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The objective of the paper was to observe the ultrastructural aspects of the endometrial biopsies taken from female patients at post-menopause with substitutive hormonal therapy (TSH). Material and methods. A number of three endometrial biopsies were taken from female patients at post-menopause with TSH. The ultrastructural analysis was carried out with the help of the electronic microscope Philips ME 301 using classical electronic microscopy methods. Results and discussions. The ultrastructural analysis has highlighted the presence of cuboidal and columnar epithelial cells, with basally situated nuclei, well represented cellular organelles, some cells having at the apical pole microvilli. At the electronic microscope, three types of epithelial cells are described, at the level of the endometrial mucosa of the woman who is in a fertile period: secretory cells (cells with an average electronic density with microvilli on the luminal surface), ciliated cells and clear cells (cells with a low electronic density). These cells have certain ultrastructural characteristics and of receptivity towards the steroid hormones. The stroma is axial with elongated cells with oval nuclei, with nucleoli and with smooth or undulated membrane. Conclusions. The ultrastructural aspects suggest the presence at endometrial level of epithelial active glandular cells, secretory cells and stromal active cells at female patients at post-menopause with TSH.

To quantify the apoptotic phenomenon on endometrial biopsies in postmenopausal patients under hormonal replacement therapy (HRT).The study lot consisted of 30 endometrial biopsies on which we studied the apoptotic phenomenon through morphological and molecular biology techniques (TUNEL reaction). Examination of endometrial biopsies before and post-therapeutically has been made.From morphological point of view, pre-therapeutically, endometrial biopsies presented apoptotic changes in about 1-3% of cells and under TSH there have been observed apoptotic changes in about 1-2% of cells. In female reproductive system, we found out a raised rate of cellular proliferation and concurrently a raised rate of apoptosis. Apoptotic phenomenon can be observed in endometrium at every menstrual cycle. In proliferative endometrium apoptosis rate is low, but in endometrial carcinoma apoptosis rate grow up. Bcl2 and Bax are expressing in normal and hyperplastic endometrium, but in endometrial carcinoma Bcl2/Bax ratio decline.Quantification of apoptosis, using morphological and TUNEL reaction methods, on endometrial biopsies in postmenopausal patients before and after therapy indicate a low rate of apoptotic phenomenon.

