Landscape of Adrenal Tumours in Patients with Congenital Adrenal Hyperplasia

Our aim is to update the topic of adrenal tumours (ATs) in congenital adrenal hyperplasia (CAH) based on a multidisciplinary, clinical perspective via an endocrine approach. This narrative review is based on a PubMed search of full-length, English articles between January 2014 and July 2023. We included 52 original papers: 9 studies, 8 case series, and 35 single case reports. Firstly, we introduce a case-based analysis of 59 CAH-ATs cases with four types of enzymatic defects (CYP21A2, CYP17A1, CYP17B1, and HSD3B2). Secondarily, we analysed prevalence studies; their sample size varied from 53 to 26,000 individuals. AT prevalence among CAH was of 13.3-20%. CAH prevalence among individuals with previous imaging diagnosis of AT was of 0.3-3.6%. Overall, this 10-year, sample-based analysis represents one of the most complex studies in the area of CAH-ATs so far. These masses should be taken into consideration. They may reach impressive sizes of up to 30-40 cm, with compressive effects. Adrenalectomy was chosen based on an individual multidisciplinary decision. Many tumours are detected in subjects with a poor disease control, or they represent the first step toward CAH identification. We noted a left lateralization with a less clear pathogenic explanation. The most frequent tumour remains myelolipoma. The risk of adrenocortical carcinoma should not be overlooked. Noting the increasing prevalence of adrenal incidentalomas, CAH testing might be indicated to identify non-classical forms of CAH.

Paget's Disease of the Bone and Lynch Syndrome: An Exceptional Finding

Our objective is to present an exceptional case of a patient diagnosed with Paget's disease of the bone (PDB) while being confirmed with Lynch syndrome (LS). A 44-year-old woman was admitted for progressive pain in the left forearm 2 years ago, and was partially relieved since admission by non-steroidal anti-inflammatory drugs. Suggestive imaging findings and increased blood bone turnover markers helped the diagnosis of PDB. She was offered zoledronate 5 mg. She had two more episodes of relapse, and a decision of new medication was taken within the following years (a second dose of zoledronate, as well as denosumab 60 mg). Her family history showed PDB (mother) and colorectal cancer (father). Whole exome sequencing was performed according to the manufacturer's standard procedure (Ion AmpliSeq™ Exome RDY S5 Kit). A heterozygous pathogenic variant in the SQSTM1 gene (c.1175C>T, p.Pro392Leu) was confirmed, consistent with the diagnosis of PDB. Additionally, a heterozygous pathogenic variant of MSH2 gene (c.2634+1G>T) was associated with LS. The patient's first-degree relatives (her brother, one of her two sisters, and her only daughter) underwent specific genetic screening and found negative results, except for her daughter, who tested positive for both pathogenic variants while being clinically asymptomatic. The phenotype influence of either mutation is still an open issue. To our current knowledge, no similar case has been published before. Both genetic defects that led to the two conditions appeared highly transmissible in the patient's family. The patient might have an increased risk of osteosarcoma and chondrosarcoma, both due to PDB and LS, and a review of the literature was introduced in this particular matter. The phenotypic expression of the daughter remains uncertain and is yet to be a lifelong follow-up as the second patient harbouring this unique combination of gene anomalies.

Primary hyperparathyroidism-related giant parathyroid adenoma (Review)

Primary hyperparathyroidism (PHPT), an endocrine condition caused by a parathyroid adenoma (PTA) in 80-85% of the cases, has shifted in the modern era to a mildly symptomatic phenotype due to the prompt recognition of hypercalcemia and to a minimally invasive surgical approach which has a curative potential. Clinical complications of PHTH are either related to high calcium or parathyroid hormone [also parathormone (PTH)] or both, while the originating tumor typically is small, without local mass effects. A distinct entity is represented by giant PTA (GPTA) which is considered at a weight of more than 3 (3.5) grams. The present article is a review of the literature involving practical points of non-syndromic PHPT-related GPTA. Most authors agree that pre-operatory calcium and PTH are higher in GPTA vs. non-GPTA. However, the clinical presentation of PHPT may be less severe, probably due to local mass effects that bring the patient to an early medical evaluation. Age distribution, sex ratio, rate of successful pre-operatory location do not differ from non-giant PTA. Hypovitaminosis D is more frequent in PTA of higher dimensions. Post-operative hypocalcemia, but not recurrent/persistent PHPT, is expected, even hungry bone disease. A higher rate of atypia is described although the tumor is mostly benign. Unusual presentations such as cystic transformation, initial diagnosis during pregnancy or auto-infarction have been reported. The ectopic localization of PTA presented in almost 15% of all cases may also be found in GPTA. What are the exact cutoffs for defining GPTA is still an open issue.

