1/15. The diagnostic dilemma of incidentalomas. Working through uncertainty.The clinical evaluation of incidentally found nodules in the adrenal, thyroid, and pituitary glands is a challenge for physicians, regardless of their level of expertise. Choosing the most direct and cost-effective diagnostic approach and deciding when to treat or not to treat are common dilemmas in clinical practice. This article outlines one diagnostic approach using medical decision-making techniques such as heuristic thinking, critical appraisal of the literature, treatment threshold probability assessment, Bayes' theorem, and discriminant properties of diagnostic tests. These skills are usually discussed in postgraduate training curricula. Nevertheless, they often seem foreign to many clinicians. Evidence suggests that training in these techniques can improve clinical decision making. Use of the skills outlined herein provides a framework to work through the diagnostic uncertainty common in the evaluation of incidentalomas. This approach does not provide perfect answers, as noted in examplar 3 in which two experts argued about the actual pretest probability and treatment thresholds for pituitary incidentalomas. Even if there were no such disagreement, each patient presents unique issues, and there will always be some uncertainty. Nevertheless, this approach provides a starting point from which critical decisions can be made for individual patients.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
2/15. Precocious puberty associated with growth hormone deficiency in a patient with craniopharyngioma: report of one case.Isosexual precocious puberty in girls is not uncommon, but its association with craniopharyngioma and growth hormone deficiency is rarely reported. We present a patient with this combination. An 8-year-old girl developed breasts and then had menarche at 7 9/12 years old. growth hormone deficiency was suspected due to inappropriate height and growth velocity in association with idiopathic precocity and a poor predicted adult height of 138.8 cm. growth hormone deficiency was confirmed by clonidine and insulin stimulation tests. Intracranial lesion was suspected due to precocity associated with GH deficiency. MRI of the sella's region revealed a 1 cm mass in the hypothalamus. After surgical resection, pathology of the tumor disclosed a craniopharyngioma which has rarely been reported to cause precocious puberty. The precocious puberty regressed after surgery. growth hormone deficiency persisted and GH therapy was given to improve growth. The growth rate of patients with both growth hormone deficiency and precocious puberty may be maintained within the normal prepubertal range by the effect of sex steroid. We suggest that in patients with central type precocity in association with an inappropriate growth status, physicians should investigate the underlying intracranial lesion, and the possibility of growth hormone deficiency.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
3/15. Rapid enlargement of a residual craniopharyngioma during short-term growth hormone replacement.CASE REPORT: A patient with residual craniopharyngioma experienced a rapid tumor relapse during growth hormone therapy. OBJECTIVE: We present this case and remind physicians that it is necessary to reevaluate the safety of growth hormone therapy in patients with residual craniopharyngioma.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
4/15. Empty sella following spontaneous resolution of a pituitary macroadenoma.BACKGROUND/AIM: Empty sella is a radiological finding characterized by the presence of arachnoid herniation into the sella, resulting in compression of the pituitary against the sella wall. The objective of this case presentation is to discuss secondary empty sella in a patient with spontaneous resolution of a pituitary macroadenoma. methods: A case of empty sella syndrome is presented. Static and dynamic testing was performed. Etiology, pituitary function, and imaging are discussed. RESULTS: A 69-year-old African-American woman was referred by her primary care physician for evaluation and treatment of 'hypothyroidisim'. Thyroid tests were performed because of muscle and joint tenderness and revealed low free thyroxine and normal thyroid-stimulating hormone levels. The diagnosis of secondary hypothyroidism was made, and magnetic resonance imaging (MRI) of the pituitary revealed an empty sella turcica. In retrospect, the patient had presented 11 years earlier with tinnitus, and an MRI of her auditory canals demonstrated an 'incidental' 1.5-cm pituitary tumor. No endocrine evaluation was done at that time, and neurosurgical follow-up of the pituitary tumor by serial MRIs demonstrated the genesis into empty sella. CONCLUSIONS: In our patient the natural history of her pituitary tumor was that it involuted and resulted in an empty sella. Although oftentimes speculated as a cause of empty sella, tumor involution has rarely been shown to be causative. In this instance, empty sella was associated with hypopituitarism. This case illustrates the importance of endocrine evaluation of patients with this radiological finding.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
5/15. Mood disorder and secondary adrenal insufficiency after pituitary tumor operation and radiotherapy.Psychological manifestations can be noted in patients with pituitary hypofunction or injuries after surgery and radiotherapy. We report on a 38-year-old female with acute adrenal insufficiency who presented with an affective disorder. The patient was brought to our emergency department because of general weakness and fever. Low plasma glucose concentration and low blood pressure were noted at arrival. She expressed mood change and persecutive thoughts. The brain MRI demonstrated no obvious brain damage except empty sella. The cortisol level was undetectable. Intravenous hydrocortisone was administered after the diagnosis of acute adrenal insufficiency. The patient improved physically after treatment, but social withdrawal and inappropriate affect persisted. We present the case and review the relevant literature to impress on physicians that the cognitive disorders in hypopituitarism can result from not only hormone insufficiency, but also the influences of pituitary tumor surgery and radiotherapy on neuropsychological functions.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