s 441 P48 Vanishing Testes Syndrome-Related Vertebral Fractures and High Cardio-Metabolic Risk in an Adult Male with Long Term Untreated Hypergonadotropic Hypogonadism Mara Carsote; C.I.Parhon National Institute of Endocrinology, Carol Davila University of Medicine and Pharmacy Anda Dumitrascu, Corina Chirita, Sorin Paun, Dana Terzea, Catalina Poiana Background: The hypogonadism-related bone mass loss despite its frequency among male osteoporosis cases it is often under diagnosed. The peak bone mass is severely affected if the hypogonadism is registered and left untreated during puberty. Aim: We present an interesting, almost bizarre case of a male who presented non-functional testes early during childhood and remained hypogonadic up to his fifth decade of life since no testosterone therapy was added during this time. Case presentation: A 46-year old male is referred for goiter evaluation. He accuses back pain. The phenotype resembled intersexuality: gynoid proportions, micropenis, no palpable testes into the scrotum, no face hair. His medical history revealed since last year: mixedema treated with levothyroxine, and ischemic heart disease with an episode of acute angina. On admission, the testosterone was 0.2 ng/mL (normal: 1.7-7.8 ng/mL), FSH of 56 mUI/mL, normal adrenal axis, as well as TSH (under substitution) were found. The bone turnover markers were twice as normal. High blood cholesterol and impaired glucose tolerance was registered. The thyroid ultrasound pointed a left lobe node of 1 cm. The testes were not found into the scrotum. Computed tomography suggested bilateral nodes of 1.6 cm into abdominal fat that were removed but no gonads were confirmed. Vanishing testes syndrome was confirmed. The central DXA pointed lumbar Bone Mineral Density (BMD) of 0.905 g/cm2, T-score of -2.8, and Z-score of -2.9. The spine profile X-Ray pointed thoracic vertebral multiple fractures. Alendronate therapy together with vitamin D and calcium supplements, as well as testosterone gel was started. Conclusion: Severe and long time standing hypogonadism affects not only the cardiac risk, as well as the skeleton integrity. Figure 1. BMD Z-scores in males and females with Addison’s disease P49 TSH Threshold Related to Lower Bone Mineral Density in Postmenopausal Patients Under TSH Suppression Therapy for Differentiated Thyroid Carcinoma Aline Farias; University of Campinas Ludmila Almeida, T.G. Melo, L.V.M. Assumpc~ao, Allan Santos, D.E. Zantut-Wittmann Introduction: TSH suppression with supraphysiological doses of levothyroxine aims to reduce risk of recurrence in the treatment of patients with differentiated thyroid carcinoma (DTC) after surgery and radioiodine therapy. Exogenous subclinical thyrotoxicosis (EST), with suppressed TSH and normal T4 levels probably has a negative effect on bone metabolism, but there is no definition of the magnitude of the effect on bone mineral density (BMD). Objective: To evaluate the relationship between TSH suppressive therapy in patients with DTC and BMD. Methods: Cross-sectional study of 109 postmenopausal women in EST followed for DTC, compared to the control group (postmenopause women with normal levels of thyroid hormones) matched for age. All participants were submitted to BMD examination and statistical data analysis was performed. Results: Mean age of patients was 58.4 ( 8.3) years, with menopause for 11.2 ( 9.5) years. The average of follow up for CDT was 88 ( 70.6) months, mean BMI 27.9 ( 4.5) kg/m, mean of TSH during the year before of BMD analysis was 0.21 ( 0.28) mUI / ml and mean of free T4 was 1.84 ( 0.21) ng / dL. Mean T-score was -1.09 (SD 1.43) in L1-L4 and -0.12 (SD 1.18) in the total femur, with 19.2% of patients with osteoporosis; 40.4% with osteopenia and 40.4% with normal BMD. There were no significant differences between T and Z-score values of patients and control group. Multivariate logistic regression analysis identified significant relationship between BMI (p !0.001; R2 0,15) and mean TSH level during the last year (p 5 0.021 and R2 0,0423) with lumbar BMD. There were also relationships between BMI (p !0.001; R2 0,26), TSH level (p !0.001; R2 0,07) and oral contraceptive use (p 5 0.007; R2 0,04) with femoral BMD of patients. The ROC curve analysis for TSH values that differentiate patients with normal BMD of those with osteopenia identified as significant threshold when TSH was inferior to 0,185_UI / ml (area under the significant curve: AUC 5 0.625, 95%, CI 0.50-0.74, p 5 0.04). Journal of Clinical Densitometry: Assessment & Management of Muscu Conclusions: The identification of a TSH threshold level in patients with DTC and EST maintaining normal BMD from those with osteopenia is unprecedented (to our knowledge). This may be of great importance to define the degree of TSH suppression in the follow-up of DTC. This is the rational to maintain TSH levels less suppressed in patients with low risk of recurrence or mortality, in order to preserve BMD in these patients. P50 Bone Mineral Density in Patients with Addison’s Disease on Replacement Therapy with Prednisolone David Chandy; Sanjay Gandhi Postgraduate Institute of Medical Sciences

Hysteroscopic and histopathologic endometrial study by commune and immunohistochemical techniques on 2 groups of menopausal women on HRT-sequential (24 months) and continuous combined (12 months) compared to pretherapy or a control untreated group showed the changes of endometrial superficial microvascular net-work, with new blood vessels and ecquimosis/subepithelial haemorrhages. Endometrial neoangiogenesis varied according to progestogens/progesterone: type (less on dydrogesterone, more important on cyproterone acetate, medroxyprogesterone acetate, norethisterone), dose (large doses of medroxyprogesterone acetate induce greater changes in sequential HRT, and small doses induce less changes), time (minimum when progestogen is cyclic at 3 months). The vascular changes are more accentuate in the first year of HRT. The correlation between the number of new vessels and type of endometrial pathology showed that the neoangiogenesis is greater in secretory and atrophic endometrium.

