PE：Poster Presentation-Endocrine (1-19

PE-1 CLINICAL EFFICACY OF SANDOSTATIN LAR 20 MG IN PATIENTS WITH ACROMEGALY AFTER INCOMPLETE SURGERY

TZU-CHING HUNG, WAN-CHI CHUANG, WEI-CHENG CHANG, 1CHIH-HSUN CHU

Division of Endocrinology and Metabolism, Department of Internal Medicine, Kaohsiung Veterans General HosPital, Kaohsiung, Taiwan; 1Department of Nursing, School of Nursing, Fooyin University, Kaohsiung, Taiwan.

Background: The objective of this study is to retrospectively survey the efficacy of sandostatin LAR 20mg in patients with acromegaly after incomplete surgery.

Methods: From October 2015 to February 2019, there were eleven subjects (4 male, 7 female) who with pituitary adenoma and complicated with acromegaly receiving operation, but the growth hormone level remained above 1 μg/l. The mean age were 55.8 yr (range from 37 to 74 yr), Nine patient (82%) was macroadenoma. There were eight patients (73%) complicated with diabetes, one with prediabetes, only two (18%) without glycemic abnormalities. They were all received sandostatin LAR 20mg injection per month.

Results: The mean duration of treatment were 26.2 ± 12.5 months (range from 7 to 47 months). The baseline levels of growth hormone were 3.3 ± 1.8μg/l, IGF-1 were 628.8 ± 197.2 ng/ml. After sandostatin LAR 20mg management, the latest levels of growth hormone decreased to 0.95 ± 0.95μg/ l (∆ 68%, P = 0.001), levels of IGF-1 decreased to 197.2 ± 64.2 ng/ml (∆ 61%, P=0.002). Nine patients (82%) with levels of growth hormone < 1 μg/l. Nine patients (82%) with IGF-1 in normal values. There were seven patients (64%) achieved growth hormone levels < 1 μg/l combined with normalization of IGF-1 values.

Conclusion: In patients with acromegaly after incomplete surgery. Sandostatin LAR 20mg injection per month is an effective treatment for most of them.

PE-2 THE MORTALITY FACTORS IN RECURRENT PARATHYROID CARCINOMA: A POOLED ANALYSIS FROM 52 YEARS OF MEDICAL LITERATURE

WEN-HSUAN TSAI, YI-HONG ZENG, CHUN-CHUAN LEE, MING-CHIEH TSAI

Mackay Memorial Hospital

Background: Background: Parathyroid cancer is a rare disease with high recurrence rate. The prognostic factors for recurrent parathyroid cancer are yet to be conclusively determined. We aimed to establish the association between recurrent parathyroid cancer and previously reported prognostic factors.

Patients and Methods: We conducted a PubMed search using the keywords ‘parathyroid cancer’, ‘parathyroid neoplasm’, and ‘hypercalcemia’ during 1966–2018 and included 55 studies, 73 patients from 3272 articles. We performed the basic symptoms stratified by serum calcium level and conducted survival analysis by Cox proportional hazard model with 95% confidence interval.

Results: For the 73 patients included in the analysis, the mean ± standard deviation age was 44 ± 13.2 years, and 36 of the patients were women (49.3%). During 5236 person-months at risk (mean follow-up 71.7 months, range 3-264), 38 patients died. The incidence of local recurrence, lymph node metastasis, lung metastasis, and bone metastasis was 60.3, 12.3, 56.2, and 24.7, respectively. Bone metastasis, disease-free interval shorter than 1 year, and total surgeries < 3 were significant prognostic factors in univariate analysis (log-rank test P = 0.063, P = 0.0006, P = 0.0056, respectively). In multivariate-adjusted analysis, the mortality risk were significantly increased in bone metastasis with hazard ratio (HR) as 4.83 (95% CI 1.16-20.2; P = 0.03), disease-free interval > 1 year as 0.17 (95% CI 0.05-0.54; P = 0.003) and total surgeries ≥ 3 as 0.09 (95% CI 0.02-0.36; P = 0.001), considering as predictively prognostic factors.

Conclusion: Bone metastasis, duration of disease-free interval, and total number of surgeries predict survival in recurrent parathyroid cancer.

PE-3 A CASE REPORT : PHEOCHROMOCYTOMA IN A 69 YEAR-OLD WOMAN PRESENTED AS RECURRENT SYNCOPE

1YAN-YU LIN, 1,2CHUNG-HUEI HSU, 1CHEN-LING HUANG, 1SHUEN-FU WENG,

1YU-PEI LIN

1Division of Endocrinology and Metabolism, Department of Internal Medicine, Taipei Medical University Hospital, Taipei, Taiwan; 2Department of Nuclear Medicine, Taipei Medical University Hospital, Taipei, Taiwan

Introduction: Pheochromocytomas are rare neuroendocrine chromaffin-derived tumors that arise within the adrenal medulla. They are usually benign, but if not diagnosed or if left untreated, they can have devastating consequences.

