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Parathyroid carcinoma (PC) is a rare neoplasm with a prevalence of only 0.005 % of all malignancies, and less than 1 % among patients with primary hyperparathyroidism. The diagnosis can be challenging due to the rarity of the disease, similarity of clinical features to parathyroid adenoma, and lack of reliable morphological signs of the tumor. For metastatic cancer of the parathyroid gland does not exist standard drug therapy due to the rare occurrence of this disease. Chemotherapy and radiotherapy failed to show any significant effect on the course of the disease. We report the case of a 27-year old woman with PC previously misdiagnosed as benign thyroid nodule and multiple lung metastases. After the immunohistochemical study and confirm of diagnosis PC the patient was treatment with multikinase inhibitor sorafenib successfully.

Background: Ectopic adrenocorticotropic hormone (ACTH)-dependent Cushing's syndrome is a type hypercorticism caused by ectopic production of ACTH and/or its precursors by neuroendocrine tumors (NET) of various localization, such as lung and thymus carcinoids, less frequently those of pancreas and gastrointestinal tract, medullary thyroid cancer, pheochromocytoma, small cell lung cancer, as well as some other tumor types. The wide spectrum of tumors associated with the ectopic ACTH syndrome (EAS) makes their diagnosis and treatment a complicated issue. Materials and methods : The study was done with surgical and diagnostic biopsy samples from 60 patients who had tumors with EAS, 36 (60%) of them being bronchopulmonary carcinoids, 10 (16.7%) thymus carcinoids, 5 (8.3%) pancreatic NETs, 3 (5%) medullary thyroid cancers, 3 (5%) NETs of unknown primary localization, and NET of appendix, cecum and pheochromocytoma (one case of each, i.e. 1.7%, 1.7%, 1.7%). There were 38 female and 22 male patients (1.72:1), with their mean age of 39 ± 14 years (range, 16 to 77 years). We analyzed their clinical data, as well as the results of morphological and immunohistochemical examination of the tumors. Results : According to the World Health Organization classification (2015), typical carcinoids (TC) of the lung were found in 77.8% (28/36) of the bronchopulmonary tumors. 22.2% (8/36) of the bronchopulmonary tumors and all thymus tumors (100%, n = 10) were classified as atypical carcinoids (ATC). Four pancreatic NETs were classified as Grade 2 (G2), 1 as G3, and NETs of the cecum and appendix as G1 and G2, respectively. At present, 29 (48%) patients are living with no relapse (mean age 39 ± 13.5 years), whereas 22 (37%) of patients developed a relapse (mean age 35 ± 13 years), and 15 (25%) of them died, regardless of the age of the patients The history of the disease was not traced in 4 cases. 5-year relapse-free survival of patients with TC of the lung was 85.7% (24/28), of those with ATC 25% (2/8), with ATC of the thymus and medullary thyroid cancer 0%. Mortality from to TC of the lung for the entire follow-up period was 3.6% (1/28), to ATC 12.5% (1/8), to ATC of the thymus and for medullary thyroid cancer 62.5% and 100%, respectively. The patients with NET of the cecum, appendix and pheochromocytoma are alive without progression for 4, 5 and 6 years, respectively. Therefore, the lowest 5-year survival of patients with EAS was observed in medullary thyroid cancer, pancreatic NET and thymus carcinoids: in 100% (3/3), 75% (3/4), and 57.1% (4/7), respectively. Conclusion: The most unfavorable prognostic factors in the EAS are the localization of tumors in the thymus, pancreas and thyroid gland. This indicates the necessity of a differentiated treatment approaches to patients with this syndrome.

A review of the literature is devoted to the issue of secondary hyperparathyroidism (SHPT) with underlying chronic renal failure. Initial manifestations of the disease can be observed even with a minimal decrease in the rate of glomerular filtration and are pathophysiologically associated with violations of normal metabolism of vitamin D with its conversion into D-hormone. SHPT pathogenesis is based on the D-hormone deprivation and triggering of pathophysiology mechanisms of bone remodelling, increased FRP-23, PTH, changes in the serum levels of calcium and phosphorus, which may further lead to significant changes in the bone tissue structure and cardiovascular complications. Active metabolites of vitamin D and vitamin D analogues (Paricalcitol) were developed for the replacement of active forms of vitamin D in conditions of D-hormone deficiency. Due to its chemical structure and pharmacokinetics, Paricalcitol is able to block the synthesis of parathyroid hormone to a greater extent and increase the absorption of calcium and phosphorus in the intestine to a lesser extent, which gives it advantages over pre-existing active metabolites

