Dana Terzea

Sertoli-Leydig cell tumor - a rare androgen secreting ovarian tumor in postmenopausal women: case report and review of literature

Sertoli‐Leydig cell tumors (SLCT) constitute only 1‐0.5% of all primary ovarian neoplasms. We report a SLCT in a postmenopausal woman aged 69 years. The physical examination revealed severe hirsutism. Basal hormonal evaluation showed high plasma testosterone and estradiol values, with suppressed plasma gonadotropins. Computer tomograph scan revealed a right ovarian tumor mass of 4,3/3 cm, confirming an androgen secreting ovarian tumor. The histopathological and immunocytochemical examination established the diagnosis of well differentiated Sertoli‐Leydig cell tumor. The tumor was positive for cytokeratin KL 1 and S‐100 protein and, in isolated tumor cells, positive for alpha‐fetoprotein. Postsurgical evolution was favorable; controls after 6 months and 3,5 years showed marked reduction of hirsutism, normal plasma testosterone values and gonadotropins in normal postmenopausal range. We discuss the complex aspects of etiology and pathogenesis, the clinical and hormonal settings, the role of immunocytochemical markers in diagnosis, as well as the therapy and the prognostic features of this ovarian tumor.

Immature ovarian teratoma with unusual gliomatosis

This study aimed to investigate an unusual case of immature ovarian teratoma with onset of mature glial cells implanted on the contralateral ovary, a challenge in the diagnosis of the second ovarian tumor. We report the case of a 31- yr-old woman, who developed at the age of 16 an immature teratoma in the right ovary that was surgically removed. Six years later mature glial implants were present on the left ovary and six months later at the level of peritoneum that relapsed after other six months. The patient suffered three surgical resections after the initial one. Paraffin sections and immunohistochemical examinations using antibodies against glial and neuronal antigens were performed. In the teratoma, the neuroectodermal tissue expressed Glial fibrillary acidic protein (GFAP), S100 protein, Epithelial membrane antigen (EMA) and Cytokeratin 34 beta E12 (Ck34beta E12), wheares the implants expressed only GFAP and S100 protein. The immature teratoma is the rarest type of ovarian teratomas. Gliomatosis peritonei is an exceptional finding, expecially with onset on the contralaterally ovary. The implant of the mature glial cells has a high risk of relapse, as seen in our case, thus close follow-up of the patient is necessary.

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

Rectal and Liver Metachronous Cancers and Sorafenib-Induced Thyroid Dysfunction.

Background: The tyrosine kinase inhibitor, a new treatment option in hepatic carcinoma, may associate thyroid dysfunction like spontaneously remitting thyrotoxicosis followed by hypothyroidism. Case report: A 66-year Caucasian female was first diagnosed and operated for a moderately differentiated rectal adenocarcinoma of 5 centimeters. Immunohistochemistry showed positive VEGF receptor 2 (Flk-1, KDR), VEGF receptor 1(Flt-1), and a Ki67 of 30%. 4 years later a hepatic adenocarcinoma (clear cells variant) was diagnosed. After surgery, daily 400 mg of sorafenib was introduced. Three months later mild symptomatic thyrotoxicosis was seen: palpitations, fatigue, and mild bilateral pedal clonus. Thyroid-stimulating hormone (TSH) was suppressed (0.044 μIU/mL, normal levels between 0.4 and 4.5 μIU/mL), and free levothyroxine (fT4) elevated. The TSH receptor antibody, the antithyreoglobulin and antithyreoperoxidase antibodies were negative. Thyroid ultrasound pointed hypoechogenic, inhomogeneous aspects. She received beta-blocker and within two months thyrotoxicosis remitted but TSH progressively increased suggesting hypothyroidism with level less 5 μIU/mL so no replacement levothyroxine therapy was added yet. Discussions: The exact mechanism of the tyrosine kinase inhibitors-related thyroid malfunction is not fully understood. Non-autoimmune destructive thyroiditis of unknown trigger causes thyrotoxicosis and later hypothyroidism as seen in our case. The clinical features vary from one person to another. The hormone replacement is rarely necessary. The baseline cancer seems irrelevant for thyroid toxicity. In our unusual case the patient had a history of two metachronous cancers. The thyroid follow up is essential during each patient therapy yet a specific pattern of follow-up is not precisely designed. Conclusion: The tyrosine kinase inhibitor-induced thyroid dysfunction includes both thyrotoxicosis and hypothyroidism. We emphasize the idea of periodic endocrine evaluation in oncologic patient treated with this class of drugs.

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.

FOLLICULAR THYROID CANCER ON REMNANT LOBE

A 77 years old woman, submitted to right thyroidectomy in 1961, presented in October 2007 for rapid growth of a left-anterior goiter, accompanied by weight loss, fatigability, nervousness, tremor, posterior neck pain, headache and intermittent fever (Fig. 1). She had a suppressed TSH (0.001mU/L) and normal fT4 showing subclinical hyperthyroidism. CT showed a heterogeneous density mass with calcifications, necrosis and prominent tumor buds, compressing trachea at diameters of 2.26/1.38 cm and displacing it to the right (Fig. 2). Maximum tumor diameters were 17/12/14 cm (Fig. 3). Total thyroidectomy was performed, with histological diagnosis of follicular poorlydifferentiated, highly invasive and angio-invasive carcinoma developed on a remnant of giant longstanding cervicalendothoracic goiter, staging: PT4B PNX ST4B G3 R1 V1 (Fig. 4) with a local relapse six weeks later. The high angiogenic propensity and the poor differentiation isolated cell pattern are markers of poor prognosis.