Melanoma in patients with Li-Fraumeni syndrome (Review)

Li-Fraumeni syndrome (LFS) is a cancer-prone, autosomal dominant syndrome caused by underlying germline gene mutations of TP53, a tumor-suppressor gene encoding the p53 protein with a major role in apoptosis, DNA repair and cell cycle regulation. Cumulative cancer incidence for LFS patients by the age of 70 years is 80-100%, mostly involving adrenocortical carcinoma, brain tumors, bone and soft tissue sarcomas, leukemia and female breast cancer from the age of 20 years. Dominant negative TP53 variant is correlated with an increased tumorigenesis risk in LFS. Sporadic TP53 mutations are related to almost half of global cancers since p53 in addition to p73 protein represent essential players in anticancer cellular protection. Epidemiological aspects concerning skin cancers, especially malignant melanoma (MM), in LFS are less clear. A low level of statistical evidence demonstrates LFS cases with pediatric MM, multiple MM, spitzoid MM, atypical presentations, mucosal and uveal MM. Retrospective cohorts indicate a higher cumulative risk than the general population by the age of 70 years for MM and basal cell carcinoma. Non-syndromic and syndromic TP53 mutations are a major pathway of metastasis, including MM. In LHS, an important level of awareness involves skin cancers despite not being a part of the typical malignancy-containing picture. Additional data are crucially needed. However, at least one dermatologic control is a step in the multidisciplinary panel of surveillance of these patients; but in cases with benign and pre-malign pigmentations, serial dermatoscopy and full body photography are recommended for early melanoma detection in order to improve the prognosis and to reduce the overall malignancy burden.

Aggressive prolactinoma (Review)

Aggressive prolactinoma (APRL) is a subgroup of aggressive pituitary tumors (accounting for 10% of all hypophyseal neoplasia) which are defined by: invasion based on radiological and/or histological features, a higher proliferation profile when compared to typical adenomas and rapidly developing resistance to standard medication/protocols in addition to an increased risk of early recurrence. This is a narrative review focusing on APRL in terms of both presentation and management. Upon admission, the suggestive features may include increased serum prolactin with a large tumor diameter (mainly >4 cm), male sex, early age at diagnosis (<20 years), and genetic predisposition [multiple endocrine neoplasia type 1 (MEN1), aryl hydrocarbon receptor interacting protein (AIP), succinate dehydrogenase (SDHx) gene mutations]. Potential prognostic factors are indicated by assessment of E-cadherin, matrix metalloproteinase (MMP)-9, and vascular endothelial growth factor (VEGF) status. Furthermore, during management, APRL may be associated with dopamine agonist (DA) resistance (described in 10-20% of all prolactinomas), post-hypophysectomy relapse, mitotic count >2, Ki-67 proliferation index ≥3%, the need for radiotherapy, lack of response in terms of controlling prolactin levels and tumor growth despite multimodal therapy. However, none of these as an isolated element serves as a surrogate of APRL diagnosis. A fourth-line therapy is necessary with temozolomide, an oral alkylating chemotherapeutic agent, that may induce tumor reduction and serum prolactin reduction in 75% of cases but only 8% have a normalization of prolactin levels. Controversies surrounding the duration of therapy still exist; also regarding the fifth-line therapy, post-temozolomide intervention. Recent data suggest alternatives such as somatostatin analogues (pasireotide), checkpoint inhibitors (ipilimumab, nivolumab), tyrosine kinase inhibitors (TKIs) (lapatinib), and mTOR inhibitors (everolimus). APRL represents a complex condition that is still challenging, and multimodal therapy is essential.