Case Report: This 69-year-old woman had underlying disease of type 2 diabetes mellitus, hypertension, and old left cerebellar infarction. She was just discharged from other hospital due to recurrent syncope episodes. However, recurrent syncope which happened more than three times in one week still occurred that she was admitted in our hospital for survey . After admission acute left cerebral infarction over posterior cerebral artery (PCA) territory was diagnosed. However, severe hypertension with fluctuated blood pressure was noted. Serum ACTH, cortisol, renin, aldosterone and 24 hr urine VMA, catecholamine were checked for secondary hypertension survey. Abnormal findings showed urine VMA 25.63mg/24hr, urine epinephrine 170.7 μg/24hr, and urine norepinephrine 780.8μg/24hr. Adrenal MRI was arranged which presented as a left adrenal mass, size up to 3.8 cm, with T2 heterogeneous intensity and post contrast enhancement, suggest clinical correlation the possibility of pheochromocytoma. After consulting urologist and discussing with her family, they decided to receive operation. Alpha blocker was used then, and prepared for surgery until blood pressure became stable.

Discussion: The typical symptoms of pheochromocytoma are paroxysmal hypertension, chest pain (or headache), palpitation, perspiration, pallor. Although most patients have either sustained or paroxysmal hypertension, some patients present with hypotension. The management of hypertension with pheochromocytoma is well-established. However, it is difficult to stabilize blood pressure in patients presenting with hypotension. Excess epinephrine and volume depletion may be the cause. Beta blocker seemed effectively reduced syncopal attacks and hypotension. Propranolol and large volume of infusion could stabilize the blood pressure. The therapeutic treatment of pheochromocytoma is operation; however, stabilize the blood pressure and control the activity of the tumor is a very important issue before the surgery.

PE-4 EXOSOMAL PROTEINS IN URINE: BRAND NEW BIOMARKERS IN POST-OPERATIVE FOLLOW-UP OF THYROID CANCER

1,2CHIH-YUAN WANG, 3TSE-YING HUANG, 1LI-TING HUANG, 1YI-CHIEH CHUNG

1Division of Endocrinology and Metabolism, Department of Internal Medicine, National Taiwan University Hospital, Taiwan; 2Department of Internal Medicine, National Taiwan University Hospital, Yunlin Branch,Taiwan; 3Department of Internal Medicine, National Taiwan University Hospital, Hsin-Chu Branch, Taiwan

Background: Thyroid cancer is the commonest malignancy in endocrine disease category. Postoperative follow-up in well-differentiated thyroid cancer usually depends on image studies and serum thyroglobulin levels for decades.The aim of our study tried to find new biomarkers instead of serum thyroglobulin.

Methods: Urinary exosome precipitation was performed. All reagents were ACS grade or higher. All solvents used, including water, were liquid chromatography (LC)/mass spectrometry (MS) grade. Standard peptides were synthesized. Multiple reaction monitor was performed and urine analysis of the samples was performed with acquisition methods containing three verified ion-pair transitions per target peptide to ensure the detection of any minor sample-specific signals. The calculated concentration is reported in μM of urine and can be defined in ng/mL when the weight of the entire processed protein is taken into account.

Results: Eleven peptides were synthesized and prepared for detecting urine exosomal protein concentrations. The concentrations of such peptide in urine exosomal level were measured. Several peptides were noted with statistically difference before and after operation, and could be stratified in various staging.

Conclusions: We found a brand new tumor biomarkers in urine exosomes; and we hope these peptides could be effective in patients of thyroid cancer, without intervention of human recombinant TSH/withdrawal of thyroid hormone replacement, and without interference of thyroid auto-antibodies.

PE-5 TRANSTUBULAR POTASSIUM GRADIENT PREDICTS END ORGAN DAMAGE IN PRIMARY ALDOSTSERONISM

1HUNG-WEI LIAO, 2VIN-CENT WU

1Chinru clinic 2Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan

Background: End organ damage could occur in primary aldosteronism (PA). However, kidney impairment could be concealed by relative hyperfiltration but emerge after treatment. We assumed transtubular gradient potassium gradient (TTKG), a kidney aldosterone bioactivity indicator, could forecast chronic kidney disease manifestation after adrenalectomy and correlate to end organ damage.

Methods: In the present nonconcurrent prospective study, we enrolled PA patients who underwent adrenalectomy in the Taiwan Primary Aldosteronism Investigation (TAIPAI) registry from 2010 to 2018. The clinical outcome was chronic kidney disease (CKD) status, defined as estimated glomerular filtration rate (eGFR) 50 mg/g (OR = 2.42; 95 % CI, 1.07 – 5.47; p = 0.034) and left ventricular mass (B = 20.10; p = 0.018). Multivariate logistic regression analysis demonstrated that TTKG ≥ 4.9 could predict subsequent CKD (OR = 5.42; 95% CI, 1.48 – 19.85; p = 0.011), 20% decrease of eGFR (OR = 2.55; 95% CI, 1.11 – 5.88; p = 0.028) at 12 months after adrenalectomy.

Conclusions: TTKG could predict emerged CKD in PA patients after adrenalectomy. TTKG as an adverse surrogate of aldosterone and hypokalemia correlated with pre-operative end organ damage in terms of high proteinuria and cardiac hypertrophy. TTKG could help us predict who may have concealed organ injury and treat these patients more actively to prevent further complication from PA.

PE-6 THE SIZE DOES MATTER: MANAGEMENT OF RUPTURE OF THYROID NODULE AFTER RADIOFREQUENCY ABLATION AND LITERATURE REVIEW

1WEN-CHIEH CHEN, 2KAI-LUN CHENG, 3WEI-CHE LIN

1Division of Metabolism, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan; 2Department of Medical Imaging, Chung Shan Medical University Hospital, Taichung, Taiwan;3Departments of Diagnostic Radiology, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan

Background: Radiofrequency ablation (RFA) is a safe and well-tolerated way for the management of thyroid nodules. Careful follow-up and monitor of complications are essential. We aim to evaluate the clinical manifestations, imaging features, and management of patients with thyroid nodule rupture after RFA in Taiwan.

