Left Adrenal Gland Research Articles

Diagnosis and Management of Adrenocortical Carcinoma with co-secretion of Cortisol and Aldosterone

Adrenocortical carcinoma (ACC) accounts for 0.05-2% of all malignant tumors. Forty-five percent of ACCs with secretory function have excess glucocorticoids alone and only less than 1% secrete aldosterone. This is a case of a 44-year-old Filipino female with hypertension and a 12-year-history of an incidentaloma of the left adrenal gland, with recent-onset complaints of increasing abdominal girth, purple striae, amenorrhea, moon facies and a dorsocervical fat pad. Laboratory findings revealed low potassium levels, non-suppressed cortisol on dexamethasone test suggesting Cushing’s syndrome and elevated aldosterone-renin ratio and plasma aldosterone concentration pointing to primary hyperaldosteronism. A computed tomography scan revealed a left-sided adrenal mass measuring approximately 23 cm in largest diameter suggestive of carcinoma without metastasis or lymph node involvement. Complete resection via open adrenalectomy was performed and histopathologic assessment revealed Adrenocortical Carcinoma with Weiss score of 4. The Ki-67 proliferative index was found to be >20%. Radiotherapy was done as an adjuvant treatment. Although rare, co-secretion of cortisol and aldosterone can occur in functional tumors of adrenocortical carcinoma. Malignancy should always be considered in patients who present with a history of a unilateral adrenal mass and/ or in those with signs and symptoms of adrenal hormone excess. Thus, a proper assessment derived from a thorough medical history, physical examination and laboratory work-up is warranted in patients with an adrenal mass to ascertain the diagnosis and provide adequate management.

A New Approach to Ultrasound Study of the Left Adrenal Lodge

Ultrasound examination of the left adrenal gland is generally associated with relatively low sensitivity and specificity. It is strongly influenced by the operator’s experience, patient characteristics, and the type of equipment available. In particular, the left adrenal gland remains a structure that is diffcult to investigate, even for experts. Therefore, we aimed to improve the ultrasound explorability of the left adrenal gland and, thus, contributing to enhancing the overall diagnostic sensitivity of the technique, allowing for a more widespread application by the addition, alongside traditional structural landmarks, of vascular landmarks. The vascular landmarks are represented by 1) the abdominal aorta at the level of the emergence of the superior mesenteric artery, 2) the splenic vein, and 3) the vascular pedicle of the left kidney. The adrenal gland is located in the space between the aorta medially, the renal pedicle caudally, and the splenic vein anteriorly. Therefore, with a left paramedian axial section, the abdominal aorta is sought at the level of D12, where the superior mesenteric artery originates. Aligning with the splenic vein, which acts as the roof of the space under examination, the area of interest is explored by tilting the probe superiorly and medially towards the aorta, inferiorly and medially towards the left renal vein, and superiorly and laterally towards the renal border, trying to maintain the view of the splenic vein as the true anterior-lateral margin of the area. In cases where the conditions allow for accurate visualization and measurement of the lesion, ultrasound may be preferred over CT for long-term surveillance, especially in young individuals, due to its lack of radiation exposure, simplicity, and lower cost.

Epidemiological analysis and overall survival of adrenal malignancies in a developing Middle Eastern country over 18 years.

