Diagnostic Value of Thyrotropin Releasing Hormone Test in 129 Patients with Suspected Tumoral Hyperprolactinemia

In 129 hyperprolactinemic (PRL 100ng/mL) and 100 normoprolactinemic patients (PRL 0–25 ng/mL), max. PRL (the difference between maximal prolactin (PRL) after thyrotropin releasing hormone (TRH) injection and basal value) was compared with basal PRL and computed tomography (CT) of the sellar region. In 122 hyperprolactinemic patients max. PRL was <100%, while tumor was found in 106 of them. In the remainder seven hyperprolactinemic patients max. PRL was 100% and CT showed no tumor. A significant difference in max. PRL between hyperprolactinemic patients without and those with verified adenoma was found and showed a significant negative correlation with basal PRL. Between 122 hyperprolactinemic patients with max. PRL <100%, mean basal PRL and duration of clinical symptoms were significantly lower in 16 patients with normal CT compared to 106 patients with tumor. All normoprolactinemic patients showed max. PRL 100% and no tumor on CT. PRL stimulation disturbance precedes tumor visualization and represents a decisive diagnostic parameter in hyperprolactinemic patients with no tumor signs

Diagnostic Value of Thyrotropin Releasing Hormone Test in 129 Patients with Suspected Tumoral Hyperprolactinemia

In 129 hyperprolactinemic (PRL 100ng/mL) and 100 normoprolactinemic patients (PRL 0–25 ng/mL), max. PRL (the difference between maximal prolactin (PRL) after thyrotropin releasing hormone (TRH) injection and basal value) was compared with basal PRL and computed tomography (CT) of the sellar region. In 122 hyperprolactinemic patients max. PRL was <100%, while tumor was found in 106 of them. In the remainder seven hyperprolactinemic patients max. PRL was 100% and CT showed no tumor. A significant difference in max. PRL between hyperprolactinemic patients without and those with verified adenoma was found and showed a significant negative correlation with basal PRL. Between 122 hyperprolactinemic patients with max. PRL <100%, mean basal PRL and duration of clinical symptoms were significantly lower in 16 patients with normal CT compared to 106 patients with tumor. All normoprolactinemic patients showed max. PRL 100% and no tumor on CT. PRL stimulation disturbance precedes tumor visualization and represents a decisive diagnostic parameter in hyperprolactinemic patients with no tumor signs