Methods: We presented 9 patients with nodule rupture after RFA at 2 medical centers between 2017 and 2019. The nodules were confirmed benign on at least 2 fine needle aspirations or core needle biopsy prior to RFA. Data including baseline characteristics, initial symptoms of rupture, imaging, management, and prognosis were reviewed. The localization of rupture was classified into anterior, posterolateral, and medial types.

Results: 9 patients (7 females and 2 males, with mean age 38.9±7.3 years) experienced nodule rupture after RFA. The complication rate of nodule rupture was 1.1% (9/791). There were 4 patients received RFA twice. The volume reduction rate (VRR) was 83.6±5.8%. The ruptured nodules were all with predominantly solid content (mean volume 73.9 ml and the maximum one was 198ml). The most common symptoms of post-RFA nodule rupture were sudden neck bulging and erythema. The anterior type was the most common type of rupture (8/9, 89%). 7 patients (78%) received antibiotics treatment initially, and 6 of who required followed invasive procedures, including aspiration, incision and drainage (I&D) and debridement. 4 patients needed hospitalization (duration 7-20 days). All patients recovered completely after longitudinal management.

Conclusion: Anterior type is the most common type of thyroid nodule rupture after RFA. Though thyroid nodule ruptures after RFA can be managed conservatively, the larger goiter may require aggressive management including I&D or debridement, and was not necessarily related to delayed nodule bleeding. Understanding these clinical and imaging features can help physicians make the correct diagnosis and treatment in time.

PE-7 URINARY SODIUM POTASSIUM RATIO ASSOCIATES WITH CLINICAL SUCCESS AFTER ADRENALECTOMY IN UNILATERAL PRIMARY ALDOSTERONISM

1MING JSE LEE, 2CHIAO YIN SUN, 2HENG CHIH PENG, 3VIN CENT WU

1Division of Nephrology, Ten Chan General Hospital, Taoyuan, Taiwan 2Division of Nephrology, Chang Gung Memorial Hospital, Keelung, Taiwan 3 Division of Nephrology, National Taiwan University Hospital, Taipei, Taiwan

Background: Urinary sodium-potassium ratios not only correlated with dietary sodium and potassium intake and blood pressure but also represented the activity of aldosterone. In this study, we evaluated the value of the urinary sodium-potassium ratio in predicting the surgical outcome of primary aldosteronism (PA) patients.

Methods: This non-concurrent prospective cohort study was conducted from 2011 to 2017 and included 241 PA patients who had undergone adrenalectomy and been followed at least one year. Demographic and laboratory data were collected. Predictors of successful clinical outcomes were analyzed using logistic regression.

Results: Among the 241 PA patients, 197 patients (81.7%) achieved clinical success. The clinical success group had higher systolic blood pressure (154.5 ± 20.3 vs 146.8 ± 14.3; P = 0.011), diastolic blood pressure (92.2 ± 14.1vs 87.1 ± 11.2; P 0.013), aldosterone level (56.8 ± 35.4 vs 56.8 ± 35.4 ng/ dL; P = 0.037), log ARR ratio (2.39 ± 0.78 vs 2.13 ± 0.85; P = 0.019), better renal function (estimated glomerular filtration rate: 96.6 ± 20.4 vs 83.8 ± 20.5 mL/min/1.73m2; P = 0.001), but lower renin (0.88 ± 3.41 vs 1.70 ± 4.84 ng/dL; P = 0.037) than absent clinical success group. Urinary sodium potassium ratio less than 3 (OR:2.5; 95% CI:1.2-5.4; P=0.015), body mass index less than 25 (OR = 2.82; 95% CI: 1.31-6.06; P = 0.008), renin less than 1 (OR = 2.51; 95% CI: 1.01-6.21; P = 0.047) and mean blood pressure more than 115 mmHg (OR = 5.02; 95% CI: 2.10-11.97; P < 0.001) could predict clinical success after adrenalectomy. Furthermore, log urine NaK ratio was correlated with serum C- reactive protein (β value = 2.326; 95% CI 0.029-4.623; P = 0.047)

Conclusion: Patients with low urinary NaK ratio, in term of hyperaldsoterone, low potassium together with low dietary salt intake, were more likely to have clinical success after surgery. PA patients with lower urinary NaK ratio were associated with less severe inflammatory status.

PE-8 DISSOCIATION OF BONE MINERAL DENSITY BETWEEN LUMBER SPINE AND HIP JOINT IN A CASE OF PROSTATE CANCER WITH BONE METASTASIS

1SU-CHIN CHEN, 2FU-SHUN KO, 1WAN-SHIH HUANG, 3AI-HUNG LIU, 1,4HONG-DA LIN

1Section of Endocrinology and Metabolism, Department of Medicine, Central Clinic and Hospital, Taipei, Taiwan; 2Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; 3Section of Endocrinology and Metabolism, Department of Medicine, Chung Shan Hospital, Taipei, Taiwan; 4Division of Endocrinology and Metabolism, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan

