Adina Ghemigian

Cystic adrenal lesions: focus on pediatric population (a review)

Background and aim The cysts may potentially affect any organ; adrenals cysts are rare. This is a review of the literature regarding adrenal cysts, focusing on children and young adults. General data Three major types have been described: pure cysts (endothelial, epithelial, and hemorrhagic or pseudocyst), parasitic (as hydatid) cysts and cystic part of a tumour (most frequent are neuroblastoma, ganglioneuroma, pheocromocytoma, and teratoma). The complications are: bleeding, local pressure effects; infection; rupture (including post-traumatic); arterial hypertension due to renal vessels compression. Adrenal hemorrhage represents a particular condition associating precipitating factors such as: coagulation defects as Factor IX or X deficiency, von Willebrand disease, thrombocytopenia; antiphospholipid syndrome; previous therapy with clopidogrel or corticosteroids; the rupture of a prior tumour. At birth, the most suggestive features are abdominal palpable mass, anemia, and persistent jaundice. Adrenal insufficiency may be found especially in premature delivery. The hemorrhage is mostly self-limiting. Antenatal ultrasound diagnosis of a cyst does not always predict the exact pathology result. The most important differential diagnosis of adrenal hemorrhage/hemorrhagic cyst is cystic neuroblastoma which is highly suggestive in the presence of distant metastases and abnormal catecholamine profile. The major clue to differentiate the two conditions is the fact that the tumor is stable or increases over time while the adrenal hemorrhage is expected to remit within one to two weeks. Conclusion Pediatric adrenal cysts vary from simple cysts with a benign behavior to neoplasia- related lesions displaying severe prognosis as seen in cystic neuroblastoma. A multidisciplinary team is required for their management which is conservative as close follow-up or it makes necessary different surgical procedures in cases with large masses or if a malignancy suspicion is presented. Recently, laparoscopic approach is regarded as a safe procedure by some authors but generally, open surgery is more frequent used compare to adults; in most cases the preservation of normal gland is advisable.

Hypothyroidism-Associated Autoimmune Thyroiditis and Papillary Thyroid Cancer

Autoimmune thyroiditis (AI) and differentiated thyroid cancer as papillary type (PTC) are sometimes associated and several common pathogenic mechanisms have been described: BRAF mutations, hOGG1 loss of heterozygosity, interleukin-10 activation, selenoproteomas disturbances. Controversies are related to a more aggressive profile of PTC if AI is presented by interferences with oxidative stress and secondary carcinogenesis. This is a case report of a 37-year old female diagnosed a decade ago with multi-nodular goiter and hypothyroidism. She was treated in different endocrine centers. She started to accuse intermittent breathing difficulties which were not related to her previous diagnosis of asthma. On admission, the thyroid function was normal under levothyroxine (LT4) therapy with high anti-thyreoperoxidase antibodies levels of 1000 UI/mL (Normal<35) confirming AI. Thyroid ultrasound showed multiple nodules of 10 millimetres (mm), and a dominant one on the right lobe of 20 mm. Total thyroidectomy and lymph nodes dissection was performed. Pathological report confirmed AI and micro-PTC was identified (of 3 by 2 mm; T1N0M0). The thyroid scintigrame was negative when LT4 substitution was stopped and the blood thyroglobuline (TG) was very low (of 0.2 ng/mL) with negative anti-TG antibodies. A good outcome is estimated and no radioiodine ablative therapy was added only TSH suppressive doses of LT4. This case confirms that long standing autoimmune hypothyroidism might not protect of differentiated thyroid cancer but the papillary microcarcinoma display a good prognosis, in this particular situation based on small dimensions of the lesion and low levels of TG after surgery.

