Massive Enlargement Research Articles

Unusual Gingival Enlargement with Aggressive Periodontitis: A Case Report

This article describes the surgical management of a young, female patient with severe gingival enlargement of unknown etiology. Gingival enlargement frequently occurs as gingival hyperplasia, representing a reaction to a known stimulus or agent and, histopathologically, implies an increase in both extracellular matrix and cell numbers. The enlargement may range from mild, in which gingival architecture is minimally affected, to severe, in which the gingiva becomes bulbous and covers the clinical crowns of teeth. A number of local and systemic factors, such as plaque, hormonal changes, drug ingestion, and heredity, can cause or influence gingival enlargement. Mild to moderate increase in gingival bulk is relatively common, but massive gingival enlargement with associated bone resorption is rare. This case involved a 19-year-old female patient who presented with generalized severe gingival enlargement with aggressive periodontitis, a condition of some five to six months in duration. Based on a thorough clinical and radiographic examination, laboratory tests, and oral hygiene instructions, an internal bevel gingivectomy was performed to remove excess gingival tissue and areas of bone loss were debrided properly. There was no recurrence eight months following the last surgery. Although we were not able to identify the exact cause of the gingival enlargement, amelioration of the unusual very soft, friable, enlarged gingivae and the severe periodontal attachment loss was observed. Before initiating any periodontal management of a case of severe gingival enlargement with aggressive periodontitis, it is recommended to perform a complete extraoral and intraoral examination with radiographs, take a family and medical history, and determine if any medications may be responsible for the gingival enlargement. Additional testing and analysis, as described in this case, may be necessary.

Prostatic Stromal Tumor of Uncertain Malignant Potential (STUMP) Presenting with Multiple Lung Metastasis

We report the case of a 68-year-old man with a stromal tumor of uncertain malignant potential (STUMP), which had metastasized to the lung. The patient complained of an enlarged mass in the anterior chest. Chest computed tomography (CT) showed a sternal abscess with multiple nodules in both lungs. A thoracoscopic lung biopsy of the nodules and incision/drainage of the sternal mass were performed simultaneously. CT of the pelvis revealed an enlarged prostate with irregular cystic lesions in the pelvis. Prostate biopsy was done and demonstrated hypercellular stroma with minimal cytological atypia, a distinct pattern of STUMP. The sternal abscess proved to be tuberculosis and the lung lesion was consistent with STUMP, which had spread from the prostate. However, to our knowledge, the tuberculous abscess might not be assoicated with STUMP in the lung. The patient refused surgical prostatectomy and was discharged with anti-tuberculosis medication. On one-year follow up, the patient had no evidence of disease progression.

Ovarian hyperresponse to luteal phase GnRH-agonist administration

Herein we report a case of ovarian hyperresponse after luteal phase GnRH-agonist administration in a woman planning to undergo ovarian stimulation for IVF in a long GnRH-agonist protocol. A normogonadotropic 25-year-old woman undergoing ICSI treatment for male factor infertility underwent three cycles of controlled ovarian stimulation, two in a GnRH-antagonist protocol, one in a long luteal GnRH-agonist protocol. In the first GnRH-antagonist cycle, ovarian stimulation was performed with 150 IE recombinant FSH and 22 oocytes were retrieved. In the second GnRH-antagonist cycle using the same protocol, six oocytes were retrieved. The estradiol levels on the day of hCG administration were 3,692 and 3,209 pg/ml, respectively. In a third cycle, 3.75 mg triptorelin was administered in the luteal phase and the patient showed ovarian hyperresponse to the endogenous gonadotropin flare with estradiol levels of 19,102 pg/ml, abdominal distension and discomfort, and massive bilateral ovarian enlargement (total ovarian volume 268 cm(3)). Ovarian cysts persisted for 4 weeks and necessitated cyst aspiration before further treatment. The flare-up effect of GnRH-agonist administration can, in rare cases, cause massive ovarian hyperresponse with associated health risks and significant postponement of treatment.