Adrenal ganglioneuroma: Prognostic factors (Review)

Ganglioneuroma, a rare neural crest-derived tumor, exhibits a benign profile in contrast to other neuroblastic tumors (neuroblastoma/ganglioneuroblastoma). Ganglioneuromas can be found anywhere autonomic ganglia are located, mostly abdominal/pelvic sites followed by the adrenal glands (one-third of cases), mediastinum/thorax and cervical area. Affecting especially children more than 10 years of age, Ganglioneuroma is either asymptomatic or may cause local compressive effects; rarely inducing nonspecific abdominal complains or arterial hypertension related to oversecretion of epinephrine/norepinephrine/dopamine. Despite a good prognosis, adrenalectomy is necessary in order to rule out a malignancy. Open procedure represents the standard therapeutic option; alternatively, centers with large laparoscopic pediatric experience and good stratification protocols have reported successful procedures. High uptake of I¹²³-MIBG is associated with a more severe outcome in cases with increased mitotic index. In neuroblastic tumors, neuron-specific enolase >33 ng/ml, age at diagnosis <49 months, and blood vessel invasion indicate a poor prognosis. Concurrent extra-adrenal/adrenal ganglioneuroma is associated with a more severe prognosis; post-surgical complications are more frequent in non-adrenal vs. adrenal ganglioneuroma. Exceptionally, immune-mediated paraneoplastic neurologic syndromes have been reported: anti-N-methyl-D-aspartate receptor encephalitis and opsoclonus-myoclonus-ataxia syndrome. ROHHAD syndrome is the underlying cause in 40-56% of cases of neuroendocrine tumors including ganglioneuroma; 70% of tumors are diagnosed within the first 24 months after hypothalamic obesity onset, associated with a severe prognosis due to hypoventilation, sleep apnea, and dysautonomia. Recently, the PKB/AKT/mTOR/S6 pathway was identified as a tumorigenic pathway in pediatric ganglioneuroma, not in neuroblastoma; mTOR inhibitors are a potential option for pre-operatory tumor shrinkage. Pediatric adrenal ganglioneuroma has a good prognosis if adequately treated; its recognition requires adrenalectomy. Further development of specific biomarkers is needed. In the present article, we aimed to introduce a review of the literature involving adrenal ganglioneuroma based on a practical, multidisciplinary perspective of prognostic factors.

Skin anomalies in acromegalic patients (Review of the practical aspects)

Acromegaly is a hormonal disorder which occurs as the result of growth hormone (GH) and insulin growth factor 1 (IGF-1) over-secretion; both hormones are related to skin anomalies. The skin acts as a large endocrine organ, hosting GH receptors in every cell while IGF-1 receptors are expressed only in keratinocytes. This review is a literature review of skin anomalies found in acromegaly, either related to the disease itself or associated with related complications such as secondary diabetes mellitus, or involving associated conditions such as genetic syndromes. The following clinical points are mentioned as follows. Excessive skin and enlargement of soft tissue are due to glycosaminoglycan deposits, edema, and hyperhidrosis (mostly facial and acral). Acanthosis nigricans, a body fold dermatosis associated with insulin resistance, involves local or diffuse hyperkeratotic plaques with or without hyperpigmentation, caused by growth factors including GH/IGF-1. Other findings include cherry angiomas (due to the effects of lipid anomalies on small vessels); oily skin features with keratosis, epidermoid cysts, crochordons, pseudo-acanthosis nigricans; a potentially higher prevalence of varicose veins and psoriasis; low level of evidence for basal cell carcinoma, respective hidroadenitis suppurativa has been noted. In addition, complicated uncontrolled secondary diabetes mellitus (DM) may result in necrobiosis lipoidica diabeticorum, diabetic dermopathy, skin bacterial infections, dermatological complications of diabetic neuropathy, and nephropathy. Finally, associated hereditary syndromes may cause collagenomas, fibromas/angiofibromas, lipomas in multiple endocrine neoplasia type 1 (MEN1) syndrome; café-au-lait macules, early onset neurofibromas, juvenile xanthogranuloma (involving non-Langerhans cell histiocytes), and intertriginous freckling in neurofibromatosis type 1. Clinical findings are differentiated from pseudo-acromegaly such as pachydermoperiostosis. Iatrogenic rash, lipodystrophy (lipoatrophy with/without lipohypertrophy) are rarely reported after pegvisomant/somatostatin analogues or after insulin use for DM. Experiments using human cell lines have shown that GH/IGF-1 over-secretion are prone to epithelial-to-mesenchymal transition (EMT) in melanoma. In non-acromegalic subjects, the exact role of GH/IGF-1 in skin tumorigenesis is yet to be determined. Skin in acromegaly speaks for itself, either as the first step of disease identification or as a complication or part of a complex syndromic context.