Ectopic Thyroid Tissue: Imagery Findings versus Pathological Report

Ana Valea DOI: 10.3252/pso.eu.18ECE.2016 Thyroid (non-cancer) Ectopic Thyroid Tissue: Imagery Findings versus Pathological Report Ancuta Augustina Gheorghisan-Galateanu 1, Mara Carsote 1, Anda Dumitrascu 2, Ana Valea3, Andreea Geleriu 4, Dana Terzea 5, Adina Ghemigian 1 1.C.Davila University of Medicine and Pharmacy & C.I.Parhon National Institute of Endocrinology, Bucharest, Romania 2.C.I.Parhon National Institute of Endocrinology, Bucharest, Romania 3.I.Hatieganu University of Medicine and Pharmacy & Clinical County Hospital, Cluj-Napoca, Romania 4.Lujerului Polyclinic, Queen Mary Healthcare Private Network, Bucharest, Romania 5.C.I.Parhon National Institute of Endocrinology & Monza Oncoteam, Bucharest, Romania

Bone Loss as Sign of Cancer Relapse

There is a tacit assumption that cancer cell lines removed from incubation and tumors that grow from the injection of these cells into mice diminish vitality quickly. When the melanoma tumors (from about 1 million B16-BL6 cells injected within 1 hr after removal from incubation) were removed about three to four weeks later and placed over the sensors of photomultiplier tubes conspicuous ~40 min periodicities of photon emissions began between 24 to 48 hr later. One million cells extracted from 10 cc suspensions of (~108) mouse melanoma cells that remained at room temperature for up to 3 days (when the smell was fetid) still produced viable tumors when injected subcutaneously. The tumors were more aqueous than those produced from immediately injected cells and were similarly fetid upon dissection unlike typical melanoma tumors. Their histopathology was qualitatively different. These results indicate that aggregates of cells in suspension or as tumors show unexpected properties that should be accommodated in models of proliferation and growth for malignant cells.

Asynchronous Mediastinal Cystic Masses

The masses of the mediastinum may present as cystic lesions and the underling pathological report varies as well as their malignancy profile. The diagnosis may be established during adulthood years despite the fact that many of them are embryological remnants. Surgical approach is the best option because of compressive effects especially in large tumours.

Parathyroid adenoma imaging-preoperative localization

ABSTRACT Primary hyperparathyroidism (PHPT) is a frequent endocrine disorder that can only be cured by a surgical procedure that is parathyroidectomy. The main causes are usually solitary benign adenoma (80-85%), diffuse or nodular hyperplasia (10-15%), or parathyroid carcinoma (<1%). Out of the known localization techniques, ultrasonography, nuclear scintigraphy and computer tomography (CT scan) are most commonly used [1]. The aim of this study is to evaluate the sensibility of ultrasonography by comparison to scintigraphy and CT scan for the preoperative localization of parathyroid adenoma in patients with biochemically confirmed primary hyperparathyroidism. Localization studies were correlated with intraoperative findings, histopathological outcomes. In a retrospective study we analyzed 60 patients out of 245 patients who had undergone parathyroidectomy for PHPT between 2012-2013 in the Surgery Department of the National Institute of Endocrinology, Bucharest. Preoperative evaluation included imaging explorations (ultrasonography, scintigraphy and cervical CT scan) and therapeutic success was confirmed by histopathological result and the evolution of hormonal and biochemical tests. Intraoperative exploration revealed a single adenoma in 59 patients and one double adenoma. Thyroid disease was associated in 27 (45%) patients

Subclinical Cushing’s syndrome with bilateral adrenal tumours in a patient with gallbladder multiple stone: therapeutical options

ABSTRACT Introduction The field of Cushing syndrome is a various area; there are still subjects incompletely clarified as the subclinical pattern as well as cortisol producing bilateral adrenal tumours. Case presentation The paper presents a 67-year old male case previously known with metabolic complications. He had an abdominal ultrasound done for unspecific complains and multiple gallbladder stones together with a right adrenal tumour were found. Later the computer tomography revealed bilateral adrenal tumours of almost 1.5 centimetres diameters (right larger than left) and a morning plasma cortisol level of 2.58 micrograms/ decilitre after low dose of dexametasone suppression test confirming the subclinical Cushing syndrome. After 6 months the endocrine and imagery profile was similar but the gallbladder patter aggravated so surgery was performed (together with right adrenalectomy) by a laparoscopic procedure. The blood pressure profile improved after surgery. Conclusion Subclinical Cushing syndrome diagnosis is challenging especially if metabolic complications or bilateral adrenal tumours are presented. Based on our observations in this case unilateral adrenalectomy improved the metabolic pattern