Rapamycin: eine neue Therapieoption bei autosomal dominanter polyzystischer Nierenerkrankung (ADPKD)?

Autosomal dominant polycystic kidney disease (ADPKD) is characterized by the massive enlargement of both kidneys caused by numerous cysts. The cyst formation begins in utero and the continuous growth of cysts leads to compression and destruction of non-cystic renal parenchyma, so that finally a kidney replacement in the 5th to 6th decade of life is necessary. So far there is no therapy that halts disease progression. Animal data show that pharmacological inhibition of a central regulator of cell proliferation, the so-called mammalian target of rapamycin (mTOR), slows disease progression. This overview provides an insight into the disease and the specific mTOR inhibitor sirolimus, which is currently tested in clinical trials.

Adrenal incidentaloma, clinical, metabolic, follow-up aspects: single centre experience

To investigate clinical characteristics, metabolic parameters and follow-up findings of subjects with incidentally discovered adrenal tumors. 376 consecutive subjects who have been evaluated since 2002 were included. Initial radiological examination was CT. Hormonal evaluation included 8.00 a.m. cortisol, DHEA-S, ACTH and in hypertensive subjects, plasma renin activity, and serum aldosterone. Urinary free cortisol (UFC), urinary normetanephrine, and metanephrine were measured. Overnight 1 mg dexamethasone suppression test was performed. Radiological evaluation was performed at 6th and 12th months and annually in subsequent visits. Hormonal evaluation was performed 6 months after the initial visit and annually in subsequent visits. Additionally, patients were evaluated for the development of Type 2 diabetes mellitus, hypertension, hyperlipidemia, and metabolic syndrome in 6-month intervals. Mean age of the participants was 54.7 ± 13.1. Female subjects were more commonly affected (70%). CT was the most frequent radiological intervention that discovered adrenal masses (57%). The vast majority of the participants (85.6%) had benign adrenal adenomas. Primary adrenocortical malignancy was detected in 4 subjects (1.1%). Subjects with adrenal adenomas had significantly smaller tumor diameters (P ≤ 0.001 vs. other tumors). Sensitivity and specificity of 40 mm as a cut-off value in the differentiation of adrenal gland malignancies from benign tumors was 73.3 and 54.8%, respectively. Most of the adrenal adenomas were non-functioning (73.5%). Subclinical Cushing syndrome (sCS) was detected in 12.5%. The overall prevalence of Type 2 diabetes mellitus, hypertension, hyperlipidemia, and metabolic syndrome was 18.4, 54.9, 59.6, and 48.1%, respectively. They were significantly more common in middle-aged and elderly subjects. During 24 months follow-up 10.2% of adenomas featured increase in tumor diameter and 2.06% developed sCS. Young subjects featured more stable tumor diameter and hormonal status. Most of the incidentally discovered adrenal tumors were non-functioning adrenal adenomas. Clinically overt hormone hypersecretion syndromes were mainly shown in young subjects, while adrenal gland malignancies and sCS were more common in older ages. Mass enlargement and development of subclinical cortisol secretion were not rare and observed especially in middle-aged and elderly subjects. Metabolic derangements were common; however, a possible independent association between adrenal adenoma and metabolic problems need to be elucidated with prospective studies.

Changes in ventral head width, a discriminating shape factor among African cichlids, can be induced by chronic hypoxia

A massive enlargement of the gill surface proved to be an important factor in the hypoxia survival of young cichlids. Because the heads of cichlids are densely packed with structures related to both feeding and breathing, we hypothesized that the extra space needed for gill enlargement requires such large structural reorganizations that outer head shape is affected. We used a three-dimensional model to describe changes in the outer head shape of cichlids. Broods of cichlids of different phylogenetic lineages, habitats, and trophic specialization were split and raised at either 10% or 80–90% air saturation. Despite the above-mentioned differences between the species that were used, all hypoxia raised groups showed similar volume enlargements. Volume increases were most prominent in the ventral suspensorial and ventral opercular subcompartments. A relation with the enlarged gills of hypoxia raised fish is likely because the gills are mainly located in these compartments. The differences in ventral width correspond to those found in other studies comprising a wide variety of genotypic and phenotypic variations. The present study shows that such variation in the ventral width is conceivable by phenotypic plasticity alone. © 2009 The Linnean Society of London, Biological Journal of the Linnean Society, 2009, 98, 608–619.