Neuroendocrine neoplasia and bone (Review)

This is a narrative review focusing on neuroendocrine neoplasia (NEN) and bone status, in terms of metastases and osteoporosis/fractures. One fifth of NEN have skeletal dissemination, this affinity being regulated by intrinsic tumor factors such as the C-X-C chemokine receptor 4 (CXCR4). Bone colonization impairs the patient quality of life, representing a surrogate of reduced survival. Patients with NEN without bone metastases may exhibit low bone mineral density, perhaps carcinoid-related osteoporosis, yet not a standardized cause of osteoporosis. Case-finding strategies to address bone health in NEN with a good prognosis are lacking. Contributors to fractures in NEN subjects may include: menopausal status and advanced age, different drugs, induced hypogonadism, malnutrition, malabsorption (due to intestinal resection, carcinoid syndrome), hypovitaminosis D, impaired glucose profile (due to excessive hormones such as glucagon, somatostatinoma or use of somatostatin analogues), various corticoid regimes, and high risk of fall due to sarcopenia. Pheocromocytoma/paraganglioma involve bone through malignant forms (bone is an elective site) and potential secondary osteoporosis due to excessive hormonal content and increased sympathetic activity which is a key player of bone microarchitecture/quality as reflected by low Trabecular Bone Score. Glucocorticoid osteoporosis is related to NEN-associated ectopic Cushing syndrome. Currently, there are a lack of studies to emphasis that excessive gut-derivate serotonin in NENs with carcinoid syndrome is a specific activator of bone loss thus a contributor to carcinoid-related osteoporosis.

Combined Effects of Vitamin D Status, Renal Function and Age on Serum Parathyroid Hormone Levels

BACKGROUND

Vitamin D status and renal function are well-known independent predictors of serum parathyroid hormone (PTH) levels. We aimed to describe the combined effects of 25-hydroxy vitamin D (25(OH)D), glomerular filtration rate (GFR) and age on serum PTH levels across the whole clinical spectrum.

METHODS

We retrieved from our endocrinology center database all PTH measurement between 2012 and 2020 for which a simultaneous measurement of serum 25(OH)D, calcium and creatinine was available. Age, sex and diagnosis were available for all subjects. Intact PTH was measured using the same electrochemiluminescence assay.

RESULTS

There were 6,444 adults and 701 children without a diagnosis of hyper- or hypoparathyroidism or abnormal serum calcium levels. In adults with 25(OH)D≥12 ng/mL multiple regression models showed that serum PTH was negatively correlated with both 25(OH)D and GFR. Regression (-0.68 and -1.59 vs. -0.45 and -0.22 respectively), partial correlation (-0.16 and -0.35 vs. -0.12 and -0.10 respectively) and determination coefficients (0.14 vs. 0.031) were higher in CKD than in normal renal function. In subjects with 25(OH)D<12 ng/mL, GFR was the only significant predictor in those with CKD (β-coefficient=-2.5, r=-0.55) and 25(OH)D was the only significant predictor in those with normal renal function (β-coefficient=-2.05, r=-0.11). Increasing age was associated with higher PTH levels only in those with normal renal function and 25(OH)D≥12 ng/mL.

CONCLUSIONS

We showed that declining vitamin D and renal function have additive effects on serum PTH in subjects without vitamin D deficiency. In vitamin D deficient subjects this dependency is stronger but is not additive anymore.

