Endocrine abnormality in paraneoplastic syndrome

Paraneoplastic syndromes denote rare but notable phenomena caused by the tumour mediated release of bioactive substances. Peptide and non-peptide hormone causes are explored with a particular focus on pathogenesis, symptoms, diagnosis and treatment. Early detection and management of paraneoplastic syndromes can improve morbidly and mortality; definitive treatment remains effective surgical or anti-tumour therapies. Pituitary autoimmunity may provide a novel presentation of paraneoplastic syndromes for which further research is warranted.

IL-6-producing Renal Cell Carcinoma Causing Renal and Endocrine Paraneoplastic Syndromes

An 83-year-old man with stable chronic kidney disease (CKD) exhibited a sudden increase in urinary N-acetyl-β-D-glucosaminidase and protein excretion, suggesting aggravated kidney damage. Simultaneously, he lost diabetic control, requiring up to 54 units of insulin daily. A detailed examination revealed the presence of renal cell carcinoma, which was surgically resected and confirmed to be interleukin-6-positive by immunohistochemistry. Postoperatively, his uni-nephrectomy necessitated hemodialysis, but the patient's insulin resistance was ameliorated; no medication was required to control diabetes, suggesting that the tumor had caused the insulin resistance. This report describes a case of a tumor secreting interleukin-6, which affects both the control of diabetes and CKD progression.

[CME: Paraneoplastic Endocrine Syndromes]

CME: Paraneoplastic Endocrine Syndromes Abstract. Paraneoplastic endocrine syndromes are caused by ectopic hormone production by malignant tumor cells. Knowledge of paraneoplastic endocrine syndromes may allow a timely diagnosis of the underlying cancer at a treatable stage and, on the other hand, appropriate treatment of the endocrine manifestations reduces morbidity and mortality of the affected patients. The most common endocrine syndromes are paraneoplastic hypercalcaemia, caused by the secretion of PTHrP, and hyponatremia, caused by the inadequate secretion of ADH. Although there may be clinical symptoms like fatigue, nausea/vomiting and renal insufficiency for hypercalcaemia and gait disturbances and mental alterations for hyponatremia, the diagnosis must be confirmed by laboratory testing and prompt the search for associated tumors.

Endocrine paraneoplastic syndromes in lung cancer

Paraneoplastic syndromes are defined as a combination of clinical disorders associated with malignant diseases that are caused by the secretion of various substances by the tumor without, however, being caused by the direct growth and infiltration of the primary tumor, or due to the development of distant metastases. Despite the fact that lung cancer represents the number one cause of death from cancer worldwide, the new methods of treatment increase patient survival and the incidence of paraneoplastic syndromes. The most important ones of these are humoral hypercalcemia of malignancy, syndrome of inappropriate antidiuretic hormone, hyponatremia of malignancy, ectopic Cushing's syndrome, carcinoid syndrome, and hypoglycemia and are usually a poor prognostic marker. Early diagnosis of those syndromes is achieved using specific criteria and may lead to early diagnosis of the underlying malignancy. It is essential to treat them with the overriding objective of improving the patients' quality of life.

Parathyroid carcinoma occurred in two glands in multiple endocrine neoplasia 1: a report on a rare case