The article describes two clinical cases of severe primary hyperparathyroidism (PHPT) caused by parathyroid carcinoma in young female patients who underwent molecular genetic testing to rule out the hereditary forms of PHPT. In both patients, heterozygous germline nonsense mutations of tumor suppressor gene CDC73 encoding parafibromin (p.R91X and p.Q166X) were identified using next-generation sequencing with Ion Torrent Personal Genome Machine (Thermo Fisher Scientific - Life Technologies, USA). It is the first description of CDC73 mutations in Russia, one of the mutations is described for the first time in the world. Identification of germline mutations in the CDC73 gene in patients with PHPT necessitates regular lifelong screening for other manifestations of hyperparathyroidism-jaw tumor syndrome (HPT-JT), PHPT recurrence due to parathyroid carcinoma as well, and identification of mutation carriers among first-degree relatives.Представлено описание двух клинических случаев первичного гиперпаратиреоза (ПГПТ) тяжелого течения у молодых больных раком околощитовидной железы, которым проведено молекулярно-генетическое исследование для исключения наследственных форм ПГПТ. Методом высокопроизводительного параллельного секвенирования на полупроводниковом секвенаторе Ion Torrent Personal Genome Machine (Thermo Fisher Scientific - Life Technologies, США) у обеих пациенток выявлены герминальные гетерозиготные нонсенс-мутации в гене - супрессоре опухолевого роста CDC73, кодирующем белок парафибромин: p.R91X и p.Q166X. В России мутации в указанном гене описываются впервые, одна из мутаций описывается впервые в мире. Выявление герминальных мутаций в гене CDC73 у пациентов с ПГПТ требует пожизненного регулярного профилактического обследования для ранней диагностики компонентов синдрома гиперпаратиреоза с опухолью челюсти (hyperparathyroidism-jaw tumor syndrome - HPT-JT), рецидива ПГПТ после хирургического вмешательства, в том числе вследствие рака околощитовидной железы, а также позволяет выявить носителей мутаций среди родственников первой линии родства.Представлено описание двух клинических случаев первичного гиперпаратиреоза (ПГПТ) тяжелого течения у молодых больных раком околощитовидной железы, которым проведено молекулярно-генетическое исследование для исключения наследственных форм ПГПТ. Методом высокопроизводительного параллельного секвенирования на полупроводниковом секвенаторе Ion Torrent Personal Genome Machine (Thermo Fisher Scientific — Life Technologies, США) у обеих пациенток выявлены герминальные гетерозиготные нонсенс-мутации в гене — супрессоре опухолевого роста CDC73, кодирующем белок парафибромин: p.R91X и p.Q166X. В России мутации в указанном гене описываются впервые, одна из мутаций описывается впервые в мире. Выявление герминальных мутаций в гене CDC73 у пациентов с ПГПТ требует пожизненного регулярного профилактического обследования для ранней диагностики компонентов синдрома гиперпаратиреоза с опухолью челюсти (hyperparathyroidism-jaw tumor syndrome — HPT-JT), рецидива ПГПТ после хирургического вмешательства, в том числе вследствие рака околощитовидной железы, а также позволяет выявить носителей мутаций среди родственников первой линии родства.

This review discusses the recent evidence showing that the skeleton itself produces at least two hormones: fibroblast growth factor 23 (FGF23) and osteocalcin. FGF23 is secreted by osteocytes in bone and acts on the kidney to inhibit 1-alpha-hydroxilation ofvitamin D and promote phosphorous excretion. The affinity of FGF23 to FGF receptor is low, but FGF23 binds to FGF receptor-Klotho complex with more affinity. Therefore, Klotho determines the kidney-specific action of FGF23. Increase in FGF23 or Klotho levels due to genetic defects or ectopic production results in low serum phosphorous levels in humans. Contrary to this, low FGF23 or Klotho levels lead to hypophosphatemia and ectopic calcification. Mouse genetics studies revealed that osteoblast product, osteocalcin, in its undercarboxylated stage acts on the pancreatic beta-cells to enhance insulin production and on peripheral tissues to increase glucose utilization as a result of increased insulin sensitivity and to reduce visceral fat. In addition to this, undercarboxylated osteocalcin may also have another hormonal role, this time as a mediator of testosterone secretion. Osteocalcin was shown to induce testosterone production in Leydig cells of the testes both in ex vivo and in vivo studies. In both localizations, at the pancreas and at the testes osteocalcin acts through the GPCR6A receptor, this activates the cAMP response element-binding protein signaling pathway. Thus, this review reports the recent studies indicating bone ’s role as an endocrine organ.

