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There is an alarming increasing incidence of PBC (premenopausal breast cancer) in countries with high income due to, on one hand, more accessible screening tools and, on the other hand, potential implications of daily lifestyle habits and endocrine disruptors of modern society on terms of facilitating tumor growth. A more severe prognostic is found in females younger than 40 years old at first detection, with advanced disease at diagnostic, and those with tumors displaying specific immunohistochemistry configuration (and associated gene profile) like ER (estrogen receptor) positive or HEGFR2 (human epidermal growth factor receptor) negative. Recently, particular aspects are reported in terms of PBC therapy: the switch from offering aromatase inhibitors/tamoxifen only in post-menopausal females was done to premenopausal subjects in addition to medication that offers ovarian function suppression (OFS) – as an alternative to classical oophorectomy - for 5 years up to 10 years extension depending on protocol and patient’ age at first diagnostic. The main endocrine considerations concerning PBC are: OFS and/or chemotherapy or oophorectomy causing prompt hypogonadism, bone status anomalies due to estrogens deficiency, potential endocrine tumors that are prone to be linked (for instance, a higher risk of cancer in acromegalic patients etc.), cardio-metabolic elements as facilitators of early tumorigenesis, fertility issues on PBC survivals etc. The purpose of the present paper is to introduce several key messages that relate to endocrine implications of PBC starting from a case. [ABSTRACT FROM AUTHOR]

Bilateral adrenal tumors (BAT) represent a vast domain of endocrinology and connected medical and surgical fields. Our purpose is to introduce several key points in relationship with long time management on a 56-year old female case who is currently admitted for reassessment of a left adrenal tumor with potential autonomous cortisol secretion. She is also known with pituitary incidentaloma since 2014, cerebral meningioma which was partially removed in 2015, uncontrolled diabetes mellitus under metformin and insulin therapy since 2017, and high blood pressure since 2021. Her medical history includes right adrenalectomy for Cushing syndrome in 2014. At that moment, she was first admitted for BAT, a tumor of 2 centimeters (cm) on the left gland according to computed tomography, respective of 3.5 cm maximum diameter on the right adrenal. The hormonal panel confirmed adrenal Cushing syndrome. After 6 months of non-interventional follow-up, the right tumor increased to 4 cm, also associating small areas of necrosis, thus a decision of unilateral laparoscopic adrenalectomy was done with good clinical post-operatory outcome. She did not develop adrenal insufficiency at any point in time, moreover, a low-normal ACTH (Adrenocorticotrop Hormone) with intermittent elevation of morning plasma cortisol levels after Dexamethasone suppression test showed a possible autonomous cortisol secretion of the left adrenal tumor during a 7-year follow-up. In 2014, the female patient received the confirmation of an adrenocortical adenoma which was consistent with cortisol over-secretion. Particular gene contributions are attributed to protein kinase A (PKA) defects (or B) that usually induce bilateral adrenocortical hyperplasia; however, they are not routinely tested in daily endocrine practice, neither had we performed it. Interestingly, the patient was detected with a cerebral meningioma after years of intermittent, mild headache. The diagnostic was established during initial endocrine evaluations. The headache was not associated with uncontrolled high blood pressure, as first expected due to excessive cortisol amount. Recently, it was identified that mutations of ARMC5 (armadillo repeat containing 5) gene are responsible for macronodular adrenal hyperplasia, but also meningioma. They may be also responsible for severe diabetes mellitus as seen here. The key points of following a patient with bilateral adrenal tumors include the timing of uni/bilateral adrenalectomy, the multidisciplinary management of associated complications, as well as the need of understanding the genetic rational behind it. [ABSTRACT FROM AUTHOR]