Advanced prostate cancer is frequently accompanied with bone metastasis. High prevalence of bone metastasis in prostate cancer were osteoblastic change with high bone density. Among the patients with prostate cancer, the values of bone mineral density (BMD) in the lumbar vertebrae were significantly higher in patients with osseous metastasis than in those without metastasis. Androgen deprivation therapy is commonly used in patients with prostate cancer and associated with bone loss and fractures. Patients should have assessment of skeletal integrity with bone mineral density or x-ray of the hip and spine. We report a case of 79-years old male with history of diabetes mellitus over 15 years under oral anti-diabetes drugs and basal insulin treatment. He also had history of prostate cancer with surgery at other hospital. A routine DEXA checkup he was found high BMD over lumbar spine (average T-score 4.4, Figure 1) but low BMD over hip joint (average T-score -1.2, Figure 1). Plain spine X-ray showed multiple osteoblastic metastasis lesion over L-spine (Figure 2). In case of high BMD over lumbar spine but osteopenia in hip joint, physicians should remain alert that this may be correlated with bone metastasis in prostate cancer. Early management may help improve quality of life and decrease potential osteoporosis or fracture risk among these patients

PE-9 HYPERTHYROIDISM INDUCED BY MOLAR PREGNANCY: A CASE REPORT

1KUAN-HUA CHEN, 2KUNG-YANG WANG, 1TING-CHU CHEN, 1CHUAN-TAI CHIU, 1SHYANG-RONG SHIH

1Division of Metabolism and Endocrinology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan; 2Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan

A 29-year-old woman received treatment for infertility in a local hospital in March 2019. The doctor provided stimulant for ovulation followed by progesterone, and soon she was pregnant. The last date of her menstrual period was 2019/03/05. However, vaginal bleeding developed in April 2019, and the amount increased gradually. In addition, she suffered from excessive vomiting, dyspnea on exertion and palpitation. She visited the hospital again, where twin pregnancy was confirmed. Unfortunately, one of the fetuses did not have heartbeats and multiple cystic lesions were noticed in the uterus. The patient was referred to National Taiwan University Hospital (NTUH) for further management.

In NTUH, abdominal and pelvic computed tomography detected an intrauterine contrast-enhanced mass. Under the impression of molar pregnancy, therapeutic dilatation and curettage (D&C) was performed on 2019/05/16. The pathological report confirmed a complete mole. However, palpitation and exertional dyspnea still persisted after the operation. Laboratory tests revealed elevated thyroxine, undetectable thyroid-stimulating hormone (TSH) and very high beta-human chorionic gonadotropin (β-HCG) levels; while anti-thyroglobulin antibody, TSH receptor antibody, and anti-thyroid peroxidase antibody were all undetectable. Thyroid sonography did not show any evidence of autoimmune thyroid disease. Carbimazole was prescribed for hyperthyroidism. One week later, thyroid function normalized, carbimazole was discontinued and the patient was then discharged. Hyperthyroidism did not recur for the next seven months of follow-up.

Discussion: β-HCG and TSH share the same alpha subunits. A very high level of β-HCG thus will induce hyperthyroidism. Compared with partial molar pregnancy, complete mole tends to induce higher β-HCG levels and therefore brings higher risk of hyperthyroidism. Therapeutic D&C is the main treatment option.

PE-10 THE IMPACT OF BISPHOSPHONATES ON MORTALITY AND CARDIOVASCULAR RISK AMONG OSTEOPOROSIS PATIENTS AFTER CARDIOVASCULAR DISEASE

1SHU-TING WU, 1JUNG-FU CHEN, 1CHIA-JEN TSAI

1Division of Endocrinology and Metabolism, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan.

Purpose: Bisphosphonates (BPs) impact on the survival and cardiovascular safety of osteoporosis patients after acute coronary syndrome (ACS) or acute ischemic stroke (AIS) was evaluated.

Methods: A nationwide epidemiological study was conducted using the Taiwan National Health Insurance Research Database from 2000 to 2010. From the 1,456 osteoporosis patients with previous ACS or AIS, mortality and cardiovascular safety was compared between 464 patients who used BPs and 464 patients who did not. Primary outcomes included all-cause mortality, and major adverse cardiovascular events.

Results: The BPs group had a lower risk of all-cause mortality than the control group. All-cause mortality after the 8-year follow-up was 13.8% (n = 64) and 21.1% (n = 98) in the BPs and control groups, respectively (HR, 0.64; 95% CI, 0.46-0.88; P = 0.006). The risks of myocardial infarction, ischemic stroke, cardiovascular death, hospitalization for heart failure or other causes of mortality were similar across groups. However, there was a higher risk of hospitalization for atrial fibrillation in the BPs group than the control group (HR, 1.76; 95% CI, 1.26-2.46; P = 0.001).

Conclusion: Among osteoporosis patients after ACS or AIS, BPs use was associated with a reduced risk of all-cause mortality. However, patients with previous cardiovascular disease who received BP treatment should be careful about the risk of atrial fibrillation.

Keywords: Bisphosphonate, Osteoporosis, Cardiovascular outcome, Mortality risk, Atrial fibrillation

PE-11 NODAL OR DISTANT METASTATIC THYROID CARCINOMA AS INITIAL PRESENTATION WITHOUT DETECTABLE PRIMARY THYROID LESION- CASE SERIES AND LITERATURE REVIEW

1LAY SAN LIM, 1JUNG-FU CHEN, 1CHEN-KAI CHOU

1Division of Metabolism, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan.

Introduction: The incidence of metastasis from differentiated thyroid carcinoma ranges between 10% and 20%, of which most are identified at the time of the primary tumor diagnosed. Nodal or distant metastasis is rarely the initial presentation of thyroid carcinoma in patients without detectable primary thyroid tumor.

