Endocrinology Clinical Cases Pdf

[Regulo Akers]

Ledby Editor-in-Chief William F. Young, Jr., MD, Mayo Clinic College of Medicine and Science, JCEM Case Reports is a new online-only, Open Access journal from the Endocrine Society. The journal publishes original clinical cases covering the entire spectrum of endocrinology, worldwide, and welcomes submissions including:

At UT Health San Antonio we support a two-year ACGME accredited fellowship program that is designed to provide fellows with a broad-based exposure to endocrine cases with the goal of developing outstanding clinicians and educators. We recruit two fellows annually.

Regular divisional activities include weekly clinical case conferences and grand rounds; monthly endocrine-nuclear medicine conferences; monthly tumor board, cytopathology conference and pituitary-neuroradiology-neurosurgery conferences. In addition, there are research seminars, clinical tutorials, and journal clubs. During the inpatient consult service, subspecialty residents participate in bedside teaching of medical students and internal medicine housestaff assigned to endocrine electives. The subspecialty resident attends two continuity clinics: The weekly Endocrine Clinic at the Texas Diabetes Institute (TDI), which is part of UHS, and the weekly Endocrine Clinic at the VA. The endocrinology clinic averages 30 patients per clinic with diverse endocrinology complaints-predominantly thyroid, pituitary and adrenal disease.

The patient care program puts emphasis on the comprehensive management of diabetes including the complications seen in ophthalmology, nephrology, neurology and podiatry. The subspecialty residents also attend a general diabetes clinic, insulin pump clinic and obesity clinic. At the end of two years of training, fellows are well prepared to take the Subspecialty Board examination in Endocrinology, Diabetes and Metabolism.

Current ongoing research projects by faculty of the Division of Diabetes include: 1) Mechanisms of insulin resistance in type 2 diabetes, 2) The relationship between hypertension, dyslipidemia, body fat, hyperinsulinemia and insulin resistance, 3) Mechanisms of free fatty acid-induced insulin resistance, 4) New pharmacologic therapies in type 2 diabetes, 5) Effect of exercise on insulin signaling and glucose metabolism, 6) Effect of intensified insulin therapy on glucose metabolism and macrovascular complications in type 2 diabetes and 7) Mechanisms of macrovascular complications and their treatment in type 2 diabetes.

The University of Texas Health Science Center at San Antonio, also called UT Health San Antonio, is a leading academic health center with a mission to make lives better through excellence in advanced academics, life-saving research and comprehensive clinical care including health, dental and cancer services.

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Tumor size (larger than 4 cm, and particularly larger than 10 cm) as well as unenhanced Hounsfield units (HU) on computerized tomography (larger than 20 or increased heterogeneity) are strong predictors of malignancy. History of extra-adrenal malignancy is associated with a diagnosis of adrenal metastasis, while a hormonally active adrenal mass (especially combined cortisol and androgen excess) is strongly suggestive of ACC.

Adrenal biopsy is not recommended in any adrenal tumor suspicious for ACC, mostly due to poor accuracy and concern for needle track seeding, as reported in research published in Clinical Endocrinology and the European Journal of Endocrinology in 2016. Furthermore, adrenal biopsy is an invasive and typically expensive procedure and is contraindicated in any adrenal mass suspicious for pheochromocytoma.

Steroid profiling, both in serum and urine samples, is currently clinically available and can provide valuable data to guide appropriate next steps in management, as reported in research published in Clinical Chemistry in 2017 and Endocrine Practice in 2019. As demonstrated in the following cases, steroid profiling is especially helpful in two clinical scenarios:

A 71-year-old woman was evaluated by her primary care physician for symptoms of worsening shortness of breath. A computerized tomography (CT) scan of the chest did not show any lung pathology but identified an incidental left adrenal mass. Subsequent CT of the abdomen revealed a 15-by-12-cm well-circumscribed heterogeneous left adrenal mass with scattered dystrophic calcifications and marked local mass effect. No other lesions were noted in the abdomen or the chest.

The patient had a known diagnosis of sleep apnea, hypertension, type 2 diabetes mellitus, obesity and dyslipidemia. She reported no personal or family history of any genetic syndrome or malignancy. During evaluation in the adrenal clinic, she was asymptomatic and denied any changes to appetite or weight.

On physical exam, no features of overt Cushing syndrome, acne, hirsutism, androgenic alopecia or edema were noted. Biochemical workup was consistent with ACTH-independent cortisol excess and androgen excess, without evidence for primary aldosteronism or catecholamine excess. Preoperative serum and urine steroid profiling were consistent with adrenocortical carcinoma, with elevated androgen and glucocorticoid precursors and metabolites. The patient underwent an open left adrenalectomy, and surgical pathology confirmed ACC (Ki-67 index of 70%).

A 65-year-old woman was evaluated for unexplained persistent low-grade fever associated with mild neutrophilia. Her medical history included hypertension, dyslipidemia and prediabetes. In addition, she had a history of stage I uterine cancer for which she underwent a hysterectomy two years prior to the current evaluation.

The patient had no personal history of genetic syndrome or family history of malignancy. Following an episode of fever with abdominal pain, she underwent a CT of the abdomen that incidentally identified a 20-by-17-by-10.5-cm large mixed solid and cystic mass in the left adrenal gland, with scattered calcifications abutting surrounding structures.

On evaluation in the adrenal clinic, mild hirsutism was noted without evidence of acne, androgenic alopecia, features of Cushing syndrome or edema. Biochemical workup revealed abnormal dexamethasone suppression test, but otherwise no hormonal excess. Preoperative serum and urine steroid profiling were not suggestive of ACC. Open left adrenalectomy was performed, and pathology demonstrated a poorly differentiated leiomyosarcoma.

These two cases of malignant adrenal tumors are both highly suspicious for ACC based on imaging and standard of care hormonal work-up. Serum and urine steroid profiles of the patient in case one were highly suggestive of ACC, but those of the patient in case two favored other diagnoses, such as metastases or lymphoma. This additional information allowed for individualized approaches to confirm the diagnoses in both patients.

Preoperative diagnosis of ACC will guide a recommendation for open adrenalectomy without delay in case one, whereas excluding ACC as in case two may lead to reconsideration of adrenalectomy in favor of adrenal biopsy or other diagnostic tests.

Serum and urine steroid profiling should be considered in any patient with indeterminate adrenal mass (tumor size larger than 4 cm, HU > 10 and especially HU > 20) prior to surgery to help guide subsequent diagnostic and therapeutic measures.

Fassnacht M, et al. Management of adrenal incidentalomas: European Society of Endocrinology Clinical Practice Guideline in collaboration with the European Network for the Study of Adrenal Tumors. European Journal of Endocrinology. 2016;175:G1.

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This Case Study illustrates some of the potential pitfalls of diagnosis and demonstrates a combination of problems of follow-up biochemical screening in a patient operated for a large pheochromocytoma at increased risk of malignant disease. The difficulty in assessing the presence of disease after initial surgical resection and reaching a diagnosis of malignancy are highlighted.

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