Eugenio Arteaga

Aldosterone-Producing Adrenocortical Carcinoma: Preoperative Recognition and Course in Three Cases

Three patients with primary aldosteronism due to adrenocortical carcinoma were studied, two with hyperaldosteronism alone and one also with hypercortisolism; in the later stages all three had hypersecretion of glucocorticoid and androgenic hormones. Although clinical presentations were similar to those of patients with benign adenoma, all had significantly higher concentrations of deoxycorticosterone and aldosterone and more profound hypokalemia. Stimulation with adrenocorticotropin in two patients showed a good cortisol response but no aldosterone response. The circadian rhythm for cortisol was normal but absent for aldosterone and deoxycorticosterone. Sequential 24-hour circadian studies in one patient showed that as the disease progressed, corticosterone and finally cortisol lost their circadian rhythms. Treatment with spironolactone, mitotane, or aminoglutethimide had transient clinical effects. The patients died 2 to 13 years later.

EFFECT OF THE COMBINATION OF DEXAMETHASONE AND SODIUM IPODATE ON SERUM THYROID HORMONES IN GRAVES' DISEASE

To investigate the effect of the combination of dexamethasone (Dex) and sodium ipodate (SI) on hyperthyroidism, we studied 24 patients with typical GRAVES disease, divided into four groups of six persons each. Three groups (Study I) were studied acutely (24 h) to determine the effects of Dex (5 mg every 12 h intramuscularly), SI (one oral dose of 3 g) and both drugs at the same doses, upon T4, T3, and rT3 at 0900 h before therapy was started and 24 h later. The group on Dex and that on SI had a similar T3 decrement of 25·9±4·0% and 35·8±5·0%, respectively, (P < 0·05), whereas the effect of both drugs combined was greater (64·2±3·6%; P<0·01, Dex, and P<0·01, SI, respectively). The increment of rT3 was markedly greater in those patients on SI than in those on Dex (561·3±149·2% and 58·9±11%, respectively, P<0·025). A fourth group (Study II) was studied for seven days while receiving both Dex (1 mg orally three times per day) and SI (500 mg orally three times per day). Both T4 (from 18·8 ± 1·1 to 13·1 ± 1·1 μg/dl, P < 0·02) and T3 (from 593 · 41 to 136·3 ± 12·7 ng/dl, P< 0·001) decreased at day 8. The initial brisk increment of rT3 at 24 h (808 ± 149%, P< 0·005) then diminished concomitantly with the fall of its precursor, T4. The pulse rate correlated with plasma T3 concentration (r= 0·67, P< 0·001) and varied from 104·7 ± 3·9 on day 1 to 77·3 ± 3·0 beats/min (P< 0·001) on day 4 and then remained stable. These results show that Dex and SI have potent inhibitory effects at the level of peripheral conversion of T4 and on the thyroid gland itself and that the combined use of these drugs significantly increases these effects. Considering the rapid clinical improvement of thyrotoxicosis achieved with both drugs, this regimen may be valuable in the initial treatment of some patients.

Adrenal macrotumors diagnosed by computed tomography

Adrenal tumors larger than 6 cm are unusual but show a greater incidence of malignant etiologies than smaller adrenal tumors. The scarce information about adrenal macrotumors (AMT) induced us to study prospectively all patients who were seen in our clinic during the period 1984–1988 and were diagnosed by computed tomography (CT) to have an adrenal mass ≥ 6 cm. The clinical characteristics, including the main complaint, tumoral secretory activity, CT findings and histologic diagnosis from 18 patients are described; they represented a 0.3% of the total amount of abdominal CT studies performed. Seventy-two % of AMT resulted to be non Cortisol or catecholamines secreting masses, and from them, a 38% corresponded to malignant etiologies characterized by marked and rapid weight loss. Four out of five hormone secreting AMT corresponded to pheochromocytomas, while the fifth one resulted to be a bilateral macronodular hyperplasia secreting Cortisol. In two cases AMT did not correspond to a genuine adrenal mass, resulting to be a malignant histocytoma in one case and a hydatidic cyst in other one. When performed in two occasions, a percutaneous needle biopsy was a valuable diagnostic tool, permitting to diagnose a lymphoma and a tuberculoma. In conclusion: 1) AMT correspond mainly to non Cortisol or catecholamines secreting tumors, often malignant; 2) not all AMT diagnosed by CT correspond to true adrenal masses; 3) percutaneous needle biopsy can be a helpful procedure for diagnosing nonfunctioning solid AMT.