Clinical symptoms of vitamin D deficiency may be quite misleading and masked as rare hereditary syndromes. We describe a family, sister and brother presented with the pain in lower extremities at the age of 14 and 16years accordingly, with severe vitamin D deficiency that was misdiagnosed in the course of the disease with pseudohypoparathyroidism and 1-alpha-hydroxylase deficiency. They benefited from treatment with alfacalcidol and ossein-hydroxyapatite complex supplement which were further discontinued due to socioeconomic factors. At presentation after 2 years without treatment extremely low 25(OH)D levels were revealed. The patients' family history was remarkable for the same clinical features in mother and her Indian ancestry. Thus we describe an uncommon manifestation of severe vitamin D deficiency in a familial setting which emphasizes the necessity of vitamin D testing in calcium or parathyroid disorders.

Aim. To evaluate the effect of parathyroidectomy and cinacalcet on anemia, lipid profile and blood pressure (BP) in uremic hyperparathyroidism.Material and methods. Uremic patients (n=39) treated with hemodialysis and having secondary hyperparathyroidism were included into the study. Radical parathyroidectomy was performed in 21 patients, 18 patients were treated with cinacalcet. BP measurement, determination of blood levels of albumin, total calcium, phosphorus, total cholesterol (TC), low (LDL) and high density lipoproteins, triglycerides, intact parathyroid hormone, and hemoglobin were performed in all patients initially and during treatment. Doses of antihypertensive and erythropoiesis-stimulating agents were also assessed.Results. Calcium-phosphorus metabolism indices improved after 6 months of cinacalcet therapy and parathyroidectomy (pConclusion. The pleiotropic effects (reduction in BP and atherogenic lipids levels, as well as decrease in anemia resistant to the action of erythropoiesis-stimulating agents) were found after parathyroidectomy and cinacalcet therapy additionally to calcium-phosphorus metabolism improvement.

The paper presents data on the role of vitamin D and calcium in the function of many human organs and tissues. Lifestyle, dietary preferences, and insufficient physical activity contribute to the high prevalence of vitamin D and calcium deficiencies in the adult population of Russia, causing different diseases and abnormalities. The authors have worked out recommendations for the preventive use of vitamin D and calcium in healthy population, give consumption rates for these substances, and describe the clinical and laboratory signs of vitamin D deficiency and indications for screening. They also propose treatment regimens for vitamin D deficiency and depict the signs of intoxication in overdose. Particular emphasis is laid on the place of vitamin D and calcium in the therapy of osteoporosis.

This review of the literature has been dedicated to experimental and clinical studies of mechanism of action and efficacy of 1—34 amino acid fragment of parathyroid hormone — teriparatide as well as others contries experience of its prescribtion. Teriparatide is an osteoanabolic agent which stimulates bone formation by affecting bone modeling and by stimulating bone remodeling. The effects on modeling lead to increased bone formation whereas the effects on bone remodeling lead to increased bone turnover. Thus, in its mode of action teriparatide differs from all others medicines currently available to treat osteoporosis. Daily subcutaneous injections of teriparatide are proved to be effective to prevent low-traumatic vertebral and non-vertebral fractures in postmenopausal women with the history of vertebral fractures. Teriparatide is effective to treat osteoporosis in male and even more effective than alendronate to treat glucocorticoid-induced osteoporosis. Due to high cost and some restriction related to the duration of therapy (up to 18 months in Russia and 24 months in others countries) teriparatide should be recommended to treat severe osteoporosis in patients with a history >1 moderate clinical vertebral fracture or two or more vertebral fragility fractures or in case the previous treatment was not effective. Teriparatide should be prescribed after bisphosphonates or other antiosteoporotic treatment, but not in the combination with bisphosphonates. The prescribtion of bisphosphonates after teriparatide is effective to maintaine and further improve the effect. Thus, teriparatide is effective to treat severe osteoporosis and osteoporosis resistant to other therapy.

