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Hypopituitarism is the main complication of nonfunctioning pituitary macroadenomas. A 64-yearold patient was admitted for marked asthenia, generalized muscle contractions, acroparesthesia and lumbar pain. Clinical examination revealed grade I obesity, discrete eyelid edema, negative Chwosteckand Trousseau signs. Hormonal profile showed the presence of somathotropic pituitary insufficiency, low testosterone levels (of 1.3 ng/mL, normal: 1.68-7.58ng/mL), gonadotropin and prolactin levels within the normal range, normal values for TSH (Thyroid Stimulated Hormone) and FT4 (Free Thyroxine). On admission, low serum and urinary cortisol values were obtained, with an appropriate response after the Synacthen test. The MRI (Magnetic Resonance Investigation) examination revealed a pituitary macroadenoma of 20/21/21 mm, compressing the optic chiasm and thalamus, with bilateral 180-degree involvement of the internal carotid artery. The ophthalmological examination described a lower scotoma in the left eye, without amputation of the visual field. Thyroid and glucocorticoid hormone replacement therapy was recommended, along with neurosurgical intervention. In pituitary macroadenomas, the close proximity to the optic chiasm and carotid arteries limits the curative therapeutic potential and increases the risk of postoperative complications. [ABSTRACT FROM AUTHOR]

Non-functioning pituitary adenoma is one of the most common endocrine tumour with a benign pattern in the majority of cases. We present the case of a 69 years old female admitted on endocrinology department for visual field defects, dizziness, memory disorder, bradylalia, bradypsychia. During medical examination, the patient presented a sincopal event, with abundant sweating and temporo-spatial disorientation. Magnetic Resonance Imaging revealed a pituitary macroadenoma of 23/33.3/37 mm with two spherical lesions overlapped ("snow man" shape), with mass effect on the cavernous sinuses extending to the posterior wall of the left sphenoid sinus. Visual field examination showed significant narrowing to both eyes. The hormonal profile revealed gonadotropic insufficiency and low Insulin-like Growth Factor 1 with normal prolactin and cortisol levels. Thyroid hormonal evaluation highlighted primary hypothyroidism due autoimmune thyroiditis. Two weeks later, adenomectomy was performed by supraorbital craniotomy. After discharge, she received the thyroid hormone replacement therapy initiated preoperatively and specific therapy for associated pathology: diabetes mellitus type 2, osteoporosis, and hyperlipidemia. Pituitary surgery is the first line treatment for the majority of patients with symptomatic endocrine-inactive adenomas. Further multidisciplinary close check-up is periodically recomended. [ABSTRACT FROM AUTHOR]

Primary hyperparathyroidism (HPTH) is a common endocrine disorder characterized by multiple organic events secondary to hypercalcemia, including renal insufficiency. We introduce a case of primary HPTH diagnosed after presentation for recent-onset of renal insufficiency. A 60-year old male with no prior medical history was initially diagnosed with renal failure in the context of progressive malaise, nausea, recent onset of moderate blood pressure. Beside low glomerular filtration rate (eGFR of 15 mL/mim/1.73m2), biochemical evaluation showed hypercalcemia of 14.4 mg/dL (normal: 8.8-10.6 mg/dL), ionic calcium of 7.27 mg/dL (normal: 4.4-5.4 mg/dL), hypercalciuria of 343 mg/24h, normal:<300 mg/24h. Examinations performed for secondary causes of hypercalcemia have revealed increased value of parathyroid hormone (PTH) of 881.2 pg/mL (normal: 12-88 pg/mL). Thyroid ultrasound and cervico-mediastinal computed tomography highlighted an inhomogeneous hypoechoic lesion on the posterior side of the left lobe, with intrathoracic extension, measuring 3.54/4.94/5.4cm with left parathyroid adenoma significance. The hormonal profile excluded multiple endocrine neoplasia syndrome (MEN). After improvement of biochemical parameters by adequate hydration and diuretic treatment, left parathyroidectomy was performed. One month later, normal PTH, calcium total, ionic calcium, and improvement of renal function have been achieved. Long-term follow-up by a multidisciplinary team was recommended. [ABSTRACT FROM AUTHOR]

Osteoporosis represents a worldwide problem due to under diagnosis, and under treatment. The major complications are fragility fractures as vertebral, etc. some of them requiring orthopedic and neurosurgical procedures. We introduce a case of a female adult who was first referred for spine surgery because of osteoporosis complications and then she was followed for a few years based on background skeleton condition. This is a 70-year old subject admitted for a new vertebral fracture assessment and therapy adjustment. She had 3 spine surgeries for multiple vertebral fractures (thoracic 7, 8, 9,10, and 12) during the last 5 years; she was intermittently treated with specific anti-osteoporotic drugs. On admission, the patient has severe kyphosis and secondary walk difficulties; intermittent non-specific lumbar pain. The mineral metabolism indicated no anomaly. DXA confirmed low T-score with reduced values compare to prior analysis. X-Ray assays at spine levels showed diffuse demineralization, multiple metallic implants at the level of thoracic vertebras T7, 8, 9, 10, 12 and another new one at T7, round kyphosis, increased physiological lordosis; osteophytosis including at hip joint. The patient was offered a yearly intravenous injection of zolendronic acid 5 mg in addition to 2000 Units of cholecalciferol and 800 units of calcium per day. Another spine surgery was considered unnecessary for the moment, but close follow-up is useful, including the management regarding therapy and lifestyle intervention for severe osteoporosis. The management of a patient with osteoporotic spine fracture is a complex and dynamic equation requiring a multidisciplinary team and life time follow-up. [ABSTRACT FROM AUTHOR]