e23067 Background: Adrenal cancer imposes a significant socioeconomic and health burden due to the resulting morbidity and mortality. Accordingly, assessment of the epidemiological characteristics of adrenal malignancies in the Middle East, where the epidemiology of adrenal malignancies is poorly evaluated, is of paramount importance in management tailoring and planning as it enables appropriate risk stratification, especially in limited resource countries. Methods: Extensive and thorough data on adrenal cancer for all individuals, both males and females, of various nationalities residing in Jordan who were diagnosed from 2000-2018 was retrieved from the Jordan Cancer Registry, the formal reporting institution for cancer epidemiology in Jordan with a total of 296 patients being included. Furthermore, comprehensive epidemiological analysis was performed with Kaplan-Meier analysis being performed to assess overall survival rates. Results: 296 patients with a mean age of 18.7 ± 22.6 years old and a male predominance of 55.4% were included in the analysis. The vast majority of the included patients were non-smokers (72.3%). Adrenal malignancy was found to be most commonly located in the left adrenal gland (41.6%), while only 7 patients (2.36%) had bilateral adrenal malignancies. 19.6% of the tumors were arising from the adrenal cortex while 70.9% of the patients had adrenal gland tumors with the origin being unknown at the time of reporting. A concerning 17.20% of the enrolled patients had poorly differentiated tumors, and 8 patients (2.70%) had undifferentiated malignancies. At the time of diagnosis, a staggering 51.0% of the patients had distant and systemic metastasis, while only 11.8% of the patients had localized malignancy. The overall 5-year survival rate was determined to be 66.8%. A statistically significant increase in the crude incidence of adrenal cancer in Jordan over 18 years was evident with a crude incidence estimated effect of 0.014 (p-value = 0.003). Conclusions: Despite that the 5-year survival is 66.8%, there is an alarmingly significant uptrend in the crude incidence of adrenal cancer in Jordan with the overwhelming majority presenting at an advanced stage, and thus the introduction of early interventions and advanced management is mandated to achieve better outcomes.

A case of tuberculosis of adrenal gland presenting as acute adrenal insufficiency following initiation of anti-tubercular therapy

Adrenal tuberculosis is one important cause of acute or chronic adrenal insufficiency in developing countries like India. There are many random cases in literature describing various clinical situations of adrenal tuberculosis presenting with adrenal insufficiency, especially after initiation of anti-tubercular therapy. A 43-year-old male recently diagnosed patient with pulmonary tuberculosis and chronic coronary syndrome was admitted for acute decompensated heart failure with pulmonary edema. He was taking fixed dose combination anti-tubercular therapy. During admission, he had hyponatremia (serum sodium 96 mEq/L) and during treatment, he developed hypotension and shock, which were appropriately treated. Due to ischemic hepatitis, anti-tubercular treatment (ATT) was modified to streptomycin, ethambutol, and ofloxacin regimen to avoid further hepatotoxicity. Hyponatremia and shock recovered. Rifampicin and isoniazid were restarted. He again developed easy fatigability, nausea, vomiting, and hypotension. Suspecting adrenal insufficiency, fasting serum cortisol, and adrenocorticotropic hormone (ACTH) were done, which revealed a low serum fasting cortisol and high ACTH. Computed tomography abdomen showed enlarged left adrenal gland with calcifications. He was started on prednisolone 2 mg/kg/day with full dose fixed dose ATT, following which his symptoms resolved.

#2889 Multiple renal tumors as an atypical clinical manifestation of granulomatosis with polyangiitis