Primary hyperparathyroidism is the most common hormonal manifestation associated with multiple endocrine neoplasia 1 (MEN1). It is generally caused by parathyroid hyperplasia, and parathyroid carcinoma is rare. Here, we report a case of MEN1 with parathyroid carcinoma in two parathyroid glands causing primary hyperparathyroidism. A 40-year-old man with primary hyperparathyroidism due to MEN1 underwent a total parathyroidectomy. His corrected calcium and intact PTH (i-PTH) serum levels were 10.8 mg/dL and 203 pg/mL, respectively. Although three glands were successfully removed, the left upper parathyroid gland could not be detected. Since the right lower parathyroid lesion had invaded into the thyroid, right lobectomy was performed. A portion of the left lower parathyroid tissue was transplanted into his forearm. The histological findings of the left lower and the right upper parathyroid glands were consistent with hyperplasia while that of the right lower parathyroid gland was parathyroid carcinoma. Since the post-surgical i-PTH levels remained high, the intrathyroidal lesion of the left lobe, which was initally diagnosed as an adenomatous nodule, was suspected to contain parathyroid tumor. A fine needle aspiration of the tumor revealed a high concentration of i-PTH. One week after the first surgery, a left thyroid lobectomy was performed. The pathological diagnosis of the tumor was parathyroid carcinoma. After the surgery, calcium and i-PTH levels were normal. Although it is rare, parathyroid carcinoma should be considered as a cause of hyperparathyroidism in MEN1 patients. Since it is difficult to diagnose parathyroid carcinoma before surgery, intraoperative findings are important for the appropriate treatment.

Paraneoplastic endocrine syndromes

The majority of neoplasms are responsible for symptoms caused by mass effects to surrounding tissues and/or through the development of metastases. However, occasionally neoplasms, with or without endocrine differentiation, acquire the ability to secrete a variety of bioactive substances or induce immune cross-reactivity with the normal tissues that can lead to the development of characteristic clinical syndromes. These syndromes are named endocrine paraneoplastic syndromes when the specific secretory components (hormones, peptides or cytokines) are unrelated to the anticipated tissue or organ of origin. Endocrine paraneoplastic syndromes can complicate the patient's clinical course, response to treatment, impact prognosis and even be confused as metastatic spread. These syndromes can precede, occur concomitantly or present at a later stage of tumour development, and along with the secreted substances constitute the biological 'fingerprint' of the tumour. Their detection can facilitate early diagnosis of the underlying neoplasia, monitor response to treatment and/or detect early recurrences following successful initial management. Although when associated with tumours of low malignant potential they usually do not affect long-term outcome, in cases of highly malignant tumours, endocrine paraneoplastic syndromes are usually associated with poorer survival outcomes. Recent medical advances have not only improved our understanding of paraneoplastic syndrome pathogenesis in general but also enhanced their diagnosis and treatment. Yet, given the rarity of endocrine paraneoplastic syndromes, there is a paucity of prospective clinical trials to guide management. The development of well-designed prospective multicentre trials remains a priority in the field in order to fully characterise these syndromes and provide evidence-based diagnostic and therapeutic protocols.

[Paraneoplastic endocrine syndromes]

Among the most interesting manifestations of neoplasms is the production of functional peptides and hormones that may induce unique clinical syndromes. It has become obvious in the last decades that a wide range of endocrine tumors secrete hormones not normally associated with the tissue in which the neoplasm arises. The resultant syndromes, some of which resemble other endocrine entities, can be the first clinical manifestation of malignant disease or a harbinger of cancer recurrence. The development of these disorders does not necessarily correlate with cancer stage or unfavorable prognosis. Early recognition of paraneoplastic endocrine syndromes is clinically important as it might lead to the detection of underlying malignancy and might prevent delay in treatment. Because paraneoplastic endocrine syndromes often cause considerable morbidity and mortality, effective treatment can improve patient quality and length of life. The aim of this study was to review the most common and the most specific paraneoplastic syndromes associated with the presence of ectopic hormone production. We emphasize the importance of considering the ectopic hormone production in the differential diagnosis of various endocrine entities.

Limited value of long-term biochemical follow-up in patients with adrenal incidentalomas-a retrospective cohort study

BACKGROUND

The prevailing view that advocates long-term hormonal follow-up of adrenal incidentalomas is currently under debate. The purpose of the present study was to examine all adrenal incidentalomas presented during five years to a single centre. We hypothesized that 24-month biochemical follow-up in patients with an initial normal screening would fail to increase the sensitivity in finding hormone producing tumours.

METHODS

The present study is a retrospective register based cohort study of 194 patients referred to the Department of Endocrinology at Södersjukhuset between the years 2006-2010. Computerized medical records were used to find and extract information on patients with newly discovered adrenal incidentalomas. The sensitivity, specificity, positive predictive value and negative predictive value were calculated to evaluate the validity of an initial normal screening when used to identify individuals with hormone producing tumours.

