Mara Carsote

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.

Virilising Sertoli-Leydig cell tumour associated with thyroid papillary carcinoma: case report and general considerations.

We present a case of a Sertoli–Leydig cell tumour manifested with progressive hirsutism, frontal alopecia and secondary amenorrhea in a 46-years-old female, evolving for 6 years until presentation. Serum testosterone level was 8.01 ng/ml and gonadotropic hormones were LH 8.57 mIU/ml and FSH 9.52 mIU/ml. Computed tomography revealed a dense, solid, heterogeneous mass of 3.5/2.8 cm in the right ovary. Bilateral ovariectomy and hysterectomy were performed. The histopathological report mentioned a Sertoli-Leydig cell tumor with intermediate grade of differentiation. Immunohistochemical stains showed positive reaction for α-inhibin, calretin and for progesterone receptor. The testosterone levels dramatically decreased after surgery (0.31 ng/ml) while levels of gonadotropes increased: LH 40.98 mIU/ml and FSH 50.41 mIU/ml. At 6 months follow-up the diagnosis of a left lobe thyroid nodule leaded to fine needle aspiration biopsy with suspicion of papillary carcinoma. Total thyroidectomy established the diagnosis of thyroid papillary carcinoma (2.17/2.18 cm) T2N0M0, stage II, followed by radioiodine administration. This is to our knowledge the first presented case of ovarian Sertoli–Leydig cell tumour associated with papillary thyroid carcinoma. This could suggest a common genetic background.

Galactocele and prolactinoma - a pathogenic association?

A galactocele is a rare form of cystic, benign lesion of the breast, appearing when a mammary duct becomes obstructed and over filled with milk. It is usually found in postpartum women, either lactating or not. There are only a few cases reported that are not immediately linked to the lactation, as seen in postmenopausal women or in men. Furthermore, the relationship to overproduction of prolactine, a growth factor for the breast epithelium is not very well defined at this moment. We present such an unusual case of a 37-year-old female patient who has no history of birth or abortion. She was diagnosed with both microprolactinoma and galactocele whose dimensions seemed to be related to the evolution of the pituitary tumor and serum prolactine. Because no other etiology could be found in the young patient for the mammary galactocele, the prolactine excess is the most probable cause. Even considering the rarity of the association it is important to point the hormonal role in changing the anatomy of the breast.

Obesity and Fractures: Between Black and White Aspects

Obesity, a worldwide medical problem, associates a large panel of disorders but traditionally osteoporosis was not considered one of them. This mini-review targets human and animal studies related to this topic. DXA is the golden standard of fracture risk assessment by providing Bone Mineral Density (BMD) which is directly correlated to Body Mass Index (BMI). Recent studies found that the correlation become weaker at BMI >30 kg/sqm while associating a higher mechanical load. The obesity-related fracture risk includes a blunt bone turnover markers status and a proinflammatory environment as IL-6, TNF-a¾³. Common pathogenic pathways involve both the skeleton and the metabolic complications of obesity as growth hormone, insulin-like growth factor-1, angiotensin II and ghrelin. On the contrary, estrogens are fat-derived by aromatase conversion being bone protective as androgens or insulin resistance. Leptin and adiponectin are produced by adipose tissue playing multiple roles including on bone cells. The overlapping factors in obese persons that elevate the fracture risk are the vitamin D deficiency and sarcopenia with increased risk of fall and diabetic bone disease cause by the type 2 diabetes mellitus which is very frequent among obese subjects. Increased cortical porosity as well as alteration of bone matrix quality to the advanced glycation products is correlated to diabetic fracture risk while BMD remain inadequately normal. The correlation between obesity and fall also associates with prior diagnosis of chronic heart disease, severe depression/anxiety, chronic use of anti-depressants or sleeping pills, and sedentary lifestyle. A new map of fractures is drawn since obesity involves a higher risk of ankle (most frequent site in obesity) and humerus fractures and a lower risk of vertebral and hip fractures. The fracture healing is difficult in obese subjects due to inflammation and co-morbidities especially diabetes. Obesity has a rapidly rising prevalence so are the associated conditions; among them fragility fractures at specific sites represents an alarming new issue despite the traditional theories that obesity protects against osteoporosis.