Abstract Background and Aims Granulomatosis with polyangiitis (GPA) is a systemic small- vessel vasculitis associated with antineutrophilic cytoplasmic antibody (ANCA), in which kidney involvement often occurs. In some cases the course of vasculitis with kidney involvement is atypical, what complicates the diagnostic process and makes appropriate treatment difficult. Finding nodular masses in the kidneys always causes an oncological concern, while in the differential diagnosis a systemic vasculitis is rarely taken into account, what may lead to an unnecessary nephrectomy. Method We present a case of granulomatosis with polyangiitis (GPA) who presented with multiple tumors in the kidneys and adrenal gland. Results 29-year-old man experienced a sudden disease onset, at the age of 18 years, when due to peripheral oedema, nephrotic grade proteinuria (13.7 g/24 h), hematuria and presence of renal failure markers (serum creatinine 3.4 mg/dL), he was admitted to hospital. A suggestion of a rapidly progressive glomerulonephritis (RPGN) was put forward and a renal biopsy was performed (in the histopathological examination of the kidney, pauci-immune crescentic necrotizing glomerulonephritis was revealed). A treatment with plasmaphereses, high glucocorticosteroid doses and cyclophosphamide pulses was instituted. Haemodialysis therapy was also applied temporarily. ANCA and anti-glomerular basement membrane (GBM) antibodies were determined to give negative results. As a result of the remission-inducing treatment, an improvement of the renal function was obtained (serum creatinine 1.6-1.9 mg/dL). In spite of the remission-maintaining treatment with mycophenolate mofetil (MMF) and oral prednisone, after 10 years again a dramatic renal function impairment occurred, with a necessity of institution of a long-term haemodialysis therapy. Furthermore, on abdominal ultrasound examination multiple focal lesions were found in both kidneys, which rendered a kidney transplantation procedure in the patient impossible. In order to extend the diagnostic procedures, a magnetic resonance imaging (MRI) of the abdominal cavity without contrast agent administration was carried out (in both kidneys disseminated focal lesions were described: non-homogeneous, with moderately enhanced signal on T2-weighted images in the central part, without signs of water diffusion restriction; in the left kidney, of 23 x 22 mm and 19 x 15 mm dimensions; in the right kidney, of 30 x 32 mm, 26 x 22 mm and 22 x 18 mm dimensions. The picture of the lesions was unspecific and atypical. In the differential diagnosis granulomas could not have been ruled out, while disseminated proliferative lesions were less likely. Besides that, in both kidneys cysts of up to 7 mm diameters were present. In the lateral limb of the left adrenal gland a focal lesion was visible, of 23 x 14 mm dimensions, of a structure identical to that of the foci in both kidneys). On high-resolution computed tomography (HRCT) of the chest at the same time, small ground glass areas were found in the lungs. On positron emission tomography/computed tomography (PET/CT) no changes were visualised, suggesting presence of a metabolically active proliferative process. Tests for ANCA, antinuclear antibodies (ANA), anti- double-stranded DNA (dsDNA) antibodies, anti- GBM antibodies were again performed and gave negative results. He was diagnosed with granulomatosis with polyangiitis without ANCA and treated with corticosteroid and intravenous rituximab (4x 787 mg). Three months later, follow-up showed reduced mass lesions in the kidney and adrenal gland by MRI. Conclusion The case highlights the atypical clinical presentation of vasculitis and the significance of considering this possibility in differential diagnosis when confronting mass lesions present in the kidney.

ACUTE MYOCARDIAL INJURY IN A PATIENT WITH TYPE–1 NEUROFIBROMATOSIS: A CASE OF SUSPECTED PHEOCROMOCYTOMA–ASSOCIATED MYOCARDITIS

Abstract A 54–year–old patient with an history of type–1 neurofibromatosis presented to the emergency department (ED) due to recurrent abdominal pain with diarrhea. Clinical examination didn’t show anything remarkable. She was mildly hypertensive, apyretic. During her staying in the ED, she complained about chest pain and an electrocardiogram (ECG) was performed. ECG showed sinus rhythm, normal heart rate, left ventricular (LV) hypertrophy with marked horizontal ST segment depression in the precordial leads and bimorphic ventricular ectopic beats with prevalent right bundle branch block superior axis morphology, likely from the medio–basal inferior LV. Troponin T (peak 958 ng/L, normal <15 ng/L) and NTproBNP (peak 2357 ng/L, normal <180 ng/L) were elevated, hemoglobin, creatinine and liver function were normal, C–reactive protein peaked at 120 mg/dL. Echocardiogram showed mildly reduced left ventricular ejection fraction (LVEF) with inferior and inferolateral hypokinesia and moderate mitral regurgitation (MR). She was admitted to cardiac intensive care unit with the suspected diagnosis of an acute coronary syndrome and was started on acetylsalicylic acid, metoprolol, furosemide and potassium canrenoate. Amiodarone was added due to frequent ventricular tachycardias. Due to the symptoms and the history of neurofibromatosis a whole body computed tomography (CT) was done. CT showed a 53 mm mass on the left adrenal gland with intense enhancement, suspected for a neoplastic origin (Figure 2). Plasmatic and urinary cathecolamines and metanephrines were increased. Positron–emission tomography (PET)/CT with 68Ga showed left adrenal uptake, compatible with a neuroendocrine tumor. Coronary arteriography showed normal coronary arteries. The patient underwent a cardiac magnetic resonance (CMR) study in the suspect of acute myocarditis. CMR showed normal biventricular function, an inferior basal hypokinesia with focal intramyocardial late gadolinium enhancement (LGE) suspected for a post–inflammatory origin and mild pericardial effusion. After pharmacological preparation a laparoscopic left adrenalectomy was performed, and histology confirmed the diagnosis of a composite pheocromocytoma. Three months after, the patient was asymptomatic, biochemistry showed normalization of both troponin T and endocrinological biomarkers, the echocardiogram showed preserved LVEF without areas of hypokinesia and mild MR. A follow–up CMR at six months from the acute injury has been scheduled.