6/15. Dependency and analgesia related to treatment with subcutaneous octreotide in patients with growth hormone-secreting tumors.OBJECTIVE: To describe three patients diagnosed with somatotropinomas in whom the analgesic effect of octreotide was observed, along with dependency to the drug. methods: These patients had pituitary macroadenomas treated with transphenoidal surgery and pituitary radiotherapy, and received high daily doses (>900 microg/day) of subcutaneous octreotide because of persistent high levels of growth hormone and insulin-like growth factor i (IGF-I). RESULTS: headache occurred prior to drug administration in all three cases, with relief soon after. We also observed tolerance to octreotide's analgesic and anti-secretory actions (one patient), craving for the drug (two patients), withdrawal syndrome (one patient), and drug abuse (one patient). CONCLUSION: Dependency syndrome may occur when high doses of octreotide are used, sometimes leading to drug abuse. Tolerance to the growth hormone anti-secretory effect of the drug may encourage physicians to increase doses to levels at which drug dependency has been observed. Sustained release somatostatin analogs may represent a solution to this problem.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
7/15. acromegaly with moderate hyperprolactinemia caused by an intrasellar macroadenoma.BACKGROUND: A 31-year-old woman presented 12 months after discontinuing the oral contraceptive pill with progressive headache to her primary-care physician. She had previously presented with irregular menses to her obstetrician-gynecologist 4 months after discontinuing the oral contraceptive pill. Her serum prolactin levels were 153 microg/l and a pituitary MRI revealed a 13 mm intrasellar mass consistent with an adenoma. The patient was given 0.5 mg cabergoline twice weekly, and after 6 weeks her prolactin levels fell to 31 microg/l. After 6 months, however, she complained of persistent frontal headache and a repeat MRI revealed that the adenoma had increased in size to 16 mm. The patient was referred to an endocrinologist for further evaluation. INVESTIGATIONS: serum insulin-like growth factor 1 levels and growth hormone levels measured 2 h after ingestion of 75 g of oral glucose. diagnosis: acromegaly and hyperprolactinemia caused by a mixed-cell adenoma, secreting growth hormone and prolactin. MANAGEMENT: Trans-sphenoidal surgery followed by medical therapy with 20 mg intramuscular octreotide-LAR monthly.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
8/15. acromegaly diagnosed in a young woman presenting with headache and arthritis.BACKGROUND: A 38-year-old woman presented with severe headaches to her primary-care physician. The patient had been diagnosed with rheumatoid arthritis and had begun having headache 4 years previously. An MRI scan revealed an 11-12 mm pituitary tumor. Her physical examination was unremarkable for the classic acral or facial changes characteristic of acromegaly, and she was referred for neuroendocrine consultation for a presumed nonfunctioning adenoma. INVESTIGATIONS: MRI of the pituitary, and laboratory investigations that included measurement of serum insulin-like growth factor 1 (IGF1) and prolactin levels. diagnosis: In view of the elevated level of IGF1 and presence of a pituitary adenoma, the patient was diagnosed with acromegaly caused by a pituitary adenoma that secretes growth hormone. MANAGEMENT: The patient underwent trans-sphenoidal surgery, which resulted in resolution of joint pain and headache, eradication of the tumor mass, normal IGF1 levels, and appropriate suppression of growth hormone (confirmed by oral glucose tolerance test postoperatively).- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
9/15. Cushing's disease. A cause of delayed growth and development.An adolescent male with a typical cushingoid appearance presented to his physician with failure of linear growth and sexual development. Although his neuroradiologic workup was negative, his endocrinologic assessment pointed to the pituitary gland as the diseased organ. Selective transsphenoidal adenomectomy has thus far resulted in normalization of cortisol and growth hormone levels and furthered linear and sexual growth.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
10/15. Ileal carcinoid tumor complicated by retroperitoneal fibrosis and a prolactinoma.A patient with mid-gut carcinoid tumor and the unusual complication of retroperitoneal fibrosis was also found to have a prolactinoma. This case brings the number of reported mid-gut carcinoid tumors complicated by a second endocrine neoplasm to five. Three of the second tumors were parathyroid in origin, and the fourth was an insulinoma. In view of the rarity of second tumors and in the absence of documented familial occurrence, it is inappropriate to exhaustively study each person with mid-gut carcinoid tumor, or their families, for a second endocrine neoplasm; however, physicians caring for patients with mid-gut carcinoid should be aware that second tumors are possible. retroperitoneal fibrosis is also a rare complication of carcinoid, but can be associated with renal failure that can be prevented by surgical intervention. Thus, physicians caring for patients with the carcinoid syndrome should also be aware of this complication.- - - - - - - - - - ranking = 2keywords = physician (Clic here for more details about this article) |
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