Ovarian Sertoli cell tumours: practical points

Rarity of Sertoli cell tumours contributes to a low index of suspicion and therefore a thorough knowledge of the clinicopathological and immunological characteristics of such tumours is essential to diagnosis and proper management of the treatment and follow-up. The current narrative review of literature was planned to focus on ovarian Sertoli cell tumours that arise from the sex cords cells, which are typically benign unilateral neoplasia incidentally detected, or associated with hormonal hyperactivity, in women of reproductive age. A priory unpublished case of a 35-year old female is also introduced as the base of discussion Abdominal massrelated syndrome and vaginal bleeding anomalies have been reported. Genetic background, if presented, is mostly related to Peutz-Jeghers syndrome caused by STK11/LKB1 mutation. The tumour displays a microscopic tubular pattern and rarely displays cords or trabecular, retiform, spindles, diffuse or areolar structures. Although immunohistochemistry can be helpful in establishing the diagnosis, the results are sometimes inconclusive and the current results require new research to establish a specific immunological panel.

Circulating 25-hydroxycholecalciferol in Relationship to Central Dual-Energy X-Ray Absorptiometry Assesses. A clinical study

The aim of the research was to realize a clinical study on menopausal patients, focused on 25-hydroxyvitamin D (25OHD) assays versus Dual-Energy X-Ray Absorptiometry (DXA) categories. This transversal, observational, real-life study was effectuated on Caucasian Romanian females. A total of 60 subjects were grouped according to lumbar T-score: normal T-score (N=28), osteopenia (N=22), and osteoporosis (N=10). The lowest average value of 25OHD is found in patients with osteoporosis, which is statistically significant lower than in patients with osteopenia. The average values of PTH were within normal levels for each group. 25OHD did not correlate with PTH or lumbar BMD. Overall the mean values of 25OHD are in deficient ranges regardless osteoporosis, osteopenia or normal DXA.

MANAGEMENT OF RECURRENT POSTOPERATIVE CUSHING’S DISEASE

Although adenomectomy remains the first-line treatment in Cushing’s disease, it is not alwayscurative for most patients. Sooner or later persistent or recurrent disease can be found in somecases. Case report: A 13-year-old girl was admitted for weight gain, menstrual disturbances, andtransient headache. Hormonal profile confirmed the clinical suspicion of Cushing’s disease.Pituitary MRI highlighted a microadenoma of 5.2 mm resected through transsphenoidaladenomectomy. No complications were registered during the procedure. After a 7 dayshospitalization, the patient was discharged without any medications. Periodic evaluationsconfirmed the disease’s remission that was maintained for a period of 2 years. During this period,the patient received only thyroxine and progesterone treatment. Two years after surgery, theadrenal hormone profile confirmed the recurrence of the disease. According to the patient’s age,ketoconazole and cabergoline treatment was instituted without any significant improvement.Because no obvious tumor mass has been revealed on the pituitary MRI, pasireotide treatment wasintroduced at the age of 18. An obvious improvement in the hormonal profile was achieved afterthree months of treatment. Cushing’s disease control requires therapeutic alternatives consistentwith the patient’s age and the complications of the disease. Pasireotide treatment may be a goodchoice for adult patients with recurrent disease after transsphenoidal adenomectomy.

5-Hydroxytriptamine and Skeleton Influence Clinical Study

5-hydroxytryptamine (5-HT) dually influences skeleton status through positive, indirect central effect and negative, direct, gut-associated impact. Circulating form is usually tested via venous blood sample. A limited number of clinical studies are published on this specific topic. We introduce a cross-sectional study on menopausal women with normal (N=29) and low bone mineral density (N=32) based on lumbar Dual-Energy X-Ray Absorptiometry (DXA) to whom serum serotonin was assessed and found no correlation with bone loss. This aspect confirms conflicting published data regarding the relationship between circulating levels and fracture risk assessment.