Mature Cystic Teratoma of Left Adrenal Gland Diagnosed as Myelolipoma

A 32 year old woman who presented with fever, sore throat and abdominal pain that was evolving from last 7 months. A huge mass was palpable in left hypochondrium and left lumbar region. All baselines were within normal range. On ultrasonography, it appeared as well defined diffusely echogenic area in epigastric region likely arising from adrenal/pancreas, while CT scan findings reported a large heterogenous fat containing mass in left supra renal region. On the basis of CT findings, diagnosis of adrenal myelolipoma was made, exploratory laparotomy was done, the adrenal mass was excised and sent for histopathology. The biopsy report has shown that microsection of lesion were composed of benign squamous and pseudostratified epithelium, fat cartilage and glial tissue. Postoperative recovery of patient was uneventful.Keywords: extragonadal teratoma, retroperitoneal teratoma, adrenal myelolipoma, mature cystic teratoma of adrenal gland

Study of Morphological changes of Adrenals in Suicidal cases, An Autopsybased Study at a Tertiary Care Centre at Odisha

Introduction –Uncertainty and instability are the norm of today’s work envioronment. .Now-a-days suicidal cases account for more than a million deaths each year. This work has been undertaken to study the Morphological adaptive changes in adrenal gland in such stressful conditions .Aim & Objectives :To correlate the Morphological adaptive changes in adrenal gland in response to chronic stress since it is a stress responding organ common to both the HPA axis &Sympathoadrenomedullary axis . Material &Methods : The study was carried out from 5th April 2021 to 5th April 2023 at SCB Medical college,Cuttack,Odisha..Right and Left adrenals of hundred suicidal cases and twentyaccidental cases (control) were studied .Results : On Morphological Analysis it was found that Adrenal gland increases both in weight & dimensions in suicidal cases as compared to Accidental cases . A normal pattern of Adrenal gland is informative of receipt of sudden violence i.e accident. Conclusion :The present study concludes and supports the idea that chronic stress as in suicide usually induces adrenal growth which may have implications for forensic people in revealing the cause of unknown deaths.

A case of enormous retroperitoneal liposarcoma with prolapse from the left inguinal canal following hernia repair

BackgroundLiposarcomas represent ~9.8–16% of soft tissue sarcomas, with the extremities and retroperitoneum being the primary sites of occurrence. While liposarcoma in the inguinal region is uncommon, few reported cases originate from the retroperitoneum and protrude into the scrotum through the inguinal canal. Here, we present a case of a retroperitoneal liposarcoma with prolapse from the left inguinal canal into the scrotum following hernia repair with a mesh plug.Case presentationA 55-year-old male patient underwent a CT scan for a suspected recurrent inguinal hernia, which revealed a sizeable adipose-dense tumor by the left kidney extruded through the left inguinal canal surrounding the scrotum. The patient had undergone mesh plug repair for a left inguinal hernia at another hospital one year ago and noticed ipsilateral inguinal swelling after the hernia repair. The patient was referred to our hospital. The tumor resection was completed with combined resection of potentially involved organs: left side colon, left kidney, and left adrenal gland. Also, complete excision of the tumor was accomplished through surgical resection of the posterior wall of the inguinal canal, the mesh plug, and the tumor extending into the scrotum. Given the nearly complete absence of the inguinal canal's posterior wall and the anterior wall’s torn state, sutures were employed to close the external obturator tenosynovitis. Additionally, the inguinal ligament was closed using a tension-free incision technique. Only a mesh was subsequently placed. The resected tumor measured 47 × 30 × 15 cm and 7.5 kg in weight. After surgical resection, a retroperitoneal liposarcoma diagnosis was established. After 2 years and 6 months following the surgical resection, no recurrence has been observed for either liposarcoma or inguinal hernia.ConclusionThe previous inguinal hernia in this case must be a prolapse of retroperitoneal liposarcoma. Thus, it is recommended to conduct a preoperative examination, which should include a CT scan, since the presence of a fatty mass within the hernia may indicate the presence of a retroperitoneal liposarcoma. Even if a preoperative diagnosis cannot be made, a long-term prognosis can be expected if the retroperitoneal liposarcoma can be completely resected at reoperation.