RESULTS

Of the incidentalomas 94% consisted of benign, non-functioning tumours. Three patients were diagnosed with cortisol hypersecretion and one with pheochromocytoma. The sensitivity, specificity, positive predictive value and negative predictive value of an initial complete negative screening to predict a hormone producing tumour were 100%, 63%, 12% and 100%, respectively.

CONCLUSION

Patients with an initially normal hormonal screening may not need further biochemical follow-up.

Paraneoplastic syndromes: the way to an early diagnosis of lung cancer

Pulmonary malignancies are the leading cause of cancer mortality around the world. The late diagnosis of lung cancer, in advanced stages, is mainly due to atypical clinical presentation. Paraneoplastic syndromes have been first described in 1825, as a group of symptoms related to a malignant disease, which are not the effect of the primary neither of the metastatic tumor. The paraneoplastic syndromes have been reported in all types of lung cancer, but more frequently in small cell lung cancer, due to its origin in neuroendocrine cell precursors. The most frequent associated syndromes described in the literature are neurological and endocrine. In most patients paraneoplastic syndromes occur prior to other symptoms of malignancy. The presence or the severity of these syndromes is not correlated with the stage of cancer. Most of the paraneoplastic syndromes disappear once the primary tumor is removed and reappear in case of cancer recurrence or metastasis. This paper is a review of paraneoplastic syndromes in lung cancer.

[Inadequate secretion of β-human chorionic gonadotropin in lung cancer]

INTRODUCTION

The inadequate secretion of β-human chorionic gonadotropin (β-HCG) during non-small cell lung cancer (NSCLC) is rare and quite ignored. The dosage of β-HCG is probably not systematically realized in women who are in age of pregnancy and who need chemotherapy (CT) despite the descriptions of cases of prescription of CT against lung cancer in women who were pregnant. The incidence of NSCLC cancer is increasing and the risk to prescribe a CT in a woman who is pregnant is also increasing.

CASES REPORTS

We describe the cases of two women and one man who had an augmentation of the β-HCG plasmatic level before the prescription of CT against lung cancer. In women, the differential diagnostic between inadequate secretion of β-HCG and pregnancy has been a problem.

CONCLUSION

The inadequate secretion of β-HCG during NSCLC is probably not so rare. The dosage of this hormone before each infusion of CT should be systematic to avoid the realization of CT during pregnancy. This raises the question of the method for differential diagnostic between pregnancy and inadequate secretion of β-HCG in young women who suffer from NSCLC, especially when a small level of β-HCG is measured.

[Paraneoplastic endocrine syndromes: diagnosis and management]

Paraneoplastic endocrine syndromes define a group of secondary signs and symptoms associated to a neoplasia, independently from the location of the primary tumor or its metastases. Paraneoplastic or ectopic endocrine syndromes usually result from aberrant hormone precursors or hormone-like substances by tumours. Knowledge of paraneoplastic endocrine complications is important both for the early diagnosis of neoplasia and the prognosis of the patient. In this review we discuss almost all reported paraneoplastic endocrine syndromes. We analyze their prevalence, etiology, laboratory diagnosis and treatment.

Paraneoplastic Cushing's syndrome as the first sign of progression of prostate cancer

Cushing's syndrome accompanying the small cell de-differentiation of the prostatic adenocarcinoma is a relatively rare clinical entity, associated with poor overall prognosis. Despite several treatment options available, there is still no effective standard therapy for this clinical condition. Herein, we report two patients with prostate cancer presenting with clinical and laboratory features of Cushing's syndrome as the first sign of disease progression (Ref. 4). Full Text (Free, PDF) www.bmj.sk.