Long Term Follow-up of Patients with Adrenal Incidentalomas- A Single Center Experience and Review of the Literature

Adrenal incidentalomas (AIs) constitute an emerging clinical entity due to the increased use of abdominal imaging for diagnostic purposes. Most often it consists of benign-nonfunctioning lesions and an increase in size during follow-up is reported in about 9% (0-26%), whereas their functional evolution is rare. Sixty-four patients (22 males and 42 females; mean age 61.6 ± 1.2 years), with AIs and follow-up of 3.1 ± 0.4 years (range 0-19) were retrospectively evaluated. The patients underwent basal and dynamic evaluation of the hypothalamic-pituitary-adrenal axis, renin-angiotensin-aldosterone system and adrenomedullary function. Mass enlargement and adrenal hyperfunction were estimated at yearly intervals. Adrenalectomy was performed in 5 patients (4 benign cortical adenomas and 1 pheochromocytoma). Abnormal manifestation, based on clinical, laboratory and histological evaluation, was observed in 4 patients [1 (1.56%) with SCS, 2 (3.12%) with pheochromocytoma and 1 (1.56%) with aldosteronoma], 3 of which were diagnosed at their initial evaluation and 1 at the 3 (rd) year of follow-up. The remainders [60 patients (93.75%)] were harbouring a non-secretory mass (8 potential myelolipomas, 8 nodular hyperplasias, 3 cystic lesions). Eleven patients (17.2%) had bilateral AIs. Mass enlargement (5-13 mm) was observed in 9 patients (14%), ≥10 mm 4 (6.25%), while mass shrinkage (5-19 mm) in 3 (4.7%) during follow-up. No hormonal evolution was noticed. AIs present usually as benign, non-secretory lesions. Criteria for surgical intervention were met at initial assessment for the majority of AIs. Size alterations during follow-up are uncommon and functional evolution is rare.

Mitochondrial DNA: An Up‐and‐coming Actor in White Adipose Tissue Pathophysiology

Mitochondrial DNA: An Up‐and‐coming Actor in White Adipose Tissue Pathophysiology

Bilateral Adrenal Gland Enlargement Secondary to Histoplasmosis Mimicking Adrenal Metastases: Diagnosis with EUS-guided FNA

Purpose: EUS-FNA of both adrenal glands has been well established in clinical practice. While adrenal gland histoplasmosis has been previously diagnosed by FNA using the percutaneous approach, EUS-FNA has not been employed in the diagnosis of this infection affecting both adrenal glands. Our purpose is to report a patient with massive bilateral adrenal enlargement due to histoplasmosis that was diagnosed by EUS-FNA. Methods: Case-report. Results: A 48-year-old Caucasian male presented with 4-month history of fatigue, abdominal discomfort, night sweats and chills. CT scan of abdomen revealed enlarged bilateral adrenal glands only. His total plasma catecholamine, normetanephrine, metanephrine, and aldosterone levels were within normal limits. The patient was referred for EUS-FNA of the adrenal glands with a possible metastatic neoplasm of unknown origin. EUS was performed, confirming enlargement of both adrenal glands. The right adrenal measured 41 × 25 mm and the left adrenal measured 73 × 29 mm (Figure 1). Trans-duodenal and transgastric fine needle aspiration biopsy of both adrenal glands was performed. Rapid onsite cytopathologic evaluation (ROSE) was consistent with granulomas. Apparent intra-cytoplasmic inclusions suggestive of organisms were visible. A Gomori Methenamine Silver stain revealed small intracellular budding yeasts, morphologically consistent with Histoplasma. The patient was admitted after EUS for amphotericin B intravenous infusion. His urine Histoplasma antigen was positive. Fungal cultures from both adrenal EUS-FNA samples grew Histoplasma Capsulatum. After one week hospital stay, he was discharged home on itraconazole for one year. Four months after initiation of treatment his urine Histoplasma antigen was undetectable and nine months after initial diagnosis, the patient was asymptomatic.Figure 1Conclusion: EUS-FNA with ROSE can be a highly effective tool in the diagnosis of uncommon infections of the adrenal glands, as histoplasmosis.