Multiple endocrine neoplasia syndrome type 1 (MEN1, Wermer syndrome) – group o а heterogeneous inherited deseases, caused by hyperlasia or neoplasia of several endocrine glands. The phenotype of MEN1 is broad, and over 20 different combinations of endocrine and non-endocrine metabolic manifestations have been described. This case demonstrates multiple formations of endocrine organs, starting non-classical with macroprolactonoma resistant to dopamine agonists therapy, other endocrine disorders developed gradually eventually: hyperparathyreoidism and hypoglycemia caused by pancreas lesions, produced proinsulin in high levels.

The authors review the current literature data on the pathogenesis, clinical manifestations and treatment of glucocorticoid induced osteoporosis in patients with endogenous hypercortisolism. High levels of glucocorticoids lead to bone loss, bone quality deterioration and low traumatic fractures as a consequence of reduced bone formation. In addition to this, muscle weakness and sex steroids hormone abnormalities increase the risk of falls and fractures. The new available data on possible mechanisms of these changes including the involvement of RANKL/RANK/OPG, Wnt-betacatenin signaling pathway and pathogenesis of myopathy are discussed. This review also outlines the practical recommendation and new questions that should be evaluated in future research.

Purpose. Endogenous Cushing’s syndrome (CS), usually affecting young and otherwise healthy patients, is a good model to validate the effects of supraphysiological levels of glucocorticoids in humans. This study evaluates circulating levels of extracellular antagonists of Wnt/ß-catenin signaling pathway (sclerostin, Dickkopf1 (Dkkl), secretedfrizzled-related protein 1 (SFRP1)) along with osteoprotegerin (OPG) and soluble receptor activator of nuclear factor kappa-beta ligand (RANKL) in patients with CS as compared to healthy individuals. Materials and methods. Forty patients with clinically and biochemically evident CS and 40 sex, age and body-mass index matched healthy individuals provided fasting serum samples (8:00-10:00AM) for measurement of sclerostin, SFRP1 and Dkkl, RANKL., OPG along with bone turnover markers. Serum samples on RANKL., OPG., Dkkl, SFRP1, sclerostin were frozen and then concurrently measured by an enzyme immunoassay (ELISA) using commercially available reagents. Serum samples on osteocalcin (OC), carboxyterminal cross-linked telopeptide of type I collagen (CTx), cortisol in serum and saliva were assayed by electrochemiluminescence (ECLIA) Cobas e601 Roche. Urinary free cortisol (24hUFC) was measured by an immunochemiluminescence assay (extraction with diethyl ether) on a Vitros ECi. All participants were questioned regarding any recent low traumatic fractures. Patients with CS underwent standard spinal radiographs in anterior-posterior and lateral positions of the vertebrae Th4-L4 (Axiom Icons R200 "Siemens"). Results. Patents with CS (30 (26-40) years old with 24hUFC 2575 (1184-4228) nmol/l (Me (Q25-Q75)) had suppressed OC and normal CTx levels as compared to healthy subjects. A significant correlation, which we observed between OC and CTx (po=0.724 (p

A 53-year old man with acromegaly was referred for neurosurgical treatment. At admission: growth hormone (GH) 240 ME/l at all time points of glucose tolerance test, IGF-1 - 415,1 ng/ml, brain MRI showed pituitary adenoma 34×32×27 mm extending suprasellar, deforming and displacing optic chiasm, parasellar to both cavernous sinuses and surrounding left internal carotid artery. Clinical blood tests revealed marked erythrocytosis - 6.1×1012, Hb - 200 g/l, HCT - 62%; urobilinigen 50 mmol/l was found in urine; otherwise the tests were normal. For exclusion of erythraemia the patient underwent trepanobiopsy of bone marrow which showed normal haemopoesis and suggested a secondary nature of erythrocytosis. In preoperative period 1100 ml of blood were evacuated by phlebotomy in 4 sessions, which resulted in reduction of erythrocyte count to 5,1×1012, Hb 160 g/l, HCT 50% and disappearance of urobilinigen. The patient was then operated by transnasal approach with debulking of most adenomatous tissue but without biochemical remission of acromegaly (GH 92-99 at glucose tolerance test). A week after surgery - erythrocytes 4,5×1012, Hb - 141 g/l, HCT - 44,1%. The patient was prescribed a octreotide depo (Sandostatin LAR) injections 20 mg/mth and at 6 months from operation was feeling well, with clinical remission of acromegaly and normalization of IGF-1 and all blood count parameters.