Ultrasonographic measurements of the normal adrenal glands in guinea pigs (Cavia Porcellus).

Hyperadrenocorticism is an uncommon but important endocrine disease in guinea pigs, but due to its subtle clinical signs and the limited information in veterinary literature, it can be underdiagnosed or misdiagnosed. Ultrasound of the adrenal glands in patients with suspected hyperadrenocorticism can help in identifying adrenomegaly. The purpose of this prospective study was to identify ultrasonographic adrenal gland dimensions in presumed healthy guinea pigs using the same standardized method described for dogs and cats. A conscious ultrasound scan was conducted on twenty client-owned, presumed healthy guinea pigs, and their adrenal glands were measured. A possible correlation between adrenal dimensions with age, sex, and body weight was investigated. The mean length, cranial and caudal pole thickness for the left and right adrenal glands were, respectively, 12.64±2.11mm and 11.55±1.52mm; 4.83mm±1.03mm and 4.69±1.34mm; 4.8±1.23mm and 4.04±0.75mm. The thickness of the left caudal pole was significantly higher than the right (P=0.02). A significant positive correlation was found between the length of the left adrenal gland and both age (r=0.46; P=.03) and weight (r=0.59; P=.01). Statistical correlation between the thickness of each cranial and caudal pole, with age, sex, or weight, was not found. The dimensions provided could prove a useful tool in the clinical evaluation of guinea pigs with suspected hyperadrenocorticism.

Gigantic adrenal pseudocyst: A case report

Adrenal cystic lesions are uncommon, non-functional, and asymptomatic. Adrenal Pseudocyst is a fibrous cyst devoid of any epithelial or endothelial lining. They have a female predominance with an incidence ratio of 3:1, usually occurring in the 3rd and 4th decade of life. We describe a case of a massive left-sided adrenal pseudocyst in a 50-year-old obese lady who had been experiencing stomach pain and distension for six months before her presentation. Investigations revealed a considerable cyst arising from the left adrenal gland. Excision via midline laparotomy incision was planned. Findings are discussed, including radiology, cytology, histology, and patient management. Adrenal Pseudocyst is a rare lesion, and imaging may mislead in diagnosis. Consider alternative diagnoses including benign and malignant masses of nearby organs, particularly the adrenal, kidney, and pancreas. After surgical excision, a pathological study is necessary for a conclusive diagnosis.

Adrenal morphology and cortical function in patients with extrapulmonary tuberculosis: response to antituberculosis treatment.

Enlargement of the adrenal glands and variable adrenocortical function have been reported in patients with pulmonary tuberculosis and, in a few studies, in patients with extrapulmonary tuberculosis (EPTB). However, none of the studies have evaluated the course of the adrenal morphology in these patients. Prospective study including 37 patients with EPTB and 37 healthy age- and sex-matched controls. The adrenal function was evaluated by measurement of cortisol levels at baseline and after stimulation with ACTH (Acton Prolongatum) before and 6 months after antituberculosis treatment. The size of both adrenal glands was evaluated using 64-slice computed tomography (CT) scanning before and 6 months after treatment. The findings were compared with those in a group of healthy matched controls. Clinical and biochemical parameters were comparable between groups. The mean baseline serum cortisol level was significantly lower in the EPTB group (397.1 ± 184.9 nmol/L) compared with the control group (696.3 ± 101.8 nmol/L). Compared with controls, patients with EPTB had significantly lower mean cortisol levels at baseline and 1 hour after ACTH, both before (397 ± 184.9 nmol/L and 750.7 ± 176.8 nmol/L, respectively) and after (529.7 ± 100.4 nmol/L and 1017.2 ± 119.7 nmol/L, respectively) antituberculosis treatment. Both the length and thickness of the right and left adrenal glands were greater in patients with EPTB than in controls but became comparable to those in controls after treatment completion. Patients with EPTB have an enlarged adrenal size and low baseline and stimulated serum cortisol levels. After treatment completion, cortisol levels increased significantly, and the adrenal size normalized in these patients.

