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Background: Central adrenal insufficiency (AI) is known to conceal diabetes insipidus (DI) by impairing free water clearance from the renal system and inhibiting polyuria, which is later unmasked by the initiation of glucocorticoids. The instances of masked DI in the literature are confined to case reports - the actual incidence is unclear. There have been no documented cases of masked DI secondary to a clival tumor, which remains a rare cause of hypopituitarism. Here we discuss a case of primary diffuse large B-cell lymphoma (DLBCL) of the clivus presenting with panhypopituitarism and the development of DI upon glucocorticoid initiation. Clinical Case: A 60-year-old man with DLBCL initially presented to an outside institution with headache, diplopia, and right eye ptosis. Brain MRI showed enhancement of the clivus without obvious pituitary gland involvement. He underwent biopsy with partial resection of the tumor and pathology confirmed DLBCL. His course was complicated by persistent fevers. Extensive work-up was unrevealing and he was transferred to our institution for further management. On admission, infectious work-up was positive for C. Difficile. He later developed septic shock requiring vasopressors and broad-spectrum antibiotics. Despite prolonged antibiotics, he remained hypotensive. Due to proximity of the clivus and sella, there was concern for pituitary involvement. A random cortisol was 9.1 [3.7-19.4 ug/dL], subsequent 250ug cosyntropin stimulation test yielded 13.1 and 14.9 at 30- and 60-minutes, respectively. Given inadequate stimulation and persistent hypotension in this critically ill patient, he was then started on stress dose hydrocortisone (HC) with prompt resolution of hypotension. Further work-up of the pituitary axes was consistent with anterior hypopituitarism: ACTH 5 [6-50 pg/mL], TSH 0.336 [0.350-4.940 uIU/mL], free T4 0.5 [0.7-1.5 ng/dL], FSH 0.3/LH 0.1 [1-10 mIU/mL], IGF-1 Conclusion:This is the first documented case of DLBCL of the clivus leading to panhypopituitarism. For tumors in close proximity to the pituitary, there should be a low threshold for pituitary axes evaluation. In addition, masked DI from central AI remains rare and requires close attention by the Endocrinologist following initiation of glucocorticoids.

Background Transgender medicine is an emergent subfield with clearly identified educational gaps. Aims This manuscript evaluates a gender-affirming healthcare curriculum for second-year medical (M2) students. Methods Students received a survey assessing Gender Identity Competency in terms of skills, knowledge and attitudes regarding transgender and gender non-conforming (TGNC) issues. The authors administered the survey before and after the delivery of the curriculum. The curriculum included five online modules, a quiz, a 3-hour case-based workshop and a 2-hour interactive patient-provider panel. Results Approximately 60% of M2 students (n=77) completed both preassessments and postassessments. The following showed a statistically significant improvement from preassessment to postassessment: student Gender Identity Competency, t(76) = −11.07, p Conclusions The curriculum improved students’ gender-affirming medical competency, knowledge and skills. The development of a sustained, longitudinal curriculum is recommended in addition to the continuing education of faculty to reinforce this expanding knowledge and skills base and to address discomfort working with this population.

Background: Only one case of uterine cancer in a trans man on testosterone is noted in literature prior to this case. No clinical evidence nor guidelines exist regarding testosterone therapy for this subset of patients. Clinical Case: A 41-year-old trans man was seen by Gynecology for vaginal bleeding, with work-up revealing thickened endometrium and biopsy with endometrial adenocarcinoma. Testosterone therapy was held, and patient underwent total hysterectomy with BSO and bilateral pelvic/aortic lymph node dissection. Pathology demonstrated stage IIIA invasive adenocarcinoma, endometrium type with focal squamous differentiation, low grade. The tumor extended into the endocervical stroma with small metastasis to one ovary. He received adjunct pelvic radiation and sandwich chemotherapy with carboplatin and taxol. Concurrently, he was referred to Endocrinology for management of hormone replacement therapy (HRT). He originally started weekly testosterone injections and anastrozole at an outside facility in 2016 and underwent bilateral mastectomy in 2017. Testosterone was held perioperatively and during chemoradiation, for a total duration of 9 months. The patient experienced worsening gender dysphoria during this time. Discussion was held on goal to restart HRT in the setting of a theoretical risk of testosterone conversion to estradiol with increased risk of cancer recurrence; thus, patient initially chose to delay re-initiation of HRT. Following the completion of chemotherapy, he started on low-dose (30mg) weekly IM testosterone with plans for continued monitoring of testosterone and estradiol levels. Conclusion: Research is needed in monitoring the effects of testosterone therapy on reproductive organs in patients assigned female at birth, and whether anastrozole therapy has protective effects for estrogen-driven cancers. Further, guidance is needed on monitoring of uterine lining in trans men and whether this should be standard of practice.