Methods: We reported 4 cases of nodal or distant metastasis without detectable primary thyroid lesion in Kaohsiung Chang Gung Memorial Hospital between 2013 and 2018.

Results: Case 1: A 72-year-old female presented with enlarged left neck level II lymph node and biopsy revealed metastatic papillary thyroid carcinoma(MPTC). CT showed multiple metastatic lung nodules. She underwent total thyroidectomy and left extended radical neck dissection. Pathology revealed bilateral nodular goiter and nodal mPTC. However, recurrent left neck nodule was detected and pathology confirmed MPTC. Intracranial and bony metastasis developed later.

Case 2: A 37-year-old female with history of follicular adenoma status post left total thyroidectomy had left neck mass. MRI showed a left cervical level II cystic lesion, suspected 2nd branchial cleft cyst. Left neck lesion was surgically removed and pathology showed nodal MPTC. Right total thyroidectomy and left modified radical neck dissection were performed. Final pathology report confirmed nodular goiter without metastatic nodal lesions.

Case 3: A 32-year-old female with history of nodular goiter status post right total thyroidectomy complained of right supraclavicular nodule. She received excision of tumor and pathology revealed metastatic follicular thyroid carcinoma (MFTC). She then received left total thyroidectomy and pathology turned out nodular goiter.

Case 4: A 66-year-old female with hepatoma post op and chemotherapy. T3 bony metastases was noted and biopsy showed MFTC. She received bilateral total thyroidectomy 2 years ago and pathology turned out left nodular goiter with a follicular adenoma and right nodular goiter.

Conclusions: Nodal or distant metastasis of thyroid carcinoma without detectable primary tumor is rare but exists in our practice. Greater awareness of this unusual initial presentation is important to avoid mistaking metastatic thyroid carcinoma for benign lesion in the setting of neck mass. Besides, long-term follow-up might be necessary in these cases because of the possible association of unusual presentation and worse prognosis.

Keywords: thyroid carcinoma, distant metastasis, lymph node metastasis

PE-12 TUBERCULAR HYPOPHYSITIS MIMICKING AUTOIMMUNE HYPOPHYSITIS: A CASE REPORT

1CHEN TING-CHUN, 1SIA HON-KE, 1TU SHIH-TE, 1WANG SHU-YI

1Division of Endocrinology and Metabolism, Department of Internal Medicine, Changhua Christian Hospital, Changhua City, Changhua County, Taiwan

Introduction: Hypophysitis is an inflammation of pituitary gland with various clinical symptoms including hypopituitarism, diabetes insipidus, amenorrhea, and mass effect. Hypophysitis is rare and not fully understood until nowadays. It may have an underlying autoimmune etiology or secondary to tumor and infection. Isolated hypophysitis due to Mycobacterium tuberculosis infection is extremely rare in Taiwan. We reported a young woman having tubercular hypophysitis mimicking autoimmune hypophysitis initially, and with hypothalamus involvement in the later course.

Case report: A 26-year-old woman presented with polydipsia and polyuria for one month. She had body weight lose from 46kg to 41 kg and ceased menstruation. Central diabetes insipidus (DI) was diagnosed by water deprivation test. Pituitary function test showed normal cortisol, freeT4/TSH, but hyperprolactinemia (Prolactin: 80.07ng/mL), and hypogonadotropic hypogonadism. Pituitary MRI revealed thickness and good enhancement of the pituitary stalk and enlargement of pituitary gland, which indicated hypophysitis, especially lymphocytic hypophysitis also known as autoimmune hypophysitis, or sarcoidosis, adenoma. The neurosurgeon suggested conservative treatment. She was treated with cabergoline, desmopressin and a course of methyl-prednisolone. Follow-up pituitary function showed declined prolactin levels and stable pituitary size in MRI images for two years. Prolactin level elevated again and pituitary MRI showed the mass lesion became larger with suprasellar extension and involved hypothalamus, optic chiasm and optic tracts. Stereotactic biopsy of hypothalamus was performed. Pathology reported granulomatous inflammation and acid-fast stain positive microorganism, Mycobacterium tuberculosis. Panhypopituitarism occurred after biopsy. Sex hormone replacement and anti-tubercular treatment were initiated. After complete treatment of anti-tuberculosis, brain MRI showed disappearance of the suprasellar mass lesion. Nonetheless, panhypopituitarism still presented.

Discussion: Tuberculosis of the central nervous system is seldom in these days, especially in young people without immunocompromised conditions or special contact history.

In our case, this healthy young woman presented with secondary amenorrhea, hyperprolactinemia and DI compatible with the pituitary MRI finding of suprasellar lesion suggested autoimmune hypophysitis, which is not the candidate of surgery.

Nonetheless, when conservative treatment failed, prompt surgical intervention is warranted since biopsy is the only means of accurate diagnosis. The typical radiological appearance of granulomatous

hypophysitis, such as tubercular hypophysitis, is similar to that of lymphocytic hypophysitis, but the treatment is different. No standard regimen of tubercular hypophysitis was established till now, but it seems reasonable to treat as tubercular meningitis.

Conclusion: We presented a case of tubercular hypophysitis mimics autoimmune hypophysitis, the former is difficult to be differentiated by clinical symptoms, laboratory tests and pituitary MRI. Biopsy or surgery should be performed promptly if medical treatment failed.