Lower Vitamin D Status in Patients with Differentiated Thyroid Carcinoma

Thyroid cancer (TC) has become the most rapidly increasing type of cancer representing 1-1.5% of all cancers diagnosed annually probably due to intensive screening. It is estimated that the death rate of TC has slowly increased from 0.49 to 0.51/100.000 in the last 10 years and 53.990 new cases will be diagnosed in 2018 in the United States. Therefore, efforts are being made in order to stop the increasing incidence and genetic alterations are thoroughly studied. One of the most recent incriminated factors in TC etiology and physiopathology is vitamin D deficiency. Besides the well-known role in bone metabolism, vitamin D has extra-skeletal effects exerted through the vitamin D receptor (VDR) and has been shown to interfere with many cellular functions such as inhibiting cell proliferation, stimulating differentiation and malignant cell apoptosis in different types of cancer. Cross-sectional, retrospective study which included 114 patients (71 with confirmed thyroid cancer and 43 patients in the control group with benign pathology). Preoperative levels of 25(OH)vitamin D, PTH, biochemical and thyroid panel were measured. The histopathologic features were analyzed. Mean values of vitamin D was 16.31 � 7.14 ng/mL with lower levels in patients with thyroid cancer (14.95 � 5.91 ng/mL) in comparison to patients with benign thyroid pathology (18.55 � 8.41 ng/mL), with a p value of 0.008. Majority of the cases were papillary thyroid cancer (97.18%) in stage 3 (45.07%). Vitamin D levels also correlated negatively with TNM staging. The necessity of further studies is a reality in order to establish if vitamin D deficiency is a possible risk factor for thyroid cancer and its correction can be considered an additional therapy.

Calcifediol Concentration vs Circulating Thyrotropin and Free Thyroxine in Human Blood of Postmenopausal Women

A total of 55 patients were: G1 of 9 patients, G2 of 23 subjects, and G3 of 23 patients. Similar age and years since menopause was found between the groups. There was no statistical significant difference between the groups regarding these aspects: p-value G1-G2 of 0.67, p-value G1-G3 of 0.72, p-value G2-G3 of 0.47. Similar results were obtained when TSH, FT4 and anti-thyroperoxidase antibodies were analysed between the groups. No TSH-25-OHD correlation reached the statistical significance, neither FT4-25-OHD, TPO-25-OD. P-values between G1 and G2 for TSH, FT4, TPO were 0.23, 0.38, respective 0.7, between G2 and G3 were 0.19, 0.1, 0.35, between G1 and G3 were 0.48, 0.84, respective 0.75. Bone profile analyze based on 25-OHD levels did not identify any statistical significance difference between the mentioned groups (including bone turnover markers).

Collagen-the Ultrastructural Element of the Bone Matrix

There is an increased interest and more studies highlight the fact that bone strength depends not only on bone tissue quantity, but also on its quality, which is characterized by the geometry and shape of bones, trabecular bone microarchitecture, mineral content, organic matrix and bone turnover. Fibrillar type I collagen is the major organic component of bone matrix, providing form and a stable template for mineralization. The biomedical importance of collagen as a biomaterial for medical and cosmetic purposes and the improvement of the molecular, cellular biology and analytical technologies, led to increasing interest in establishing the structure of this protein and in setting of the relationships between sequence, structure, and function. Bone collagen crosslinking chemistry and its molecular packing structure are considered to be distinct features. This unique post-translational modifications provide to the fibrillar collagen matrices properties such as tensile strength and viscoelasticity. Understanding the complex structure of bone type I collagen as well as the dynamic nature of bone tissues will help to manage new therapeutic approaches to bone diseases.

Genetic Testing in Differentiated Thyroid Carcinoma � Important or Not?