From headache to Rathke’s cleft cyst followed by diabetes insipidus with panhypopituitarism

ABSTRACT Introduction The Rathke cyst represents an unusual benign tumour derived from Rathke’s cleft remnants. The diagnosis is potential seen at any age. The most frequent signs are mostly mass effects as headache, visual field defects and hypopituitarism. Case presentation 30-year old female is admitted for persistent headache that was later associated with secondary amenorrhea and visual field defects for the last two years. The clinical data are consistent with high levels of serum prolactin, gonadotropes deficiency, as well as central hypothyroidism. The magnetic resonance imagery found a pituitary tumour of 2.7 centimetres with extrapituitary extension up to the optic chiasm. Surgery was performed in order to remove the tumour. The pathologic report confirmed a Rathke’s cleft cyst. Diabetes insipidus associated with panhypopituitarism was diagnosed and treated after the procedure. Close follow-up is necessary. Conclusion This case highlights the fact that headache sometimes embraces a severe neoplasia diagnosis and that the iatrogenic complications after surgery are lifelong care demanding

Menopause and prolactin secreting tumours

ABSTRACT Introduction Prolactinomas without galactorhhea may be considered menopause or not diagnosed. This is a cases series. Case1. 76-year female with menopause at age of 52 was discovered at 66 yrs with high prolactin and a pituitary micro-nodule. Bromocriptin was continued for 6 years then switched to cabergoline with constant imagery. The patient did not display at all galactorrhea. Osteoporosis was diagnosed at age of 66 with previous 2 fragility fractures. Case2. 45-year female is known with secondary amenorrhea (without galactorrhea) for the last 7 years being considered menopause. She experienced headaches thus a MRI was performed and found a pituitary tumour of 1.5cm. Low FSH with increased prolactin was revealed. Cabergoline was started. Within 2 months the menses resumed and headache mildly improved. After 3 months prolactin normalised under weekly 2 mg of cabergoline. Periodical prolactin control is necessary as well as a pituitary scan at 6 months. Case3. 39-year female had a 3 yrs history of secondary amenorrhea. A prolactin of 117ng/mL and a microprolactinoma of 0.77cm were found. Cabergoline was started and progressively increased up to 1.5mg per week. The prolactin quickly normalised up to 8ng/mL within 4 months. She was followed for 2 years and the imagery found a tumour reduction to 0.44cm. Conclusion Prolactinomas associate a great variety of clinical presentations. They interfere with menopause by mimicking it in cases without galactorrhea. Also a newly diagnosed prolactinoma during menopause needs long term therapy and followed-up for especially for bone safety.

Infertility as the onset of Cushing’s disease: is pasireotide a treatment option?

ABSTRACT Introduction Cushing’s disease is a complex endocrine disorder characterized by excessive glucocorticoid secretion caused by an ACTH-secreting pituitary adenoma. Hyperandrogenism and menstrual disorders such as amenorrhea and oligomenorrhea complete the clinical picture of Cushing’s syndrome. Infertility is relatively common, involving complex pathogenetic mechanisms, which differ depending on the cause of hypercortisolism. Case presentation We present the case of a female patient diagnosed with Cushing’s disease during the investigations carried out to assess infertility. After transsphenoidal adenomectomy, the patient underwent treatment with pasireotide and dopamine agonists, achieving normalization of gonadotropin and estradiol levels. Conclusion Current guidelines recommended transsphenoidal adenomectomy as first-line therapy in an attempt to correct hypercortisolism and restore fertility in patients with Cushing’s disease. In case of relapse pasireotide and dopamine agonists can be effective in normalizing the hormonal profile