Congenital monomelic muscular hypertrophy of the upper extremity

Pathological muscular hypertrophy results from either muscular or neurogenic damage. Rarely, it is caused by a congenital malformation consisting of a unilateral muscular hyperplasia of the upper extremity. We report on a young woman with an enlargement of the right upper extremity. Electromyography showed polyphasic, large motor unit potentials in the affected muscles. MRI and ultrasound assessment demonstrated diffuse enlargement of muscle mass without signs of edema. Muscle biopsy revealed sections with marked variations in fiber size with no signs of inflammation or marked loss of muscle fibers. Factors assumed to be important in the pathophysiology of this phenomenon are discussed.

Growing Teratoma Syndrome

A 40-year-old man presented with abdominal pain and right scrotal swelling. Physical examination revealed a right testicular tumor and CT scan showed a large retroperitoneal mass. The patient underwent right radical orchiectomy, and pathology showed mixed germ cell tumor. After 1 cycle of chemotherapy, CT scan showed interval enlargement of the retroperitoneal mass. Percutaneous biopsy was consistent with teratoma. The patient refused surgical intervention and was noncompliant with follow-up. Four months after presentation, CT scan showed increasing abdominal lymphadenopathy. The patient received 4 cycles of chemotherapy. He presented 4 months later with massive lymphadenopathy and expired before planned palliative surgery.

Brachial plexus neuropathy resulting from a massively enlarged papillary thyroid carcinoma

Well-known complications of thyroid enlargement and papillary carcinoma include compression or invasion of the trachea, esophagus, and/or vascular structures. Recurrent laryngeal nerve invasion by thyroid carcinoma is not uncommon, and phrenic nerve invasion has also been described. Preoperative dysfunction of a vocal cord, which often implies invasive carcinoma, may necessitate recurrent laryngeal nerve sacrifice and is therefore rreversible. We present an unusual case of reversible brachial plexus compression in a patient with massive thyroid enlargement and papillary carcinoma.

Hemangioma of the Clitoris Presenting as Clitoromegaly: A Case Report

A 20-year-old woman with massive clitoral enlargement is presented to discuss the differential diagnosis and the treatment of this condition.

Prospective evaluation of tumor size and hormonal status in adrenal incidentalomas

Because of the increased use of imaging interventions, more subjects have been diagnosed with adrenal incidentaloma in recent years. To evaluate the risk of mass enlargement, hormone hypersecretion and development of adrenal carcinomas during short-term followup. There were 317 subjects with incidentally discovered adrenal tumors in the registry. Forty subjects were excluded because of clinically overt hormone secretion at diagnosis and subjects with complete data were included in radiological (no.=150) and hormonal (no.=150) follow- up. Radiological evaluation was performed with computed tomography (CT) and/or magnetic resonance imaging (MRI). There were 143 subjects with adrenal adenomas and 7 subjects with other tumor types (cyst or myelolipoma). Median follow-up duration was 24 months. Increase in tumor size was detected in 25 subjects (17.4%) with adenomas and 1 subject with adrenal myelolipoma (14.3%). Decrease in tumor size was found in 7 subjects (4.8%) with adrenal adenomas. One patient was diagnosed with adrenocortical carcinoma during follow-up. In subjects with non-functioning adrenal adenoma (NFA, no.=120) or subclinical Cushing syndrome (sCS) (no.=30), no subject developed clinically overt hormone hypersecretion, while 8 (6%) subjects in the NFA group developed sCS. Tumor diameter and follow-up duration were significantly higher in subjects who developed sCS. In conclusion, we demonstrated that, despite being infrequent, adrenal tumors may increase in size, develop overt or subclinical hormone secretion or feature malignant transformation. Therefore, radiological and hormonal follow-up should be recommended to the patients. More investigations are needed for the establishment of long-term follow-up protocols.