Thyroid carcinoma is the most common endocrine cancer representing 1-1.5% of all cancers diagnosed annually. Differentiated thyroid carcinoma (DTC) with the 2 main subtypes, papillary (PTC) and follicular (FTC), is the most common. DTC incidence has increased significantly in recent years, mainly due to increased and early use of imaging techniques (thyroid ultrasonography) and fine needle biopsy of thyroid nodules. Although after radical treatment, DTC is considered to be curable, histologic and clinical presentation is very diverse, the recurrence rate being 10-30%, while 5% of patients are resistant to conventional therapy, and some are even incurable. In recent years, there has been progress in terms of describing genetic changes in thyroid carcinoma, genetic testing providing important information that may influence therapeutic decision. The practical importance of these genetic mutations (for example, BRAF V600E, RAS, etc.) and their roles in tumorigenesis, the clinical features, treatment and prognosis of thyroid carcinoma is still controversial and incompletely elucidated.The increase knowledge of molecular pathogenesis and tumorigenesis in thyroid cancer lead to the emergence of new therapies with targeted antitumor effect and minimal toxicity. Patient selection should be made taking into account the risk stratification and tangible benefits, molecular tests being expensive and inaccessible.

A new TRβ mutation in resistance to thyroid hormone syndrome

Thyroid hormones (TH) exert their actions by binding nuclear receptors alpha (TRα1) and beta (TRß1 and TRß2). Resistance to thyroid hormone (RTH) is a clinical syndrome with various clinical manifestations, its hallmark being decreased tissue sensitivity to the action of thyroid hormones. We report the case of a family harbouring a novel TRß mutation. Sequencing of the TRβ gene revealed a single nucleotide substitution-C to G in codon 340: glutamine was replaced by glutamic acid. The clinical picture and biochemical and hormonal panel showed significant differences within the family, despite their sharing the same mutation. We also present the result of low-dose antithyroid treatment in one member of the family diagnosed with this rare condition.

Serotonin: beyond menopause

Serotonin is a brain neurotransmitter, a local gut-produced pro-kinetic agent and a platelets-released monoamine with haemostasis role. We focus on revealing the serotonin interferences with menopause mainly related to climacteric syndrome and bone health. This is a short commentary type of manuscript, centred on English language PubMed research. Serotonin is connected to the hypothalamic thresholds for temperature regulation in vasomotor symptoms that is why drugs that elevate the serotonin synaptic plaque exposure like SSRI (serotonin selective reuptake inhibitors) are indicated. Serotonin is also linked to bone field but its testing into the blood has not been unanimously found to be correlated with bone mineral density or menopausal bone remodelling markers. Conditions with age-related onset as carcinoid tumours bring a serotonin excess but not necessary a bone loss. From climacteric syndrome to bone regulation and to pathological domain of neuroendocrine neoplasia, serotonin plays a complex role on menopause’s field.

LONG-TERM FOLLOW-UP AFTER TRANSCRANIAL HYPOPHYSECTOMY IN MACROPROLACTINOMAS

Currently, transcranial hypophysectomy is infrequently used since the trans-sphenoidal approach isvery effective and less invasive. Prolactinomas represent one of the rarest indications for pituitarysurgery due to the spectacular effects of dopamine agonists as cabergoline. A 66-year-old femalepresented at age of 52 with headache, low blood pressure. The investigations revealedpanhypopituitarism, high prolactin and a large pituitary mass with obstructive hydrocephalus at theleft lateral ventricle. Transcranial surgery was performed through a right approach withoutcomplications. The pathological report confirmed a pituitary adenoma with intense cellularpleomorphism. A 29-year-old male was admitted at the age of 28 for severe headache, multipleepisodes of vomiting, and hypotension. Pituitary insufficiency and hyperprolactinemia werecorrelated to the presence of an intrasellar tumor of 2/2 cm with extension to the right cavernoussinus, optic chiasm. The pathological report confirmed a pituitary adenoma. Transcranial pituitarysurgery represents an option only in selected large macroprolactinomas. After procedure, a goodoutcome is expected despite the potential secondary eye field defects or pituitary insufficiencywhich needs medication. Sometime the panhypopituitarism caused first by the tumor itself persistsafter surgery (as in our first case) or it is corrected (as adrenal insufficiency in the second case).The presence of a residual prolactin producing tumor requires long term specific therapy withdopamine agonists.