PE-13 TREATMENT EFFICACY AND SAFETY OF ULTRASOUND-GUIDED PERCUTANEOUS RADIOFREQUENCY ABLATION FOR PTMC: TAIWAN EXPERIENCE

1WEI-CHE LIN,

2KAI LUN CHEN, 3CHEN-KAI CHOU, 4CHENG-CHIAO HUANG, 5SHENG-DEAN LUO, 6SHUN-YU CHI, 7YEN-HSIANG CHANG, 7PEI-WEN WANG

1Department of Diagnostic Radiology, Kaohsiung Chang Gung Memorial Hospital; 2Department of Medical Imaging, Chung Shan Medical University Hospital, Taichung, Taiwan; 3Division of Endocrinology and Metabolism, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital; 4Departments of Surgery, Taipei Medical University Hospital, Taipei, Taiwan; 5Department of Otolaryngology, Kaohsiung Chang Gung Memorial Hospital; 6Departments of Surgery, Kaohsiung Chang Gung Memorial Hospital; 7Department of Nuclear Medicine, Kaohsiung Chang Gung Memorial Hospital

Background: To evaluate the therapeutic efficacy and safety of ultrasound-guided percutaneous radiofrequency ablation (RFA) of papillary thyroid microcarcinoma (PTMC).

Methods: From February 2018 to August 2019, we enrolled 16 patients (12 female, 4 male, mean age 52.6 ± 10.6 years) with 18 PTMC for single session of ultrasound-guided percutaneous RFA. All nodules were confirmed by at least two time ultrasound-guided aspiration, and all the patients had normal thyroid functions. The maximum diameter and volume of all nodules were recorded before treatment and during 1, 3, 6 and 12 months follow-up.

Results: The RFA procedures were completed with a mean time of 45.3 ± 28.1 min. The procedures were tolerated well in all the patients. The baseline maximum diameter and volume of nodules were 0.85 ± 0.18 cm and 0.35 ± 0.71 cc, respectively. Compared to baseline condition, significant regression of the maximum diameter (0.78 ± 0.30, p = 0.027) and volume (0.21 ± 0.42, p = 0.043) of nodules were noted in 12 months follow-up after RFA. Two PTMCs experienced complete disappear one year after RFA. During follow‐up, no patient experienced local tumor recurrence or distant metastasis. No patients had lymph node metastasis or new PTMC development.

Conclusion: Thermal ablation is an excellent local tumor control method in patients with low‐risk PTMCs. Strict inclusion criteria and technical expertise are required to obtain favorable results.

PE-14 TREATMENT RESPONSE AND OUTCOME OF R2 RESECTION IN DIFFERENTIATED THYROID CANCER - A RETROSPECTIVE ANALYSIS

1YVONNE EE WERN CHIEW, 1JUNG-FU CHEN, 1CHEN-KAI CHOU

1Division of Metabolism, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan

Background: Majority of differentiated thyroid cancer has favorable outcome, even in patient with advanced disease. Surgical resection with the possible adjunction of radioiodine therapy is recommended for treating differentiated thyroid cancer. The aim of this study is to analyze whether R2 resection affects the treatment response and outcome of differentiated thyroid cancer by using the institutional database of our hospital.

Methods: We reviewed our institutional database of 1247 patients with thyroid cancer operated between January 2013 and July 2018, follow up until December 2019. A total of 252 patients with differentiated thyroid cancer had tumor extension beyond the thyroid capsule. They were grouped into patients with either negative surgical or microscopically positive margin(R0/R1), or with gross residual disease(R2) after surgical resection of thyroid cancer. The parameter and outcome of the two groups (R0/R1 versus R2) were assessed and analyzed.

Results: The median age of the 252 patients with tumor extension beyond the thyroid capsule was 54 years (range 13–87 years). 192 patients (76.2%) were female. Among the 252 patients, 211(83.7%) patients underwent surgery with R0 or R1 tumor resection, 41(16.3%) patients received R2 tumor resection. 205(97.2%) of patients with R0 or R1 resection had thyroid cancer stage I/II, and 6(2.8%) patients has thyroid cancer stage III/IV. 20(48.8%) and 21(51.2%) patients of R2 group had thyroid cancer stage I/II and stage III/IV, respectively. The treatment response when stratified by excellent/ biochemical incomplete/structural incomplete/indeterminate, was 69.4%, 20.6%, 8.6% and 1.6% respectively in R0/R1 group. In patients with R2 resection, 46.3% of them had excellent response, 34.1% was biochemically incomplete and 19.5% was structurally incomplete. The recurrence rate was 8.5% in R0/R1 group and 24.4% in R2 group. Among the R2 group, 87.5% of them had T4a or T4b tumor, 12.5% had T3b tumor. The 2 groups had similar median age. However, higher percentage of patients with T3b tumor achieved excellent response (87.5%) compared to T4a or T4b patients (36.4%). None of the R2 resected patients with T3b tumor had structurally incomplete treatment. All the recurrence and distant metastasis cases in R2 group were patients with T4a or T4b tumor.

Conclusion: Patient with gross residual disease(R2), especially those with advanced stages, T4a or T4b tumor, are more likely to have structural or biochemically incomplete treatment and higher recurrence incidence. A more rigorous follow up with detailed examination were suggested in these patients.