Spontaneous Contralateral Adrenal Hemorrhage during Periduodenal Abscess Drain Placement

A spontaneous adrenal hemorrhage is a rare complication occurring in the setting of interventional radiology procedures. Here, we present the case of a 73-year-old male who underwent CT-guided drainage of a periduodenal collection. During the procedure, he developed sudden onset left back pain and hypertension, which revealed a left adrenal gland hemorrhage on CT imaging. Potential mechanisms for this complication include a physiological stress response, procedure-associated hypercoagulability, and direct trauma to the adrenal gland. Moreover, an adrenal hemorrhage should be monitored closely as it can lead to severe clinical consequences requiring treatment with IV analgesics and antihypertensives.

Clinical, Biochemical, and Radiological Retrospective Analysis in Patients with Adrenal Incidentaloma – A Secondary Publication

Objective: To evaluate the epidemiological, demographic, clinical features, treatment approaches, and survival of patients followed up for adrenal incidentaloma. Methods: Data from 46 patients who were treated and followed up due to adrenal incidentaloma in the Endocrinology Department of Mersin University Health Research and Application Hospital between 2010 and 2014 were retrospectively analyzed. Results: Of the cases included in the study, 13 were male, 33 were female, and the mean age was 54.09 ± 10.7 years. The most common reason for admission was abdominal pain in 34.78% of the patients, the most commonly diagnosed radiological method was dynamic adrenal CT in 60.87%, and the most common location was the left adrenal gland. The mean lesion diameter was between 26.8 ± 16.5 mm. The frequency of hypertension was 50%, obesity 47.8%, type 2 diabetes 21.7%, osteoporosis 42.8%, and metabolic syndrome 41.3%. According to hormonal evaluation results, non-functional adrenal adenoma (NFAA) was found in 82.61%, subclinical Cushing’s syndrome (SCS) in 15.21%, and aldosteronoma in 2.1%. Myelolipoma, pheochromocytoma, and adrenocortical adenoma were diagnosed in 8 cases undergoing adrenalectomy. One patient died due to liver failure. No hormonal activation or growth in lesion size was detected during the follow-up of the patients. Conclusion: Due to the very different pathological and radiological appearances of adrenal incidentaloma, it is important to evaluate demographic, etiological, clinical, laboratory, and radiological data as a whole in the treatment and follow-up.

P-05 Malignant pheochromocytoma with a negative biomarker hormonal assay: A case report

Abstract Description Malignant pheochromocytoma is a rare, predominantly sporadic, but also familial disease, with a malignancy frequency of about 10%. Clinical Case A 25-year-old male was referred to us by the general surgeon after he had a hypertensive crisis during the appendectomy surgery and then accidentally discovered a left adrenal gland mass by CT scan. Assessment of the patient done by physical examination, the height 168cm, weight 53 kg and the BMI 19 kg/m2 and the vital sign was Bp 200/110, and PR 87 b/min. Investigations: normal renal function test and negative metanephrines, normetanephrine and aldosterone, renin and aldosterone renin ratio also normal serum electrolytes. Imaging abdomen CT shows a mass measuring 4.8 X3.7X6.2 cm in its (AP, TS&CC dimension) in the left adrenal gland (encircle), density 40-50 HU. with central hypo density represented cystic necrosis. Right adrenal is normal limbs following intravenous contrast, the left adrenal mass enhances brightly (130-140HU) with central cystic necrosis … consisting with typical features of pheochromocytoma. The patient referred to expert surgeon and there was some preoperative preparation inform of the patient received phenoxybenzamine (alpha blocker) the receive propranolol to control reflux tachycardia and normalized the blood pressure, resection of left adrenal mass was done and the gross tissue biopsy was sent to histopathologist, and the result revealed a diagnosis of malignant pheochromocytoma, after two weeks from operation CT images post operatively after total resection of left adrenal mass revealed clear bed no residual SOL with surgical clips seen. Conclusion Marker-negative Pheochromocytomas are an uncommon form of the illness. Even more dangerous forms, malignant pheochromocytomas typically release metabolites. However, a doctor must be alert to patients with negative markers who exhibit typical symptoms and must make a diagnosis using a combination of clinical, radiologic, and biochemical testing. When choosing patients for presurgical alpha blockade, this is extremely important. Table 1