Riedel's thyroiditis is a fibrous invasive type of chronic thyroiditis with a benign pattern which is characterized by a dense fibrotic and inflammatory process that invades the thyroid gland and adjacent structures of the neck Our purpose is to introduce such a rare case with challenges of rapid diagnosis associating severe local complications which required thyroid surgery. A 71-yearold female patient was admitted because of developing a neck mass in association with dysphagia and weight loss. Thyroid enlargement, especially of the right lobe, had a woody consistency. Ultrasound showed an asymmetric enlargement, with absent vascular flow. Normal thyroid function associated positive anti-thyroperoxidase antibodies. The diagnosis of Hashimoto's thyroiditis was confirmed but the clinical evaluation (a large compressive goiter) raised the suspicion of a thyroid malignancy. Fine needle aspiration provided unsatisfactory tissue sample because of the fibrous consistency. Due to the persistent aggravating compressive symptoms emergency thyroidectomy was performed. The pathologic report showed: chronic Hashimoto thyroiditis with an extensive fibrous tissue transformation of the right lobe, chronic inflammatory and sclerosing pattern suggestive for Riedel's thyroiditis. The postoperative evolution had no complications, levothyroxine substitution was initiated, and the pain and dysphagia completely disappeared. Clinical presentation of Riedel's thyroiditis, a rare thyroid condition, mimics practically any other thyroid pathologies, especially sub-acute thyroiditis and malignancy. The differential diagnosis is essential for the treatment plan since missing the diagnosis may be fatal. Atypical cases which rapidly developing compressive symptoms require lifesaving surgery. [ABSTRACT FROM AUTHOR]

The autoimmune background as found in chronic thyroiditis (CT), also known as Hashimoto's thyroiditis or autoimmune lymphocytic thyroiditis, does not represent an indication of surgery but the discovery of macro-nodules may represent a risk for thyroid cancer, thus thyroidectomy becomes an important tool of approach. Environmental triggers, less or more described up to this moment, are a contributor to higher prevalence of CT and to the shift through more frequent cases of papillary thyroid cancers (PTC) rather than follicular type. This is a mini-review of literature focused on the association between CT and differentiated thyroid cancer, especially PTC. The research used as key words all the mentioned synonyms used for CT. A number of 62 references are selected, since 2004 (while 45 of them are published between 2015 and 2017), and 53 of them are accessible via PubMed database. The CT - PTC relationship may be described at different levels: PTC is presented more frequently than follicular thyroid cancer in relationship with iodine supplements including cases with autoimmune background; 2. CT is involved in multifocal PTC but this histological pattern may not be more aggressive than generally expected because lymph nodes are somehow blocked by the immune process and protected by lymph nodes metastasis from primary thyroid source of PTC so the risk of recurrence and aggressive profile is not higher than seen in CT-free subjects. Team approach is essential for many aspects as the detection of CT and the selection of those rare cases that need thyroidectomy. The association between CT and PTC is actually more frequent that expected, especially for micro-PTC subtype. Overall, the survival of PTC patients does not seem to be influenced by CT if surgery is correctly applied despite a risk of multifocal intra- and not extra-thyroid spreading of malignancy. [ABSTRACT FROM AUTHOR]

Acromegaly is a rare chronic, progressive disease caused by the increased secretion of growth hormone (GH) and subsequently insulin-like growth factor 1 (IGF-1). Benign thyroid overgrowth is a common phenomenon in this pathology, but some studies revealed that acromegaly is associated with an increase in the prevalence of malignant thyroid nodules. We present two cases of acromegaly associated with papillary thyroid carcinoma. A 69-year-old female accused at the age of 43 headache, enlarged hands and feet, secondary amenorrhea. The investigations revealed high IGF-1 and GH levels and a pituitary GH producing macroadenoma. 19 years after transsphenoidal adenomectomy, a multinodular goiter with areas of calcifications and intra and perinodular vascularization were discovered. Total thyroidectomy was performed and histopathology highlighted a papillary thyroid carcinoma. A 53-year-old male was admitted at the age of 45 with intense headache, dizziness, sexual dysfunction and a multinodular goiter. Clinical signs of acromegaly were correlated to the presence of an intra-sellar tumor with extension to the optic chiasm. Transsphenoidal adenomectomy was first decided and it was followed by conventional radiotherapy, somatostatin analogue and GH blocker afterwards. For multinodular goiter a fine needle aspiration showed the need of total thyroidectomy which was further performed and a minimally invasive papillary microcarcinoma was confirmed. The relationship between acromegaly and thyroid carcinoma could be related to the stimulatory effects of long-lasting excess of IGF-1 and GH on TSH induced thyroid cellular growth. Therefore, it is necessary to carry out effective treatment and periodic thyroid ultrasound examination in patients with acromegaly; usually thyroidectomy follows hypophysectomy to achieve GH control first. [ABSTRACT FROM AUTHOR]