RECURRENT SARCOIDOSIS WITH PSOAS MUSCLE GRANULOMA AND HYPERCALCAEMIA IN A PATIENT ON CHRONIC HAEMODIALYSIS

A 59-year-old man who had been on HD for 24 years was admitted to our hospital for progressive enlargement of groin masses bilaterally, with hypercalcaemia. He was first diagnosed with sarcoidosis at the age of 34 years and treated at that time with steroid eye drops because sarcoidosis was limited to bilateral hilar lymphadenopathy, enlargement of the parotid glands and uveitis. At the age of 35 years, HD was initiated for end-stage renal disease of unknown aetiology, though sarcoidosis-related renal involvement remained uncertain. On admission, physical examination showed large masses in the groin. Laboratory examination revealed serum calcium of 12.6 mg/dL, phosphate 4.3 mg/dL, alkaline phosphatase 197 IU/L, intact parathyroid hormone 3.1 pg/mL (normal, 10–66), 1,25(OH)2D3 40 pg/mL (normal, 20–60) and angiotensin-converting enzyme (ACE) 19 U/L (normal, <10). Computed tomography identified the bilateral groin masses to be enlargement of the psoas muscles (Fig. 1). Percutaneous biopsy of the psoas muscle showed non-caseating granuloma with multi-nucleated giant cells surrounded by epithelioid cells (Fig. 2). The final diagnosis was recurrent sarcoidosis. After initiation of prednisolone therapy at 40 mg/day, serum Ca level returned to normal range. Serum levels of 1,25(OH)2D3 and ACE decreased to 2.9 pg/mL and 12.9 U/L, respectively. At the last check-up 2 years after the start of prednisolone, he remains on HD without any complications associated with sarcoidosis, and the groin masses are no longer palpable.

Arachnoid cysts of the fourth ventricle - short illustrated review

Arachnoid cysts are frequent anomalies of the CNS. They are benign lesions within the arachnoid membrane and have been reported to occur in virtually all locations where arachnoid is present. An intraventricular location, however, is rare and occurrence within the fourth ventricle is particularly uncommon. The first report was published in 1979 on a paediatric patient. Since then, only a few further examples have been reported. Most of these patients presented with hydrocephalus. Shunting procedures were performed, but did not afford long-term improvement of symptoms. Definitive treatment consisted of open resection of the cyst-wall. We report a 34-year-old woman with a large arachnoid cyst within the fourth ventricle who suffered from progressive cerebellar dysfunction. MRI showed massive enlargement of the fourth ventricle by an intraventricular arachnoid cyst which contained multiple septations. Complete excision of the cyst was necessary to reinstitute free CSF-flow and was performed via a median suboccipital approach. This report gives an overview of examples published to date and discusses pathogenesis and clinical features of arachnoid cysts in this location as well as operative strategies including neuroendoscopic techniques.

Natural course of benign adrenal incidentalomas in subjects with extra-adrenal malignancy