P-06 Catecholamine-induced cardiomyopathy: A rare presentiation of pheochromocytoma

Abstract Introduction Pheochromocytoma and paraganglioma (PPGL) are rare neuroendocrine tumors. Clinical manifestations consist of various cardiovascular signs and symptoms related to excessive secretion of catecholamines. Catecholamine-induced cardiomyopathy is a rare but life-threatening complication of PPGL. Excessive discharge of catecholamines results in vasoconstriction, coronary vasospasm and myocardial ischemia. Three types of cardiomyopathies can be observed in patients with PPGL; dilated cardiomyopathy, Takotsuba cardiomyopathy and hypertrophic cardiomyopathy. Clinical Case Herein, we present a case with PPGL complicated with heart failure probably due to excessive secretion of catecholamines. A 19 years-old man was admitted to emergency department with dyspnea and hypotension. He exhibited severe signs of heart failure with very high liver function tests; ALT: 3647 U/L (8-65) and AST: 4542U/L (7-40), probably due to hepatic congestion. Echocardiogram performed in ICU reported %10 left venticular ejection fraction with diffuse akinesia. Remarkable improvement of liver function was recorded following the introduction of heart failure medicines. A computed tomography scan that was performed for abdominal pain and distension revealed a six cm tumour at the left adrenal gland compatible with pheochromocytoma. Laboratory analyses were; 24-hour urine metanephrines: 1938mcg (44-261), normetanephrines: 17934mcg (103-390). Following necessary preoperative preparations, laparoscopic left adrenalectomy was performed and a 70 mm adrenal tumor, histopathologically compatible with pheochromocytoma, was excised. His postoperative laboratory findings were; 24-hour urine metanephrines: 248 mcg (44-261), normetanephrines: 4368 mcg (103-390), chromogranin A: 554.9 ng/ml (0-100), 3-methoxytyramine: 0.34 nmol/l (0-0.17). A 68-Ga-DOTA-Peptide PET/CT following 12 weeks of surgery demonstrated hypermetabolic lesions at left suprarenal area. A second open surgery was performed and lymph node metastases were detected (Figure 1). His cardiac functions ameliorated significantly following the removal of tumors. Genetic analysis for PPGL syndromes were negative for KIF1B, SDHB, NTRK1, TMEME127, VHL, RET, SDHD genes. Work-up is still pending for the mutations of SDHA, SDHC and SDHAF2 genes. Conclusion Cathecolamine-induced cardiomyopathy is a rare entity associated with PPGL. Urgent recognition of related clinical signs and symptoms and detection of PPGL is lifesaving. It should be kept in mind in patients presenting with symptoms of heart failure, hypotension and multisystem crisis in the absence of coronary or valvular heart disease.Figure 1.Pheochromocytoma with lymph node metastasis. (H&E x100)

Cutaneous Metastases as an Initial Presentation of Neo Infiltrative Process in the Lungs: Case Report and Literature Review