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

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

Severe hepatocytolisis syndrome - a challenge in medical therapy of Cushing’s disease

Introduction Cushing’s disease is a rare endocrine disorder characterized by persistent hypercortisolism due to excessive, autonomous ACTH secretion by a pituitary adenoma. Transsphenoidal adenomectomy is the main therapeutic option in Cushing’s disease. When imaging studies are unable to demonstrate an obvious pituitary mass complete tumor resection is difficult and often encumbered by risk of relapse. Medical therapy is a second-line option or the first-line treatment for patients with high surgical risk, incomplete surgical resection or relapse. Rarely classic clinical manifestations limit the selection of medical therapy for Cushing’s disease. Case presentation We present the case of a male patient with Cushing’s disease complicated with diabetes mellitus and severe hepatocytolisis syndrome with no visible pituitary adenoma on MRI studies. In the absence of technical equipment petrosal sinus sampling could not be performed in order to improve surgery outcome

Conclusion The presence of unbalanced diabetes and severe hepatocytolisis syndrome made it impossible to use steroidogenesis inhibitors (mitotane, ketoconazole, metyrapone, etomidate) or inhibitors of ACTH secretion as pasireotide that represent a new option in achieving control of hypercortisolism

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

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

Menopause and prolactin secreting tumours

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.

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

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

ADRENAL SURGICAL APPROACH IN A WOMAN WITH SYNCHRONOUS BILATERAL ADRENAL TUMORS

Bilateral adrenal tumours are very rare and display various endocrine profiles. The unilateralapproach is indicated if a nonsecretor contralateral pattern is suspected in order to avoid adrenal insufficiency.We present a 48-year-old woman with a history of bradimenorrhea at the age of 44.The gynecological evaluation was negative but two adrenal tumours were found. CT revealed aright adrenal tumour of 2 cm and a left one of 2.4 cm. Low-normal ACTH and high serumchromogranin A were confirmed. After one year, the left tumour increased to 4 cm so laparoscopictransabdominal left adrenalectomy (with 3 trocars) was successfully performed without anyincident. No conversion was required. Neither intraoperative nor postoperative complicationsoccurred. The patient was hospitalised 5 days and the wounds healed normally. The pathologicalreport revealed a benign corticoadenoma. The endocrine evaluation after one week showed thatafter surgery ACTH de-suppressed to normal and chromogranin A normalised. The right adrenaltumour was followed-up for another year and the diameters were stationary. The patient was stillhypertensive and she was offered adequate therapy (which we considered essential for high blood pressure). Life-long periodical check-up is necessary.Unilateral adrenalectomy in patients with both side tumours allows an adequate pathological report and avoids unnecessary contralateral surgery if an incidentaloma is revealed, thus allowing the preservation of adrenal function.

Familial isolated primary hyperparathyroidism due to HRPT2 mutation

Primary hyperparathyroidism is a common endocrine disorder that is mostly caused by solitary tumors within the parathyroid glands. Characterized by early debut and higher frequency of multiple parathyroid masses, familial forms of primary hyperparathyroidism are caused by the already known mutations of: menin (MEN1 syndrome), RET proto-oncogene (MEN2 syndrome), HRPT2-parafibromin (hyperparathyroidism-jaw tumor syndrome), calcium sensing receptor gene (familial hypocalciuric hypercalcemia). A specific mutation in FIHP has not been identified in the majority of affected families. Recent studies revealed menin, HRPT2 and calcium-sensing receptor mutations in patients with FIHP. Whether FIHP is a variant or an early stage of MEN1 syndrome or hyperparathyroidism-jaw tumor syndrome is yet to be established. We present three siblings with familial isolated hyperparathyroidism due to solitary parathyroid adenoma and favorable evolution post-parathyroidectomy. Genetic tests revealed HRPT2 mutation.

[The etiopathogenetic hypotheses in polycystic ovary]

First described in 1935, polycystic ovary syndrome (PCOS) is a frequent endocrine disease (6% in female population). However its pathogenicity is not yet completely understood. The possible etio-pathogenic mechanisms include: neuroendocrine disorders (hypothalamic, as a result of congenital androgenism or of disorders of neurotransmitters or pituitary, with excess of LH), ovarian disorders (enhanced sensibility at LH, local growth factors, hyperactivity of Cit P450cl7 alpha enzymes), adrenal disorders, insulin resistance, genetic determinism, puberty onset. The authors discuss in detail this hypothesis and these possible importance.