostatin analogues (SA), we adopted the normalization of IGF-I matched for age and sex. Tumor size was evaluated by MRI/CT and the degree of invasiveness by Hardy score (I to IV).Tumor samples (26) were obtained during TS, processed for histopathology and stored at -70ÂC for molecular studies. NP (07) were obtained during autopsy. Total DNA and RNA were extracted by TRIzolÂ. Codons 201 and 227 of the GNAS gene and the whole AIP gene were sequenced. Relative expression of BTG2 and GNAS genes and miRNAs let-7a, miR-16a, miR-21, miR-141, miR-143, miR-15a, miR-145, miR-23a, miR-23b, and miR-24-2 was measured by qPCR (TaqMan probes) using 2-&#916;&#916;Ct method. Results: Frequencies of GNAS and AIP mutations were 35% and 3.8%, respectively. There was no difference between the mean age (39.0  11.5 vs 43.6  9.0 years, p=0.32), basal GH (62.4Â128.1 vs 39.9  48.3 &#956;g/L; p=0.39), IGF-I (435.5  230.8 vs. 556.9  238.3; p=0.32) and PRL (25.7  29.8 vs. 30.9  32.8 ng/L, p=0.69) in plasma concentration, and tumor aggressiveness (p=1.00) between (gsp+) and (gsp-) groups. We observed that 80% (04/05) of gsp+ whereas 33% (02/06) of the gsp- achieved control (p=0.07) after SA therapy adjuvant to TS. When SA, dopamine agonists and/or external radiotherapy were associated 100% (05/05) of gsp+ group and 44% (04/09) of gsp- group (p=0.08) showed disease control.There was no difference in GNAS expression between somatotropinomas and NP (1.07  0.55 vs 0.98  0.28, p=0.97) as well as between somatotropinomasgsp+ and gsp- (1.04  0.59 vs 1.10  0.55, p=0.97, respectively). Hardy I/II tumors showed higher GNAS expression than Hardy III/IV (p=0.02), but there was no association between GNAS expression and disease control with surgery alone or associated with other adjuvant therapies. We observed hypoexpression of BTG2 and miR-16a and miR-141 in somatotropinomas compared with NP (-6.6 fold, p=0.002; -10.0 fold, p=0.01; and -50.0 fold, p=0.0003, respectively) with no difference between gsp+ and gsp- somatotropinomas. There was miR-21 overexpression in somatotropinomas compared with NP (20.2  18.5 vs 2.5  3.6; 10.2 fold, p=0.02), with no difference between gsp+ and gsp- somatotropinomas. However, miR-145 and miR-23b were more hipoexpressed in gsp+ compared to gsp- (-4.8fold, p=0.03 and-2.7 fold, p=0.02). There was no association between the expression of BTG2 and a panel of miRNAs with aggressiveness or disease control. Conclusion: In this series of assumed sporadic somatotopinomas, the frequencies of mutations in GNAS (35%) and AIP (3.8%) were similar to the literature. There were no differences in clinical and biochemical characteristics, aggressiveness, response to therapy, and GNAS expression in patients with gsp+ and gsp- somatotropinomas. Hypoexpression of BTG2, a tumor suppressor gene related to p53 and Rb signaling pathways, low expression of tumor suppressor miRNAs and high expression of oncomirs in somatotropinomas suggest a role in the somatotrophic tumorigenesis

Insulin autoimmune syndrome in an occidental woman: a case report and literature review

SUMMARY Insulin autoimmune syndrome (IAS, Hirata's disease) is a rare hypoglycemic disorder characterized by spontaneous hypoglycemia associated with extremely high circulating insulin levels and positive anti-insulin antibody results. Thus far, most cases have been reported in Asian countries, notably Japan, with few cases reported in western countries. As a possible cause, it is associated with the use of drugs containing sulfhydryl radicals, such as captopril. This report refers to a 63-year-old female Brazilian patient with a history of postprandial hypoglycemia. After extensive investigation and exclusion of other causes, her hyperinsulinemic hypoglycemia was considered to have likely been induced by captopril. Most cases of IAS are self-limiting. However, dietary management, corticosteroids, plasmapheresis, and rituximab have already been used to treat patients with IAS. In our case, after discontinuation of captopril, an initial decrease in insulin autoantibody levels was observed followed by improvement in episodes of hypoglycemia. Although it is a rare disease, IAS should be considered in the differential diagnosis of endogenous hyperinsulinemic hypoglycemia. Patients with suspected IAS must be screened for autoimmunity-related drugs for insulin. Initial clinical suspicion of IAS can avoid unnecessary costs associated with imaging examinations and/or invasive surgical procedures