The main manifestations of central diabetes insipidus (CDI), a disease of absolute deficiency of hypothalamic hormone vasopressin, are severe thirst and polyuria, which severely interferes with normal life of patients. In some cases CDI may be the first sign of wide spread metastatic process, appearing many years after successful treatment of oncological diseases.

Calcium-sensing receptor (CaSR), a member of G proteincoupled receptors family, plays a key role in systemic calcium homeostasis regulation. It is expressed in a variety of tissues, and is responsible for maintaining plasma calcium concentration. In addition, the CaSR is known to regulate some important cellular processes such as apoptosis and proliferation. CaSR is a drug target for calcimimetics and calcilytics, agents used for modification of parathyroid cells function and treatment of some pathologic conditions. Inactivating or activating mutations of the CaSR gene cause different disorders of calcium metabolism. Polymorphic variants of the gene have been described in healthy populations.

In this article we describe a clinical case of primary hyperparathyroidism, gout tophus and diabetes mellitus type 2. The relationship between hyperuricemia and hypercalcemia linked to primary hyperparathyroidism is discussed.

The reported clinical case represents an example of characteristic traits in lipid metabolism and fat tissue deposition in hypercorticosolism. Probable causes for fat mass expansion in glucocorticosteroid excess, its distinctive cushingoid distribution, role of 11β-HSD1 and glucocorticoid receptors and reversibility of specific abnormalities after correction of hypercortisolism are discussed in the context of physiological and pathological aspects of glucocorticosteroid action.

The cardiovascular system was analyzed in patients with symptomatic (n = 31) and mild primary hyperparathyroidism (n = 34) whose mean age was 54.6 years; 95% females). In the patients with symptomatic primary hyperparathyroidism, the PQ interval was longer and the QT interval was significantly shorter than those in patients with mild hyperparathyroidism. Left ventricular hypertrophy was noted in 45.2% of patients with symptomatic and in 15.2% of those with mild hyperparathyroidism (p = 0.013). Left ventricular diastolic dysfunction was also more common in the group of symptomatic hyperparathyroidism. There was a statistically significant correlation between the levels of parathyroid hormone, total and ionized calcium and the duration of QT interval and the determinants of diastolic function and left ventricular hypertrophy. The revealed cardiovascular disorders in patients with primary hyperparathyroidism are presumed to depend on the increase rate of parathyroid hormone and total and ionized calcium.

Hypogonadism is the most popular cause of BMD decreasing not only in women, but also in men. There are several studies showed a correlation between duration of hypogonadism and BMD reducing degree. Despite wide light exposure of osteoporosis problem at women with hyperprolactinemia, there are a few researches devoted to the same question at men. The aim of our study was to assess the biochemical parameters of bone metabolism and the bone mineral density (BMD) in men with tumoral and not tumoral hyperprolactinemia. In 24 men with hyperprolactinemia and 17 healthy controls we evaluated BMD, serum osteocalcin (OK) and C-terminal telopeptide of type I collagen (CTX), as well as calcium total, ionized calcium and alkaline phosphatase. All men with hyperprolactinemia were also studied after 24 months of cabergoline treatment. The results showed significant differences between study groups in BMD of vertebra and femur bone (p = 0,000052 up = 0,002718). We confirm increasing of BMD in vertebra and femur bone after cabergoline treatment (p = 0,003 и p = 0,027).