Endocrine paraneoplastic syndromes in small cell lung carcinoma. Two case reports

Paraneoplastic syndromes are frequently detected in many small cell lung cancer (SCLC) patients. In the present paper we report 2 cases of patients diagnosed with SCLC, in whom 2 distinct endocrine paraneoplastic syndromes were identified during diagnosis. In the first patient, severe hyponatremia and renal sodium loss with inappropriate antidiuresis was found during routine laboratory tests. Serum antidiuretic hormone (ADH) level was within normal limits, but the atrial natriuretic peptide (ANP) level was elevated. The second case presented with severe hypercalcemia secondary to an excessive parathormone (PTH) secretion. We discuss the 2 cases and review the literature.

The Current Role of Venous Sampling in the Localization of Endocrine Disease

Endocrine venous sampling plays a specific role in the diagnosis of endocrine disorders. In this article, we cover inferior petrosal sinus sampling, selective parathyroid venous sampling, hepatic venous sampling with arterial stimulation, adrenal venous sampling, and ovarian venous sampling. We review their indications and the scientific evidence justifying these indications in the diagnosis and management of Cushing's syndrome, hyperparathyroidism, pancreatic endocrine tumors, Conn's syndrome, primary hyperaldosteronism, pheochromocytomas, and androgen-secreting ovarian tumors. For each sampling technique, we compare its diagnostic accuracy with that of other imaging techniques and, where possible, look at how it impacts patient management. Finally, we incorporate venous sampling into diagnostic algorithms used at our institution.

Surgically correctable hypertension caused by primary aldosteronism

Surgically correctable forms of primary aldosteronism are generally held to be less common than forms requiring medical therapy. However, with the availability of improved diagnostic techniques and the adoption of a systematic and thorough diagnostic work-up they can be identified more commonly than expected. Adrenal vein sampling (AVS) for measurement of cortisol and aldosterone has emerged as the 'gold standard' diagnostic test for identifying unilateral causes of primary aldosteronism that are amenable to surgical cure. Adrenalectomy can provide long-term normalisation of blood pressure and correction of primary aldosteronism in about 55% of patients with an aldosterone-producing adenoma and can markedly ameliorate blood pressure control in the rest. This chapter summarises the diagnostic work-up suggested for identifying these forms and examines the other diseases mimicking mineralocorticoid excess that enter into the differential diagnosis of surgically curable primary aldosteronism.

[Paraneoplastic syndromes: a review]

Modern oncology often obtains good results against earlier neoplasms, whilst it's still in difficulties against the advanced ones. The knowledge of paraneoplastic syndromes is crucial both to cure patients and to do an earlier diagnosis. When we recognize a paraneoplastic syndrome that comes before the clinic beginning of a neoplasm, perhaps we save a life. This review discusses all the main paraneoplastic syndromes, focusing mainly on their clinical aspect and reminding the most commonly associated cancers.

Síndromes hormonales paraneoplásicos

We can define paraneoplastic syndromes as a combination of effects occurring far from the original location of the tumour and independently from the local repercussion of its metastases. Paraneoplastic hormonal syndromes depend on the secretion of hormonal peptides or their precursors, cytokines and, more rarely, thyroidal hormones and Vitamin D, which act in an endocrine, paracrine or autocrine way. Sometimes, paraneoplastic syndromes can be more serious than the consequences of the primary tumour itself and can precede, develop in parallel, or follow the manifestations of this tumour. It is important to recognise a paraneoplastic hormonal syndrome for several reasons, amongst which we would draw attention to three: 1) It can lead to the diagnosis of a previously undetected, underlying malign or benign neoplasia; 2) It can dominate the clinical picture and thus lead to errors with respect to the origin and type of primary tumour; and 3) It can follow the clinical course of the underlying tumour and thus be useful for monitoring its evolution. The molecular mechanisms responsible for the development of these syndromes are not well-known, but it is believed that they might be inherent to the mutations responsible for the primary tumour or depend on epigenetic factors such as methylation. In this review, we consider the following paraneoplastic hormonal syndromes: malign hypercalcaemia, hyponatraemia (inappropiate secretion of the antidiuretic hormone), ectopic Cushing's syndrome, ectopic acromegaly, hypoglycaemia due to tumours different from those of the islet cells and paraneoplastic gynaecomastia; we make a brief final reference to other hormones (calcitonin, somatostatin, and VIP).