Sertoli-Leydig cell tumors (SLCT) constitute only 1-0.5% of all primary ovarian neoplasms. We report a SLCT in a postmenopausal woman aged 69 years. The physical examination revealed severe hirsutism. Basal hormonal evaluation showed high plasma testosterone and estradiol values, with suppressed plasma gonadotropins. Computer tomograph scan revealed a right ovarian tumor mass of 4,3/3 cm, confirming an androgen secreting ovarian tumor. The histopathological and immunocytochemical examination established the diagnosis of well differentiated Sertoli-Leydig cell tumor. The tumor was positive for cytokeratin KL 1 and S-100 protein and, in isolated tumor cells, positive for alpha-fetoprotein. Postsurgical evolution was favorable; controls after 6 months and 3,5 years showed marked reduction of hirsutism, normal plasma testosterone values and gonadotropins in normal postmenopausal range. We discuss the complex aspects of etiology and pathogenesis, the clinical and hormonal settings, the role of immunocytochemical markers in diagnosis, as well as the therapy and the prognostic features of this ovarian tumor.

Background We report a case of a 71-year-old woman diagnosed with Stewart-Treves syndrome, a rare occurrence after breast cancer treatment. Methods The patient, with a history of cancer in the left breast, was subjected to radical mastectomy with regional lymph node dissection, radiation and chemotherapy in 1985. In 2009, the patient presented with a 4 months history of enlarging plaques of purplish maculae and nodules in the area of chronic lymphedema. A skin biopsy was performed. Serial sections from the material were stained with HE Ki67 positivity was 60-65% and ACT was positive in vessels. The clinical and pathologic features confirmed the diagnosis of Stewart-Treves syndrome. The patient was treated with radiotherapy and remission of all cutaneous lesions of the arm was obtained. Conclusions Treatment of post-mastectomy lymphangiosarcoma is still unsatisfactory, since this tumor develops in long-standing chronic lymphedema many years after the initial surgery, long term follow-up of patients with chronic lymphedema is required.

Background Ectopic production of adrenocorticotropic hormone (ACTH) by neuroendocrine tumours (NET) is a rare condition, occult presentations often hampering the diagnosis. Although NET are relatively frequent in the ileon and Meckel diverticulum, we describe the first Cushing’s syndrome due to ectopic adrenocorticotropic syndrome (CS-EAS) arising from a Meckel diverticulum. Case presentation A 44-year-old man was admitted with recent onset of diabetes, myopathy, edema and hypokalemic metabolic alkalosis consistent with Cushing’s syndrome. Both basal and dynamic laboratory evaluation suggested CS-EAS. Laboratory testing also showed high serum levels of chromogranin A (CgA) and urinary 5-hydroxyindoleacetic acid (5HIAA). Pituitary and neck/thorax/abdomen/pelvis imaging proved to be normal, while somatostatin analogue (99mTc-HYNIC-TOC) scintigraphy revealed increased focalized ileum uptake on the right iliac fossa. Pre-operative ketoconazole and sandostatin treatment controlled the hypercortisolism within a month. Pathological analysis of the resected submucosal 1.8 cm tumour of the Meckel diverticulum and a metastatic local lymph node confirmed a well differentiated neuroendocrine tumour (grade I), whereas immunohistochemistry was positive for ACTH, chromogranin A and synaptophysin. Post-operative clinical and biochemical resolution of Cushing’s syndrome was followed by normalization of both CgA and 5HIAA, which were maintained at the 6 month follow-up. Conclusion The identification, characterization and follow-up of this rare cause of ectopic ACTH secretion is important in order to assess the long-term prognostic and management.

This study aimed to investigate an unusual case of immature ovarian teratoma with onset of mature glial cells implanted on the contralateral ovary, a challenge in the diagnosis of the second ovarian tumor. We report the case of a 31- yr-old woman, who developed at the age of 16 an immature teratoma in the right ovary that was surgically removed. Six years later mature glial implants were present on the left ovary and six months later at the level of peritoneum that relapsed after other six months. The patient suffered three surgical resections after the initial one. Paraffin sections and immunohistochemical examinations using antibodies against glial and neuronal antigens were performed. In the teratoma, the neuroectodermal tissue expressed Glial fibrillary acidic protein (GFAP), S100 protein, Epithelial membrane antigen (EMA) and Cytokeratin 34 beta E12 (Ck34beta E12), wheares the implants expressed only GFAP and S100 protein. The immature teratoma is the rarest type of ovarian teratomas. Gliomatosis peritonei is an exceptional finding, expecially with onset on the contralaterally ovary. The implant of the mature glial cells has a high risk of relapse, as seen in our case, thus close follow-up of the patient is necessary.