New Clues that May Link Osteoporosis to the Circulating Lipid Profile

Bone Mineral Density (BMD) is a gold standard for the diagnosis of osteoporosis and is also important in the assessment of fracture risk. Other risk factors have been identified that together make up fracture risk assessment tools such as FRAX. Another potential factor, circulating lipids, has been suggested because of reports linking statins to fracture risk reduction. We analyzed the lipid profile in a cohort of women diagnosed with postmenopausal osteoporosis based on bone density determination: 610 women with osteoporosis (mean lumbar spine T-score −3.16±0.81, mean yrs. since menopause 15.79±8.9) were grouped according to age at evaluation (< 50 years, 51–60 years, 61–70 years, > 70 years), the presence/absence of a history of a fragility fracture, statin and/or antiresorptive drug use. There was no correlation between BMD and Body Mass Index (BMI: P>0.05, r2<0.02). However, when BMD was correlated with both BMI and the lipid profile (Triglycerides, Cholesterol, LDLc, HDLc), significant correlations were found in 5 cohorts: 51–60 years with fractures (n=61, r2=0.14, P<0.01), 61–70 years (n=201, r2=0.09, P<0.01) with fractures (n=88, r2=0.14, P<0.01) or without fractures (n=113, r2=0.24, P=0.02) and over 70 years (n=247, r2=0.11, P<0.01).

Effects of combination therapy: somatostatin analogues and dopamine agonists on GH and IGF1 levels in acromegaly

Background and aims Acromegaly is a complex endocrine disorder caused by excessive secretion of GH, secondary to a GH secreting pituitary adenoma or a mixed pituitary adenoma secreting GH and PRL. Methods The aim of this study was to evaluate the effects of combination therapy: dopamine agonist and somatostatin analogue on GH and IGF1 levels in a group of 30 patients with acromegaly. Cabergoline in a dose of 2 mg/week and 4 mg/week respectively was associated with Sandostatin LAR in a dose of 20 mg/month and 30 mg/months respectively. Eight patients were treated with Lanreotide 30 mg/week and Cabergoline 2 mg/week and 3 patients were treated with Bromocriptine 10 mg/day and Sandostatin LAR 30 mg/month. Results Combination therapy: Cabergoline and Sandostatin achieved normal levels of IGF1 in 32% of the patients, better results being obtained after 12 months of treatment in the group treated with 4 mg Cabergoline/week. In 37% of cases the levels of IGF1 decreased by 50% after 12 months of treatment. In the group treated with Cabergoline and Somatuline a normal level of IGF1 was achieved in 25% of patients after 12 months of treatment. The outcome for the group treated with Sandostatin and Bromocriptine was similar to that obtained under Cabergoline 2 mg/week. There was no significant correlation between the level of GH and the type or dose of dopamine agonist used. Conclusions In conclusion, combination therapy consisting of dopamine agonist and somatostatin analogue achieves a significant reduction of IGF1 levels in patients with mixed adenomas secreting GH and PRL. A decrease in IGF1 levels is directly correlated with the dose of Cabergoline used.

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.

Vanishing testes syndrome-related osteoporosis and high cardio-metabolic risk in an adult male with long term untreated hypergonadotropic hypogonadism

The male hypogonadism-related bone mass loss is often under diagnosed. Peak bone mass is severely affected if the hypogonadism occurs during puberty and is left untreated. We present an interesting; almost bizarre case of a male with non-functional testes early during childhood and undiagnosed and untreated hypogonadism until his fifth decade of life. Forty six year male is referred for goitre, complaining of back pain. Phenotype suggested intersexuality: gynoid proportions, micropenis, no palpable testes into the scrotum, no facial or truncal hair. His medical history had been unremarkable until the previous year when primary hypothyroidism was diagnosed and levothyroxine replacement was initiated. Later, he was diagnosed with ischemic heart disease, with inaugural unstable angina. On admission, the testosterone was 0.2 ng/mL (normal: 1.7-7.8 ng/mL), FSH markedly increased (56 mUI/mL), with normal adrenal axis, and TSH (under thyroxine replacement). High bone turnover markers, and blood cholesterol, and impaired glucose tolerance were diagnosed. The testes were not present in the scrotum. Abdominal computed tomography suggested bilateral masses of 1.6 cm diameter within the abdominal fat that were removed but no gonadal tissue was confirmed histopathologically. Vanishing testes syndrome was confirmed. The central DXA showed lumbar bone mineral density of 0.905 g/cm2, Z-score of -2.9SD. The spine profile X-Ray revealed multiple thoracic vertebral fractures. Alendronate therapy together with vitamin D and calcium supplements and trans-dermal testosterone were started. Four decades of hypogonadism associate increased cardiac risk, as well as decreased bone mass and high fracture risk.

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