Endocrine Abstracts

Case: A 59-year-old female with a past medical history of surgically treated primary hyperparathyroidism (PHPT) and breast cancer presented with irregular periods, post-menstrual bleeding, hot flushes, fatigue, and left loin pain. Furthermore, she reported weight gain of approximately 8 lb over 6 months and easy bruising in the absence of antiplatelet and anticoagulant therapy. There were no central, respiratory, or gastrointestinal symptoms. She was normotensive, and the clinical examination was unremarkable. She was established on Tamoxifen therapy. Her father had colonic polyps, while her mother suffered from a uterine malignancy. Initial blood work is detailed in Table 1. For loin pain, the ultrasound scan of the renal tract showed mild dilatation of the right renal pelvis. An overnight dexamethasone suppression test showed undetectable serum cortisol (<30 nmol/l), and a genetic screen for multiple endocrine neoplasia (MEN-1) returned negative. A CT thorax, abdomen & pelvis (CT TAP) showed a left lower lung lobe mass measuring 43 mm with no radiological evidence of metastases. Cranial imaging was unremarkable. The lung mass did not demonstrate FDG uptake on PET CT, and there was no evidence of FDG avid nodal or distant metastasis. It was felt that the lung mass represented an oestrogen-secreting neuroendocrine tumour, and a left lower lobectomy was planned. The biopsy results were deemed unusual and difficult to interpret. The post-operative oestrogen levels were undetectable (Table 2), and patient symptoms resolved. A follow-up CT TAP 6 months post-op showed no new lesions. The patient remains under Endocrinology follow-up with persistently suppressed oestrogen and gradually rising gonadotrophin levels.

Learning points: 1. Significantly elevated oestrogen levels in this age group should prompt clinicians to search for central and peripheral causes.

A systematic approach under MDT guidance is imperative to investigate atypical and vague symptoms of rare pathologies.