Patients with extra-adrenal malignancies are diagnosed increasingly with benign adrenal tumors, as well as non-oncology subjects. We aimed to demonstrate the natural course of adrenal adenomas in terms of mass size and hormonal status in oncology and non-oncology subjects. We also compared the characteristics and behavior of adrenal adenomas with adrenal malignancies. In our registry of adrenal tumors (n = 335), we prospectively evaluated 29 oncology subjects (EAM+) and age, gender, and follow-up duration matched 110 non-oncology subjects (EAM-) with adrenal adenomas. Median follow-up was 24 months. We also included 16 subjects with adrenal malignancies (primary; 3 and metastasis; 13). Tumor size was followed-up with CT or MRI at 6th and 12th months and annually in subsequent visits. Hormonal assessment was repeated at the 6th month after the initial visit and annually in subsequent visits. Initial tumor size, mean increase in tumor size, and number of subjects who showed mass enlargement or developed subclinical Cushing Syndrome were comparable (P > 0.05) between EAM+ and EAM- groups. Subjects with malignant adrenal tumors were older (P = 0.06), had larger tumors at presentation (P < 0.001), and showed mass enlargement during a shorter follow-up duration (P < 0.001). Oncology subjects with adrenal adenomas featured similar baseline and follow-up parameters in terms of mass enlargement and development of subclinical Cushing Syndrome when compared with non-oncology subjects. Malignant adrenal tumors were characterized with large, rapidly growing tumors of older ages. Conservative approach can be suggested to oncology subjects for adrenal adenomas unless clinical and radiological suspicion of adrenal malignancy is present.

Myopathic changes in bilateral hypertrophy of the first dorsal interosseus muscle of the hand

A 43-year-old healthy man presented with bilateral hypertrophy of the first dorsal interosseus muscles of both hands. Neurophysiologic and laboratory examinations revealed no pathologic findings. Doubled muscle width was found by ultrasound. Myopathic changes were present in muscle biopsy with varying fiber sizes but without inflammatory features. The clinical impression of massive bilateral symmetric enlargement of the first dorsal interosseus muscles was characterized by subtle, non-specific muscular pathology.

Primary Retroperitoneal Mucinous Tumors

Primary retroperitoneal mucinous tumors (PRMTs) are uncommon neoplasms occurring almost exclusively in women. PRMTs are divided into mucinous cystadenoma (MC), mucinous borderline tumors or tumors of low malignant potential (MLMP), and mucinous carcinomas (MCas). In this retrospective study, we present the clinicopathologic features of 18 such cases, the largest series to date. All patients were women, ranging in age from 20 to 63 years (mean 38.6 y). All except 2 patients presented with an enlarged mass during a routine examination or by self-palpation. All tumors were located exclusively in the retroperitoneum, with histologic or clinical confirmation of the lack of ovarian involvement. The tumors ranged from 7 to 26 cm (mean 13.2 cm). The gross appearance was variable: unilocular cyst with a thin wall (4 cases), predominantly cystic with papillary areas or nodule(s) (8 cases), multiloculated cyst with or without nodules (1 case each), and predominantly solid with cystic areas (4 cases). Histologically, there were 2 cases of MC, 7 of MLMP (7 cases; 3 of them with intraepithelial carcinoma and 1 with microinvasion), and 9 of MCas (9 cases, 5 of them associated with MLMP and 1 associated with MC). Three of the MCas had areas of anaplastic or sarcomatoid carcinoma whereas 1 had an associated sarcoma. Immunohistochemical studies were performed in 6 cases. Cytokeratin 7 was diffusely positive in all cases studied, whereas cytokeratin 20 and cytokeratin 17 were focally positive in 4 and 2 cases, respectively. All patients underwent surgical resection of the entire tumor. Two patients with MCa and sarcoma or sarcomatoid carcinoma received chemotherapy. Follow-up was available in 16 cases, ranging from 1 to 148 months (mean 40 mo, median 22 mo). Two patients died of disease at 5 and 9 months; both had MCa with anaplastic carcinoma or sarcoma. Three patients with MCa were alive with disease at 14, 26, and 58 months. The remaining patients were alive with no evidence of disease. In this study, MLMP and MCa were more common than MC. PRMTs seem to be nonaggressive neoplasms, except in cases containing anaplastic carcinoma or sarcoma.

Xanthogranulomatous Inflammation of the Uterus

On ultrasound assessment, a non-specific 17 11 mm mass was seen in the uterine fundus. The patient’s bleeding pattern improved after one cycle of combined oral contraceptives, but recurred 11 months later. Repeat ultrasound showed an enlarged homogeneous mass in the uterine wall measuring 36 33 mm (Figure 1). The patient was hemodynamically stable with mild leukocytosis (10.9 109/L with 90.6% neutrophils).