Prikaz bolesnika s ektopičnom sekrecijom ACTH i znacima Cushingova sindroma

Ectopic ACTH secretion was the first paraneoplastic endocrine syndrome described in the literature. The most common tumors associated with ectopic ACTH production are small-cell lung cancer and atypical carcinoids. High cortisol levels have also been described in patients with adenocarcinoma and large-cell carcinoma of the lung, other carcinoid tumors, thymoma, neural crest tumors, medullary carcinoma of the thyroid, and bronchial adenomas. Patients rarely live long enough for frank Cushing’s syndrome to develop. A 30-year-old male is described, who was admitted to endocrinology ward for clinical features of Cushing’s syndrome. Outpatient examination showed high levels of plasma cortisol on several occasions, without suppression of night dexamethasone test. Laboratory tests performed during his hospital stay showed an increased level of serum cortisol without suppression of night dexamethasone test, increased level of ACTH, and decreased testosterone level, increased 17 OHCS in urine. CT scan of adrenal and pituitary glands, and chest x-ray were normal. The patient was discharged with an appointment made for surgical exploration of the pituitary gland. Transnasal selective partial hypophysectomy was performed, however, excisional biopsy showed no microadenoma while the symptoms persisted postoperatively. The patient received TCT hypophysis in a maximal dose, and elevated ACTH level was found to persist after 37 days of treatment. One year later, the patient was readmitted for persistent cushinoid appearance. After complete investigations for ectopic ACTH secreting tumor, chest x-ray showed an infraclavicular, circular, sharply demarcated inhomogeneous lesion of the left lung, 2x3 cm in size. Three months later, lobectomy was performed and pathohistologic examination pointed to a carcinoid (argentaffinoma). During hospitalization, the symptoms of Cushing’s syndrome regressed. In conclusion, CRH test which usually distinguishes between hyperadrenocorticism associated with ectopic ACTH secretion and hypersecreting adrenal tumors is sometimes misleading because of the large overlap in normal and abnormal responses. In this case, chest or abdominal CT scan or MRI should be performed, because these are the most common sites of ectopic ACTH secreting tumors.Prvi paraneoplastični endokrini sindrom opisan u literaturi bila je ektopična sekrecija ACTH. Najčešći tumori udruženi s ektopičnom sekrecijom ACTH su mikrocelularni karcinom pluća i atipični karcinoidi. Visoke razine kortizola opisane su i u bolesnika s adenokarcinomom i karcinomom velikih stanica pluća, karcinoidima, timomom, tumorima neuralnog grebena, medularnim karcinomom štitnjače i bronhalnim adenomom. Bolesnici rijetko žive dovoljno dugo da razviju manifestan Cushingov sindrom. Opisan je slučaj 30-godišnjeg muškarca koji je primljen na odjel s kliničkim znacima Cushingova sindroma. Ambulantno ispitivanje pokazalo je u više navrata visoke razine kortizola koji se nije snižavao u kratkom deksametazonskom testu. Tijekom boravka u bolnici je uz već navedeno uočena visoka razina ACTH, sniženi testosteron i povišen 17 OHCS u mokraći. CT nadbubrežnih žlijezda i Rtg snimka prsnog koša bili su uredni. Bolesnik je otpušten uz dogovor za kiruršku eksploraciju hipofize, te je učinjena transnazalna djelomična hipofizektomija. Ekscizijska biopsija nije pokazala znakove tumora, a klinički znaci Cushingova sindroma ustrajali su nakon operacije. Bolesnik je podvrgnut radioterapiji hipofize u maksimalnoj dozi, međutim, vrijednosti ACTH su još uvijek bile povišene. Nakon godinu dana bolesnik je ponovno primljen na odjel zbog ustrajnih znakova Cushingova sindroma. Nakon potpune obrade u smislu traženja ektopične sekrecije ACTH, snimka prsnoga koša pokazala je infraklavikularno oštro ograničenu, nehomogenu sjenu u plućima, veličine 2x3 cm. Tri mjeseca kasnije učinjena je lobektomija, a patohistološki nalaz je ukazao na karcinoid (argentafinom). Tijekom hospitalizacije simptomi Cushingova sindroma su se povukli. U zaključku, CRH test koji obično razlikuje hiperadrenokorticizam udružen s ektopičnom sekrecijom ACTH i hipersekreciju iz adrenalnih tumora, ponekad je neprikladan zbog značajnog preklapanja u normalnom i abnormalnom odgovoru. U tom slučaju, nužan je detaljan pregled prsnoga koša i trbuha, budući da su to najčešća sijela tumora koji ektopično izlučuju ACTH

Chiasma Syndrome in Acromegalic Patients – Correlation of Neuroradiologic and Neuroophthalmologic Findings

The study evaluated neuroophthalmologic and computerized tomography (CT) findings in 100 patients with somatotrophic adenoma and clinical picture of acromegaly, who underwent transsphenoidal adenomectomy. Prior to the surgery, visual field was normal in 77 patients. The diameter of adenoma in these patients ranged from 8 to 30 mm on CT, and the average value was 13.5 mm. Various kinds of visual field disturbances were present in 23 patients. The diameter of their adenomas ranged between 18 to 35 mm, with the average of 24.7 mm. Compared to visual field defects, CT findings of suprasellar adenoma extension were better correlated with chiasma syndrome (p < 0.001). All patients with suprasellar mass greater than 10 mm had chiasma syndrome. Degenerative adenoma changes (hemorrhagic necrosis), which precipitate abrupt increase in size of the tumor, were more frequently seen in patients with chiasma syndrome. The incidence of chiasma syndrome directly correlates with the degree of suprasellar extension of the tumor