Cutaneous metastases are a rare clinical entity with a representation of about 0.8% as a secondary MS deposit originating from another tissue/organ. Most often, skin metastases are associated with a high degree of malignancy and a poor prognosis. Our case report is a 72-year-old male patient who was referred to CT because of a large soft-tissue cutaneous lesion of the upper right hemithorax, somewhere below the right shoulder joint. At the radio diagnostics department, an MDCT native series and series after i.v. contrast was performed, which allowed us to detect a neo infiltrative process of the lung and secondary deposits in the lung itself, liver, left adrenal gland and along the seventh rib on the left. It was recommended to perform bronchoscopy and biopsy of the lung tissue, for the purpose of further differentiation and further treatment. A pathohistological analysis of the skin change itself was carried out, with an answer for a finding that corresponds to a deposit of a malignant neoplasm with spinous differentiation.

Morte súbita causada por embolismo tumoral em um cão

ABSTRACT: Tumor embolization is a well-described cause of unexpected death in human oncologic patients; however, it is poorly explored in veterinary medicine. We report a case of pulmonary tumor embolization in a dog with sudden death. During necropsy, a neoplastic mass was observed replacing the left adrenal gland and forming an intravascular thrombus within the central adrenal vein. A large embolus occluded the left pulmonary artery. The adrenal mass was histologically confirmed as a pheochromocytoma, and the embolus was constituted of neoplastic cells. Multiple smaller neoplastic emboli were observed within the pulmonary artery branches. Tumor embolization should be considered as a possible cause of sudden death in dogs, particularly in oncologic patients.

Local management of unresectable lung atypical carcinoid tumor: a case report and review of literature

Neuroendocrine tumors comprise a rare but increasing heterogeneous group of malignancies arising from neuroendocrine cells, most commonly from the lung and gastrointestinal tract. Due to the vast histopathological differentiation of each subtype and the scarce clinical data published, choosing the most effective therapy can be challenging. Radiotherapy can play a significant role in the treatment of locally advanced metastatic tumors, however there is a lack of randomized clinical trials in this setting. This article reviews the current knowledge on the classification and treatment of unresectable lung atypical carcinoids. We present a clinical case of a ULAC treated with systemic therapy and RT in different settings of the disease. The subject is a 48 years old male, diagnosed with a well differentiated pulmonary NET, classified as cT4N3M1b (supraclavicular and mediastinal adenopathies and an adrenal metastatic lesion) with disease progression after systemic treatment, and with superior vena cava compression. The primary tumor and involved nodal areas were treated to 54Gy/30 fractions using VMAT. SBRT was given to the metastatic left adrenal gland. Five months after RT, CT showed a volumetric reduction of <25% of the thoracic disease and adrenal gland’s lesion stability. The disease remained stable for the next year and a half, when local and distant progression occurred, starting systemic treatment. A year and a half later, the patient presented with brain metastasis and underwent radiosurgery. At last follow-up, 5 years after diagnosis, the patient maintains treatment with capecitabine and temozolomide and is clinically stable. Definitive RT should be considered in the management of ULAC to improve local control.

Laparoscopic Posterior Radical Antegrade Modular Pancreatosplenectomy for Distal Pancreatic Carcinoma.

Distal pancreatic carcinoma is a highly malignant tumor with strong invasiveness, often growing to the edge of the pancreas and penetrating the pancreatic capsule to infiltrate surrounding tissues. In conventional distal pancreatosplenectomy (DPS), tumor cells are prone to spread along the direction of blood and lymphatic reflux due to surgical compression. Additionally, inflammation makes it challenging to achieve R0 resection, leading to a lower patient survival rate. To address these limitations, radical antegrade modular pancreatosplenectomy (RAMPS) was developed, emphasizing deeper excision, including the left anterior renal fascia, the left anterior renal adipose sac, and even the left adrenal gland, to improve the R0 resection rate. With the advancement of minimally invasive surgical techniques, laparoscopic RAMPS (L-RAMPS) is being considered technically safe and feasible in oncology. However, due to technical difficulties and a lack of supporting evidence for clinical application, only a few institutions are currently conducting L-RAMPS. In this context, this article presents detailed techniques for laparoscopic posterior radical antegrade modular pancreatosplenectomy (L-pRAMPS), offering promise for future clinical applications.