Wiederholungseingriffe an den Nebennieren

Repeat adrenalectomy may be required due to ipsilateral recurrence of benign or malignant adrenal tumors after previous total or subtotal adrenalectomy. Even for multivisceral resection in patients with adrenocortical carcinoma, complete resection of local recurrent tumor offers results similar to those of primary resection (5-year survival 40-60%). In contrast, since no benefit on long-term survival has been shown so far by tumor debulking, palliative tumor resection should only be performed individually for control of severe endocrine symptoms. The effect of endoscopic adrenalectomy in patients with large tumors (>5 cm) or suspected malignancy has still not been well examined. Further studies are required. In any case, during open or endoscopic approach, tumor spillage must be avoided to prevent local tumor cell implantation. Following subtotal adrenalectomy, the risk of ipsilateral recurrence correlates with disease, follow-up, localization, size of the adrenal remnant, and, in case of familial pheochromocytoma, probably with genotype.

[Neuro-endocrine tumors of the gastrointestinal tract: epidemiology, classification, prognosis, diagnosis and therapeutic modalities]

The neuro-endocrine tumors of the gastrointestinal tract comprise a heterogeneous group of slow-growing malignancies with great differences regarding their localization, tissue of origin and their entopic and ectopic production of hormones. They can be subdivided in carcinoid tumors and endocrine tumors of the pancreas. According to their secreted products they manifest as endocrinological syndromes or as local space-occupying tumors. This review focuses, besides summarizing the available epidemiological data and describing tumor localization and classification, on the differing symptom complexes and the prognosis of the various tumor entities. Furthermore, the value of available diagnostic techniques and the role of different therapeutic modalities like surgery, radiation, biotherapy and cytostatic chemotherapy are discussed.

[Preoperative diagnostics in patients with adrenal tumors]

The aim of the study was analysis of preoperative diagnostics of patients who underwent laparoscopic adrenalectomy. In the preoperative diagnostics in 10 patients (22.2%) pheochromocytoma was found, in 8 (17.8%) Conn's syndrome, in 4 (8.9%) Cushing's syndrome and in 1 (2.2%) adrenal virilization. Full accordance between histopathological findings and preoperative diagnosis was achieved in 91% of cases. Four cases of discrepancy were: 1 false positive preoperative diagnosis of aldosteronoma, 1 false positive and 2 false negative diagnosis of pheochromocytoma.

[Ectopic hormone-producing tumors--research and clinics]

Recent progress in endocrinology, cytokine research, and oncology has provided new information for further understanding of ectopic hormone-producing tumors. The mechanisms responsible for this morbidity need further investigations to clarify the neuroendocrine nature of tumor cells. Meanwhile, a common hormonal substance produced by a specific tumor could serve as a specific tumor marker for the tumor, as is the case of ProGRP for small cell lung cancer. The development of drugs for ectopic hormonal syndrome might be a good lesson of the molecular targeting for hormone signaling pathways. It is reasonable to postulate that the clinical entities covered by the term 'ectopic humoral syndrome' will be increasing.

Endocrine paraneoplastic syndromes in lung cancer

Lung tumors are capable of synthesizing and secreting peptide proteins (hormones) that lead to a variety of endocrine paraneoplastic syndromes. Knowledge about the clinical manifestations, pathophysiology, and treatment of these syndromes has evolved over time. This article provides an up-to-date overview of this knowledge.

[Disordered hormone regulation in gynecomastia]

Gynecomastia develops when there is an increase in the ratio of estrogen to androgens. Whereas mild forms of gynecomastia are frequently encountered in the male population, any breast enlargement that is prominent, painful, progressive or of recent onset always requires a careful evaluation, as it may be an important clue to disease elsewhere. Underlying causes are plenty and include drugs, congenital and acquired disorders of androgen and estrogen production, various tumors, renal failure, cirrhosis of the liver, and thyrotoxicosis. Evaluation includes a careful patient's history, physical examination of sexual characteristics and the breast tissue, and measurements of serum LH, FSH, testosterone, estradiol, hCG-beta, TSH and tests of liver and kidney function.