The aim was to estimate the effects of treatment with alendronate (Fosomax 35 mg) in postmenopausal women with osteoporosis and subclinical hyperthyroidism. Thirty postmenopausal women (64 (60-69) years old) with osteoporosis (T-score ≤ -2,5) and subclinical hyperthyroidism (77% with endogenous subclinical hyperthyroidism and 23% on L-thyroxine suppres-sive therapy after thyroidectomy due to differentiated thyroid cancer) were randomly assigned into two groups: 1-14 women received Fosamax 35 mg a week in combination with 500 mg of calcium and 400 UI of Vitamin D3 (VD) daily; 2-16 women received 1000 mg of calcium and 800 UI of VD daily. Euthyroidism was achieved in all women with endogenous subclinical hyperthyroidism. An increase in physical activity was recommended to all patients and a hypolipidemic diet was given to those who had had high cholesterol level. Biochemical parameters (calcium (Ca), phosphorous (P), creatinine (Cre), alkaline phosphatase (ALP), cholesterol, low density lipoprotein (LDL), high density lipoprotein (HDL), triglycerides (TG), cholesterol/HDL ratio) in fasting serum as well as calcium/creatinine ratio in fasting urine (U-Ca/U-Cre); biochemical markers of bone metabolism: osteocalcin (OC) and C-terminal telopeptide of type I collagen (b-CTx) serum ("ECLIA", Roche Elecsys 1010/2010), BMD (DXA; Prodigy, Lunar) at the lumbar spine (L1-L4), femoral neck (FN), total hip (TH) and radius total (RT) were measured at the baseline visit and after 1 year of treatment. At the baseline visit there were not found any differences between the 1 and the 2 groups. After 12 months of treatment the markers of bone metabolism as well as ALP decreased significantly in both groups, though the decreases were significantly greater (p

An open clinical trial evaluating effects of Pravastatin (P) 20 mg, Fluvastatin (F) 40 mg versus Calcium-D3 Nycomed Forte (1000 mg calcium and 800 ME cholecalciferol - CaD3 ) on bone metabolism, bone mineral density (BMD) and lipid metabolism have been conducted. We studied 80 osteopenic women from 60 to 80 years old, divided into three groups: 30 participants were treated by CaD3 during 12 months, at the same time 30 ones applied P, and 20 women were treated by L for the 6 months. All of the remedies showed similar influence on the spine BMD (the basal BMD remained intact). CaD3 and L were able to prevent proximal hip from BMD loss whereas patients treated P proceeded to lose bone mass (up to 1.3-1.5%). We have found that CaD3 provides an antiresorptive action (СТх became 27.2% lower and OC -4.1%), that P doesn't touch bone metabolism indices and dual action of L: it suppress a bone resorption (СТх was 14,1% reduce) and show an invigorative action on bone formation (ОК 25,5% raised). The CaD3 treatment was the less expensive, and the highest cost had P course. Our comparative study reveals that CaD3 is preferable in solitary osteoporosis prevention. However when osteopenia or validity OP risk factors coexist with dyslipidemia, type II particularly, use of L may be rational because of it's 6th month therapy had rather equal effect to one of year CaD3 consumption.

The article devoted to the secondary hyperparathyroidism in patients with end-stage chronic renal failure

Schwartz-Bartter Syndrome (synonyms: syndrome of inappropriate secretion of antidiuretic hormone syndrome of inappropriate secretion of vasopressin, anti-diabetes insipidus) - this is a rare disease characterized by excessive secretion of antidiuretic hormone (ADH) from the posterior pituitary, or other source, resulting in developing hyponatremia and water intoxication. Hyponatremia dilutions at Schwartz-Bartter Syndrome is usually non-specific symptoms, such as headache, nausea, vomiting and confusion. Marked reduction in blood sodium levels may lead to seizures or even coma.

Three groups of premenopausal women with diffuse toxic goiter (DTG) of different duration and different activity of thyrotoxicosis were examined for assessing calcium-phosphorus metabolism, osseous metabolism, and mineral compactness of bone tissue by ultrasonic (US) densitometry and bienergetic x-ray absorptiometry. Manifest hypercalciuria and hyperphosphaturia with normal levels of Ca2+ and inorganic phosphorus in the blood were revealed in patients with newly detected and recurrent DTG. In patients with hyperthyrosis the blood alkaline phosphatase activity and hydroxyproline excretion with the urine on an empty stomach were increased, these changes being most of all expressed in the group with newly detected thyrotoxicosis; however, these shifts were liable to normalize when stable drug-induced euthyrosis was attained. A reliable correlation between free T4 in the blood serum and osseous metabolism was revealed, which may indicate a direct effect of TH excess on bone tissue metabolism. The osteopenic syndrome was detected primarily in the proximal portions of the femoral bone, the severity of osteopenia reliably correlating with the disease duration. The authors come to a conclusion about the informative value of US densitometry and bienergy x-ray absorptiometry for the diagnosis of early stages of the osteopenic syndrome in DTG.