Severe paraneoplastic hypoglycemia in a patient with a gastrointestinal stromal tumor with an exon 9 mutation: a case report

BACKGROUND: Non-islet cell tumor induced hypoglycemia (NICTH) is a very rare phenomenon, but even more so in gastrointestinal stromal tumors. It tends to present in large or metastatic tumors, and can appear at any time in the progression of the disease. We present herein a case of NICTH in a GIST tumor and report an exon 9 mutation associated to it. CASE PRESENTATION: A thirty nine year-old man with a recurrent, metastatic gastrointestinal stromal tumor presented to the hospital with nausea, dizziness, loss of consciousness, and profound hypoglycemia (20 mg/dL). There was no evidence of factitious hypoglycemia. He was stabilized with a continuous glucose infusion and following selective vascular embolization, the patient underwent debulking of a multicentric 40 cm × 25 cm × 10 cm gastrointestinal stromal tumor. After resection, the patient became euglycemic and returned to his normal activities. Tumor analysis confirmed excessive production of insulin-like growth factor II m-RNA and the precursor protein, "big" insulin-like growth factor II. Mutational analysis also identified a rare, 6 bp tandem repeat insert (gcctat) at position 1530 in exon 9 of KIT. CONCLUSION: Optimal management of gastrointestinal stromal tumor-induced hypoglycemia requires a multidisciplinary approach, and surgical debulking is the treatment of choice to obtain immediate symptom relief. Imatinib or combinations of glucocorticoids and growth hormone are alternative palliative strategies for symptomatic hypoglycemia. In addition, mutations in exon 9 of the tyrosine kinase receptor KIT occur in 11–20% of GIST and are often associated with poor patient outcomes. The association of this KIT mutation with non-islet cell tumor induced hypoglycemia has yet to be established

Unilateral nonhaemorrhagic adrenal infarction as a cause of abdominal pain during pregnancy

International audienceAdrenal infarction is usually associated with bilateral adrenal hemorrhage in the setting of antiphospholipid syndrome or hemodynamic variation. Few cases of unilateral nonhemorrhagic adrenal infarction (NHAI) have been described in the literature. Here, we report a case occurring during pregnancy. A 30-year-old woman presented at 32 weeks of gestation with sudden-onset right abdominal pain and contractions. Unilateral adrenal infarction was diagnosed following computed tomography (CT). It showed an enlarged right adrenal, without hyperenhancement. Because of persisting contractions, despite medical care, she delivered a healthy, albeit premature, girl. Abdominal pain decreased right after delivery. Three month later, CT imaging showed atrophy of the right adrenal and a normal left adrenal. The patient's adrenal hormonal function was normal. Accurate diagnosis of NHAI remains difficult as its clinical presentation is not specific. It can only be performed with adrenal imaging. Magnetic resonance imaging shows diffuse enlargement of one or both adrenals and an edema on T2-weighted images. Anticoagulation therapy may be discussed. Patients should be evaluated between 3 and 6 months after the event to assess adrenal size and function. In summary, NHAI during pregnancy is probably underdiagnosed and obstetricians should be aware of this or diagnostic difficulty

Added value of buccal cell FISH analysis in the diagnosis and management of Turner syndrome