Primary hyperaldosteronism (PH) caused by an aldosterone producing adrenal tumour is cured after adrenalectomy. However, long term follow-up is needed focusing on arterial hypertension and metabolic complications. A 69-year-old male was confirmed with PH at the age of 62. At that moment he had an 18-year history of high blood pressure (maximum 200/100 mmHg) in association with diabetes mellitus and hyperlipidemia. He developed hypopotassemia requiring spironolactone. No hypoaldosteronism was registered but a normalization of adrenal endocrine profile. While the patient was first evaluated for PH at the age of 62, a routine thyroid check-up showed multinodular enlargement with a large cyst on the right lobe. Six years later, the patient has moderate high blood pressure values controlled under daily 80 mg of telmisartan. This is a 49-year-old female with irrelevant family history who became hypertensive at the age of 37. At the age of 42, while she was investigated for performing a cholecystectomy, a left adrenal tumour of 1.2/0.9/0.9 cm was discovered at CT. Three years later she was investigated for secondary hypertension after associating mild hypopotassemia. A tumour production of aldosterone was linked with the adrenal mass. Currently, 4 years after the adrenal excision, biochemistry and endocrine panel is normal with residual high blood pressure controlled with low doses of calcium and beta adrenergic blockers. Surgery for adrenals in primary hyperaldosteronism is one elegant option which may cure the condition. A high index of suspicion and a systematic approach are useful in identifying and proving the diagnosis. Association with other endocrine disorders diversify the clinical appearance. Delaying the diagnosis and adrenalectomy decreases the chance of high blood pressure remission after adrenal removal. [ABSTRACT FROM AUTHOR]

Renal hyperparathyroidism (HPTH) is first treated with vitamin D supplements and later parathyrodectomy is required; usually total removal of the four glands with self-transplantation and rarely partial resection is performed. We introduce a case of end-stage renal disease (ESRD) with very high parathormone (PTH) levels long-time after total parathyroidectomy without autoimplant, lacking the evidence of anatomical parathyroid presence. A 59-year-old female with ESRD since the age of 38 and hemodyalisis performed until the present day. The vitamin D supplementation was not adequate thus 8 years ago PTH was found increased (of 2070 pg/mL, normal: 15-65pg/mL), requiring surgery (total parathyroidectomy). Patient experienced low PTH values immediately after surgery. Further vitamin D and calcium supplements were offered and the values of total calcium remained low-normal while PTH assays were no longer done until recently. Currently, an elevated PTH of 1622 pg/mL with normal total calcium and severe vitamin D deficiency was found confirming once again renal HPTH. The imagistic tests did not reveal suggestive parathyroid masses at cervical and mediastinal computer tomography, both by using 99mTc PERTECHNETATE and SESTAMIBI parathyroid scintigraphy. Anterior cervical ultrasound suggested two right remnants of 4 mm, probably parathyroids. The best treatment for this moment is the adequate correction of vitamin D deficiency so daily oral vitamin D3 1000 UI, calcitriol 0.75 µg, and calcium carbonate 1500 mg were started. Three months later PTH decreased at 900pg/mL. If PTH might have a good response to the medication, surgery may be delayed. Moreover, the lack of adequate parathyroid masses identification will increase the surgical approach difficulty requiring intra-operatory localisation on a patient already associating multiple comorbidities. [ABSTRACT FROM AUTHOR]

The surgical approach in the pituitary secreting or non-secreting tumours had a complex development during the last century up to the microscopic transsphenoidal or endoscopic techniques. This is a mini-review of endocrine features in adenomas requiring their remove starting from a case presentation. A 54-year-old female is admitted for endocrine evaluation because of her medical history. At the age of 45 she presented secondary amenorrhea, mild right eye proptosis, and persistent diffuse headache. A pituitary adenoma of 21 by 19 mm was found. Selective transnasal trasnsphenoidal hypophysectomy was performed. The surgery went well without any incidents. The patient was hospitalised for 14 days. She was released without hypopituitarism, or diabetes insipidus. The immunohistochemistry report showed a weak reaction for GH but the adenoma was considered non-functioning. In 2015 severe headache was progressively seen and it became mostly unresponsive to usual analgesic medication so amitriptylin, and gabapentin were introduced in order to control the pain. MRI showed a right pituitary tumour of 12 by 19 by 13 cm with right cavernous sinus invasion. A second selective pituitary surgery was recommended but the patient still delays it. Hypophysectomy represent the first line of treatment in all the hormonally active pituitary masses (except for the majority of prolactionomas) and in non-secretor macroadenomas. Close endocrine and imagery check-up is indicated at diagnosis and later on even in cases with complete neurosurgical remove, as seen in this case, because the risk of relapse is presented even after a few years. Repeating the surgical procedure is advisable due to compression and local invasion risks, as well as the risk of hypopituitarism. [ABSTRACT FROM AUTHOR]