Keywords: Differentiated thyroid cancer, Tumor resection, Recurrence

PE-15 RIEDEL’S THYROIDITIS MASQUERADING AS THYROID MALIGNANCY ON ULTRASOUND: A CASE REPORT

1YOU-TING LIN, 1CHING-CHU CHEN, 1CHING-CHUNG CHANG, 1CHWEN-TZUEI CHANG, 1RONG-HSHING CHEN, 1TZU-YUAN WANG, 1WEI-LUN HUANG, 1SHENG-PANG HSU

1Division of Endocrinology and Metabolism, Department of Internal Medicine, China Medical Hospital, China Medical University, Taiwan,

Background: It has been recently suggested that Riedel’s thyroiditis is to be a part of IgG4RD spectrum. Many clinicians are convinced that the thyroid would be diffusely involved and enlarged while considering its inflammatory background of Riedel’s thyroiditis, but rarely reported as a masquerading malignant mass. We herein introduce a case of Riedel’s thyroiditis, a probable histological features of IgG4-related disease, mimicking thyroid malignancy on ultrasound.

Case report: A 66-year-old woman presented to our endocrine out-patient clinic for consulting whether or not to continue taking the levothyroxine prescribed at local clinic for unknown entity of right thyroid nodule for years. Initial physical examination of the neck disclosed a symmetric thyroid gland with no palpable bilateral lobes. Laboratory investigations after she discontinued levothyroxine by herself for four consecutive weeks demonstrated serum thyroid-stimulating hormone level, serum free T4 level and serum thyroid peroxidase antibody level were within normal reference laboratory values, but an elevated anti-Thyroglobulin antibody level at 1521 IU/mL (reference range <40 IU/ mL). Preoperative neck ultrasound scan disclosed an ill-defined, solid, hypoechoic nodule 12x10x10 mm with microcalcifications and extrathyroid extension. Histological examination after right total and left subtotal thyroidectomy revealed the thyroid follicles were obliterated by extensive dense fibrous tissue with storiform, keloid-like hyalinzing fibrosis, which also infiltrated adjacent skeletal muscles. The number of IgG4-positive cells were up to 15 per high power field and the IgG4 to IgG ratio was less than 40%. Riedel thyroiditis, a probable histological features of IgG4-related disease, should be considered.

Discussion: Riedel thyroiditis (RT), a rare inflammatory disorder of uncertain etiology and characterized by fibrotic replacement of thyroid tissue with vascular obliteration, is suggested to be a part of IgG4-RD spectrum. RT can demonstrate either a homogenegous hypoechoic texture and pseudonodular appearance due to fibrous tissue or a hypoechoic mass with irregular delimitation, even involves adjacent tissues under ultrasound scan. It is important for clinicians to be aware of this clinicopathological and unusual ultrasonic manifestation of Riedel’s thyroiditis.

PE-16 IODINE NUTRITIONAL STATUS OF BREASTFEEDING WOMEN IN NORTHERN TAIWAN 2019

1CHUN-JUI HUANG, 2FAN-FENG WANG

1 Division of Endocrinology and Metabolism, Department of Medicine, Taipei Veterans General Hospital, Taiwan; 2 Department of Medicine, Yangming Branch, Taipei City Hospital, Taipei, Taiwan

Background: Pregnant and lactating women are vulnerable to iodine deficiency. Our survey of pregnant women in 2018 revealed sufficient iodine status in an urban area of Northern Taiwan, but the condition in lactating women is unknown. This study was conducted to evaluate the iodine nutritional status of lactating women residing in and around Taipei metropolitan area.

Methods: A total of 198 subjects were recruited from Taipei Veterans General Hospital in 2019. Random spot urine samples were collected and a simple food frequency questionnaire was completed by the participants. Urinary iodine concentration (UIC) was measured by inductively coupled plasma mass-spectrometry.

Results: The median UIC of the total surveyed population was 120 μg/L, which indicated sufficient iodine status. The distribution of UIC was as follows: 3.0% with UIC < 20 μg/L, 14.6% with UIC within 20-49 μg/L, 22.7% with UIC within 50-99 μg/L, 29.3% with UIC within 100-199 μg/ L, 14.6% with UIC within 200-299 μg/L, and 15.7% with UIC ≥ 300 μg/L. Postpartum nourishment diet was very common in Taiwan and 74.7% (n = 148) of the surveyed population was under specially designed diet for postpartum care.

Conclusions: The results suggest that the iodine status in lactating women in an urban area of Northern Taiwan is adequate.

PE-17 METHIMAZOLE INDUCED CHOLESTATIC JAUNDICE: A CASE REPORT

1FONG-JUI KUO, 2, 3TON-HO YANG, 1, 2, 4CHING-CHIEH SU

1Division of Endocrinology and Metabolism, Department of Internal Medicine, Cardinal Tien Hospital, New Taipei City, Taiwan; 2School of Medicine, Fu Jen Catholic University, New Taipei City, Taiwan; 3Division of Gastroenterology & Hpatology, Department of Internal Medicine, Cardinal Tien Hospital, New Taipei City, Taiwan; 4Graduate institute of Applied Science and engineering, Fu Jen Catholic University, Taipei, Taiwan

Background: Hepatic dysfunction and jaundice are sometimes present in patients with hyperthyroidism. They can be clinical manifestations of the disease or the adverse effect of antithyroid medications. Methimazole is widely prescribed for patients with hyperthyroidism. However, cholestatic jaundice is one of the rare but serious adverse events of methimazole therapy.

Methods: We reported a case of cholestatic jaundice after a few weeks of methimazole use.