Abstract STUDY QUESTION Is there an added diagnosis value of buccal cell FISH analysis compared with blood lymphocyte chromosomal investigations in patients with Turner syndrome (TS)? SUMMARY ANSWER Buccal cell FISH analysis, a non-invasive technique, modified the chromosomal results obtained with the blood karyotype in 17 patients (12%) of our cohort. WHAT IS KNOWN ALREADY Few studies have evaluated buccal cell FISH analysis and compared them with blood karyotype in patients with TS. STUDY DESIGN, SIZE, DURATION A prospective, monocentric cohort study was conducted in a rare diseases centre (CMERC) between July 2017 and August 2019. PARTICIPANTS/MATERIALS, SETTING, METHODS In total, 142 adult patients with TS, and at least 5% 45,X cells in a previous blood karyotype, were recruited. All the patients’ files were included in the CEMARA database. This national database has been declared to the French data protection agency (CNIL approval number 1187326). In compliance with French law, consent regarding non-opposition to collect and use the data was obtained from each patient. A FISH analysis on a buccal smear was performed. MAIN RESULTS AND THE ROLE OF CHANCE The percentage of 45,X cells was identical between the two tissues in only 32.4% of cases. The discrepancy was higher than 41% for 12% of the cohort. The percentage of 45,X cells was higher in blood in 53 (37.3%) patients, and higher in buccal cells in 43 (30.3%) of cases. In 17 (12%) cases, the blood karyotype had to be reconsidered in regard to the buccal cell analysis. LIMITATIONS, REASONS FOR CAUTION It would have been interesting to evaluate karyotypes in cells from other tissues such as cells from skin biopsy or from the urinary tract and even from blood vessels or gonads in case of surgery and to compare them with each patient’s phenotype. However, most of the time, these tissues are not available. WIDER IMPLICATIONS OF THE FINDINGS Although blood lymphocyte karyotype remains the gold standard for the diagnosis of TS, buccal cell FISH analysis is an efficient tool to evaluate the global chromosomal constitution in these patients, thus allowing them to have better care and follow-up. For instance, identifying a Y chromosome can prevent the occurrence of a gonadoblastoma, as gonadectomy should be discussed. On the other hand, finding normal XX cells in a patient with a previous diagnosis of homogenous 45,X TS, may be psychologically helpful and relevant for gynaecological care. STUDY FUNDING/COMPETING INTEREST(S) No specific funding was sought for the study. The authors declare no competing interests. TRIAL REGISTRATION NUMBER N/AN/A

Glyburide versus insulin for the prevention of perinatal complications of gestational diabetes: a pragmatic, non inferiority, randomised trial

54th Annual Meeting of the European-Association-for-the-Study-of-Diabetes (EASD), Berlin, GERMANY, OCT 01-05, 2018International audienc

Impact on testicular function of a single ablative activity of 3.7 GBq radioactive iodine for differentiated thyroid carcinoma

What are the consequences of radioactive iodine (RAI) therapy for testicular function

Traitement par témozolomide des tumeurs hypophysaires agressives et carcinomes hypophysaires : résultats à court et long terme à partir d’une cohorte française de 31 patients

National audienceIntroduction Le traitement par témozolomide permet une réponse dans 40 à 50 % des tumeurs hypophysaires agressives ou carcinomes, les données à long terme restent rares. Objectif Étudier la réponse précoce (3–6 cycles) et le devenir des patients traités par témozolomide en France à partir d’une enquête rétrospective. Résultats Trente et un patients (F/M = 10/21) : 20 adénomes, 11 carcinomes, 16ACTH, 10PRL, 2GH, 2GH/PRL, 1 non fonctionnel ont bénéficié d’une médiane de 6 cycles (3–24), avec un suivi médian de 18 mois (0–72) après la fin du traitement. La tolérance était correcte (thrombopénie n = 4 ; pancytopénie n = 3). L’âge médian au diagnostic était 40,5 ans (13–76), le délai avant traitement de 6 ans (0–18). Tous les patients ont bénéficié d’une radiothérapie, 27/31 d’une exérèse chirurgicale (1–5). Le TMZ a été initié à la dose de 150–200 mg/j 5 jours par mois, associé à une radiothérapie dans 5 cas. La réponse initiale était bonne : 17/31 (54.8 %), avec des taux similaires entre ACTH (56 %), PRL (50 %), plus importants pour les adénomes (65 %) que les carcinomes (36 %). En fin de traitement, une réponse se poursuivait chez 12/17 après 7,5 (5–24) cycles, 3 patients (ACTH) étaient toujours en rémission après 24 mois (12–36). Tous les seconds essais de témozolomide ont été des échecs (n = 6). Il n’y avait pas de réponse après 5,5 (3–18) cycles chez les 14 non répondeurs avec un taux de décès de 8/14 cas résistants comparativement à 2/17 répondeurs. Conclusion La réponse initiale au témozolomide est satisfaisante mais le maintien du contrôle tumoral sur le long terme rare. La meilleure stratégie thérapeutique pour ces tumeurs hypophysaire reste à défini