Endocrine Abstracts

A 32 years old female, presented with bilateral moderate flank pain resolved with analgesics. She visited physician and advised CT Abdomen & Pelvis. It showed bilateral adrenal nodules. She referred to PKLI Urology & Endocrinology Department.

Workup advised. Investigations: Normal TFT’s Ultrasound neck: normal thyroid gland with TI-RAD IV nodule in right lobe. AM cortisol 7.6 ng/dl Urine VMA 6.79 24 hour urinary metanephrines >600 and normetanephrines > 800 Calcium 11 mg/dl PTH 218.3 pg/ml Calcitonin 30.5 pg/ml Prolactin 3.4 ng/ml Parathyroid planner imaging with SPECT showed scintigraphic evidence of hyperfunctioning parathyroid tissue at inferior pole of left lobe of thyroid gland. CT with adrenal protocol showed right adrenal gland enlarged and enhancing lesion measuring 5.2 cm with precontrast attenuation of 50 HU, attenuation arterial phase enhancement of 114 HU and absolute washout of 23%, similarly another enhancing lesion measuring 4.6 cm is noted arising from left adrenal gland with non-contrast attenuation of 45HU, arterial phase attentuation of 108HU and absolute washout of 23% with no locoregional lymph nodes. PET-CT-DOTATE scan showed bilateral, avid, heterogenous nodular adrenal masses. Since patient was symptomatic with biochemical and radiological evidence of Phaeochromocytoma, she was started on Alpha and Beta blockers before surgery. Her case was discussed in MDT, recommended bilateral adrenalectomies, genetic testing, total thyroidectomy and parathyroidectomy. She underwent Bilateral Robotic adrenalectomy and started replacement corticosteroids (10 mg +5 mg +5mg) and Fludrocortisone (100 mg/day). On followup, it was discussed about hemithyroidectomy and selective parathyroidectomy. Her clinical and biochemical profile were consistent with MEN-2A, unfortunately we could not be able to perform genetic studies due to financial constraints. Histopathologically, macroscopic cut section revealed yellow lobulated tumour in both adrenal glands. Microscopic findings suggested encapsulated neoplasm in the adrenal gland, composed of cells with basophilic cytoplasm and variable salt and pepper nuclei, polygonal with numerous areas of spindled-shaped appearance have markedly pleomorphic nuclei arranged in Zellbellen pattern with some diffuse areas of capsular invasion seen however, no extension into extraadrenal tissues or vessels, no areas of necrosis seen. Immunohistochemistry: Synaptophysin: Positive Chromogranin: Positive Ki 67: 1-2%, S100:Highlights supratenticular cells Reticulin: Highlights Zellbellen pattern After recovering from previous surgery, she underwent right hemithyroidectomy and parathyroidectomy Histopathology A) LEFT LOWER INFERIOR PARATHYROID:Parathyroid Adenoma B) Right Hemithyroidectomy:Medullary Thyroid Carcinoma Unifocal, size 0.5x0.5x0.2 cm, Angiolymphatic invasion: Identified, Perineural invasion & Extrathyroidal extension: Not identified, Margins:Closest inked margin 0.3 cm Pathologic staging: pT1 pNx pMx Now planning for completion thyroidectomy and neck dissection.