Results: This 52-year-old women with Graves’ hyperthyroidism had developed cholestatic hepatitis after a one-month course of methimazole treatment. Clinical workup revealed hyperbilirubinemia as well as impaired liver function. Concomitant liver diseases, such as viral hepatitis (A, B, C) or CMV viral infection, autoimmune hepatitis, IgG4 disease, primary biliary cirrhosis and calculus of bile duct, were excluded by blood tests and imaging studies. Liver enzyme levels returned to normal after discontinuing methimazole followed by glucocorticoid administration.

Conclusions: In this case, methimazole caused severe but reversible cholestatic jaundice. It is indeed rare, but physicians and patients should be aware of this serious adverse effect. To the best of our knowledge, this is the first reported case of methimazole induced cholestatic jaundice in Taiwan.

PE-18 SUCCESSFUL GESTATION AFTER REMOVAL OF PITUITARY TSH PRODUCING TUMOR IN A INFERTILE FEMALE PATIENT

1CHIATE WU, 2JING SHAN HUANG, 3TSUNG HSUAN LAI, 1CHING-LING LIN

1Division of Endocrinology and Metabolism, Department of Internal Medicine, Cathey General Hospital, Taiwan; 2Division of Neurosurgery, Department of Surgery, Cathey General Hospital, Taiwan; 3Division of Obstetrics & Gynecology, Cathey General Hospital, Taiwan

This is a 36 years old female seeking help at Infertility Department. Elevated TSH and fT4 were noted therefore transferred to the Endocrinology department due to the discrepancy of the result. Pituitary MRI was arranged after the patient’s In vitro fertilization treatment had failed for the second time and one nearly 0.8 cm less contrast-enhancing nodular shadow over the right side of the pituitary gland just medial to the siphon segment of right ICA and mild suprasellar extension was found. Pituitary microadenoma was impressed, favored TSH-secreting tumor, rule out thyroxine resistance syndrome based on her clinical manifestation. Admitted into the endocrinology ward for complete pituitary study with Insulin Stress Test, GnRH Test, and TRH Test. Result favored ThyroxineSecreting Pituitary adenoma. Symptoms of Hyperthyroidism with palpitation developed afterward and Endoscopic Endonasal Trans-sphenoidal Hypophysectomy/ adenomectomy (Naviagation system (BRAINLAB) assisstence) was done by the neurosurgeon. Hyperthyroidism symptoms relieved after the surgery and follow up thyroid function falls back within the normal range. The patient underwent 3rd round of In vitro fertilization treatment however miscarriage occurred due to habitual abortion. 4th round of In vitro fertilization treatment was successful after 6 months of hormonal therapy at the Obstetrics and Gynaecology department and the patient gave birth to a preterm baby at 30+2 gestation week with Placenta previa and preterm pre-labor rupture of the membrane via cesarean section.

PE-19 METHIMAZOLE-INDUCED ANCA AND ANTI-GBM-ANITBODY POSITIVE RPGN IN A PATIENT WITH GRAVE’S DISEASE: A CASE REPORT

1WEI-CHANG CHEN, 2CHING-LING LIN, 3MING-TSO YAN

1Division of Endocrinology and Metabolism, Department of Internal Medicine, Cathay General Hospital, Taiwan, 2Division of Endocrinology and Metabolism, Department of Internal Medicine, Cathay General Hospital, Taiwan, 3Division of Nephrology, Department of Internal Medicine, Cathay General Hospital, Taiwan

Anti-neutrophil cytoplasmic antibody(ANCA)-associated vasculitis may cause symptoms or signs with multisystem involvement such as renal failure, pulmonary hemorrhage, gastrointestinal dysfunction and peripheral neuropathy. Patient with Grave’s disease who was treated with antithyroid drugs may suffer from rare but severe adverse effect such as agranulocytosis, thrombocytopenia and ANCA-positive vasculitis, especially propylthiouracil. Here we reported a case of methimazoleinduced pauci-immune and anti-glomerular basement membrane(GBM) rapidly progressive crescentic glomerulonephritis in a 55 years old Taiwanese woman with Grave’s disease who was treated with Methimazole for 6 years. Initial clinical presentation as dyspnea, decreased urine output, general edema and painful sensation over lower extremities without muscle weakness. Antithyroid drug was stopped, steroid pulse therapy and oral immunosuppression therapy with Mycophenolate were used as impression of ANCA-positive vasculitis related glomerulonephritis, pleuritis, pericarditis and peripheral neuropathy. The kidney biopsy showed diffuse extra-capillary proliferative(crescentic) glomerulonephritis which is compatible with pauci-immune type(type III) glomerulonephritis. However, anti-GBM disease could not be totally excluded because of linear IgG staining of GBM in immunofluorescent study. Serum testing for anti-GBM, p-ANCA and anti-myeloperoxidase(MPO) antibody were all positive. Plasmapheresis was performed immediately and follow-up serum testing for anti-GBM and anti-MPO showed negative after plasmapheresis for six times. Unfortunately, oligouria persisted after above treatment and she received regular hemodialysis thereafter. Anti-thyroid drugs related adverse effect varies and may cause severe clinical manifestation such as renal failure which may need steroid therapy, immunosuppression therapy, plasmapheresis and eventually renal replacement therapy. Here described a rare, may be the first case of methimazole-induced ANCA and anti-GBM RPGN. The patient also a victim of permanent renal replacement therapy despite steroid, immunosuppression therapy and plasmapheresis.