Ectopic TSH-secreting pituitary adenoma of the vomerosphenoidal junction

OBJECTIVE

We describe an unusual case of ectopic TSH-secreting pituitary adenoma arising from the vomerosphenoidal junction.

CLINICAL PRESENTATION

A 52-Year-old man with a long-standing history of hyperthyroidism was referred to the University Hospital in September 2001 because of increasingly disabling symptoms of nasal obstruction. For the past 18 Years the patient had complained of palpitations, hypertension, weight loss, and nervousness. A presumptive diagnosis of Graves' disease was made. Treatment with methimazole was begun, but the patient was lost to follow-up. On admission, physical examination revealed signs of hyperthyroidism and a large diffuse goiter. Tests of thyroid function showed inappropriate secretion of TSH with hyperthyroidism. Both a TSH-secreting pituitary adenoma and resistance to thyroid hormone could be taken into account. There was no evidence of pituitary tumour by magnetic resonance imaging (MRI), but a large space-occupying lesion involving the nasal cavity and the nasopharynx was incidentally discovered. INTERVENTATION AND TECHNIQUE: Using an endoscopic endonasal approach, the tumour was removed en bloc together with the sphenoid floor, sphenoid rostrum, bony septum, and part of the soft palate mucosa. Histological features and immunophenotype were those of a TSH-secreting tumour.

CONCLUSION

Although exceedingly rare, ectopic TSH-secreting pituitary tumour should be borne in mind in cases of inappropriate secretion of TSH with hyperthyroidism and no evidence of pituitary tumour by computed tomography and/or MRI when a mass located along the migration path of the Rathke's pouch is demonstrated by radiological examination. To our knowledge, this is only the second reported case in the literature.

[Diseases of the pituitary gland: clinical aspects and biochemical evaluation]

Endocrine inactive and prolactin-secreting adenomas are the most commonly observed forms of pituitary tumors counting for more than 50 percent of diseases. In most cases first clinical symptoms can be attributed to insufficiency of the adenohypophysis which is also true for gonadotropin and thyroid stimulating hormone (TSH) producing adenomas. Clinical signs and symptoms of secondary insufficiency and primary forms of endocrine deficits do not differ significantly and the diagnosis may be hampered by involvement of more than one organ system. In contrast, symptoms and signs of ACTH or GH producing tumors are more impressive leading to diagnosis at an earlier stage. In case of corticotropic and somatotropic dysfunction dynamic tests are necessary for diagnosis. Close cooperation of endocrinologists, radiologists, and neurosurgeons is necessary for the effective workup of pituitary gland diseases.

[Imaging of endocrine tumours of the pancreas]

Islet cell tumors are rare pancreatic or peripancreatic neoplasms that produce and secrete hormones to a variable degree. Neuroendocrine tumors of the pancreas can occur sporadically or in association with multiple endocrine neoplasia type 1 (MEN I). Biologically active neuroendocrine tumors produce early symptoms and are often difficult to diagnose owing to their small dimensions, whereas biologically inactive forms are often large and sometimes found by chance. Imaging has a major role in the preoperative localization of the primary tumor and detection of metastases, providing an anatomic substrate whereas it plays a primary role in the regional staging of these neoplasm, for which surgery is the first and essential therapeutic approach. Several techniques are available including computed tomography (CT), magnetic resonance imaging (MRI), endoscopic ultrasound, intraoperative ultrasound, somatostatin receptor scintigraphy, and arterial stimulation with venous sampling; each with unique advantages and certain limitations. Recent technical advances in Multidetector CT, and dynamic MRI using breath hold sequences have improved the sensitivity of these modalities markedly.