Hemoptysis as first sign of a thyroid differentiated cancer represents an atypical behavior of a cervical mass, usually associating lung metastasis or direct tracheal invasion. Late presentation (for instance, due to COVID-19 pandemic circumstances) associates a poor prognosis. This is a case report. We aim to introduce a 70-year old female case who was admitted for an atypical cervical mass associating hemoptysis as onset; the diagnostic of metastatic papillary thyroid cancer was established; the delay of hospital admission did not allow a radical intervention with curative purpose. The lady was admitted as an emergency for an endocrine checkup of a progressively growing cervical mass in addition to hemoptysis that developed a few weeks before. Specific blood endocrine panel confirmed the normal thyroid function with negative thyroid autoimmunity. Anterior cervical ultrasound showed intensely hypoechoic, inhomogeneous, large structure, with macro-calcifications (TIRADS 5). Fine needle aspiration cytology exam revealed a papillary carcinoma of thyroid, consistent with Bethesda 6 score. Computed tomography detected a voluminous thyroid tumor process of 92 by 58 by 89 mm. The superior, middle and inferior left later-cervical lymph nodes which are located posterior to the later-cervical vascular package, have maximum diameters of approximately 30/34 mm (axial) and 54 mm (vertical). Multiple micro-nodules of oval form in both lungs have diameters up to 29 mm (probably secondary lesions). Osteolytic tumor lesion at the level of the lateral arch of the vertebral body thoracic T 1 and the head of the left first rib extends to the level of the left foramen from the spaces cervical C7 to thoracic T1, respective between thoracic T1 and T2, with maximum diameters of 23/32 mm. CT also showed brain metastasis, as a iodophil, inhomogeneous, well-contoured tumor that is located on the right frontal precentral gyrus, with maximum diameters of 10/13 mm (axially) and 13 mm (vertically) and small areas of perilesional edema. Further adjuvant therapy was refused by the patient; palliative tracheostomy is needed. Atypically aggressive presentation of well differentiated thyroid cancer of papillary type might be associated with delayed presentation; whether this comes as direct consequence of pandemic era is still a matter of debate. [ABSTRACT FROM AUTHOR]

Primary thyroid lymphoma represents a challenging, multi-disciplinary condition that it may be found in addition to positive antibodies against thyroid. Early recognition is essential for an adequate management. A thyroid nodule but usually the entire goiter may rapidly progress to a voluminous mass causing local compressive symptoms. Most of the patients with primary thyroid lymphoma had a history of Hashimoto thyroiditis. Epidemiologically, primary thyroid lymphoma represents an exceptional entities opposite to papillary or follicular cancer. The first tool of evaluation is ultrasound; in order to appreciate the local and distance invasion, computed tomography is useful. Fine needle aspiration and cell block analysis or biopsy and immunohistochemistry report are essential for adequate diagnostic in order to avoid unnecessary surgery. Diffuse large B-cell lymphoma is the most frequent histological type. Chemotherapy and local radiation represents the elective management. Considering this unusual condition, awareness is the key operative word for different practitioners. [ABSTRACT FROM AUTHOR]

Early recognition of a pituitary secretor tumor offers a better prognostic; thus acromegaly might be recognized before the actual clinical picture of acromegaly is detectable. This is a 59-year old, non-smoking female admitted for: post-operatory evaluation of acromegaly. The clinical evaluation is non-specific. One year prior she was diagnosed with acromegaly based on cerebral imaging assessment due to intermittent headache. She was treated with cabergoline a few months before neurosurgery was done; post-operatory panel showed complete remission of acromegaly. Prompt detection of the disease allowed the early intervention with a very good outcome. The remission of GH excess after neurosurgery depends on tumor size and practical experience of the surgeon. The longer time of high growth hormone levels exposure the higher is the risk of cardio-metabolic and oncologic complications. [ABSTRACT FROM AUTHOR]

We aim to address incomplete procedures of adrenalectomy for pheochromocytoma (PHEO) on a bases of a mini-review. Dopamine, adrenaline and noradrenaline – secretor tumors are rare in general population, representing a neuroendocrine neoplasia with a strong genetic driving force and uncertain profile concerning a malignant behavior which may be less or more predicted based on initial post-operative report. There is no linear correlation with the post-operative recurrence in terms of clinical presentation, timing and prognostic. The first laparoscopic – based PHEO removal was done in 1992; and since then, the open procedure was replaced in majority of cases by the new gold standard – laparoscopic adrenalectomy; a current conversion rate is of 5%; alpha and beta - blockade is mandatory for preoperative management since an adrenergic crisis might be triggered by higher intraabdominal pressure during laparoscopy; bilateral PHEO may be addressed through one time procedure; minimally invasive technique is done trans-peritoneal or retroperitoneal; robotic – assisted laparoscopic procedure is the next logical step from traditional laparoscopy; in children, minimally invasive procedure is less likely to be used as in adults. Partial adrenalectomy (in terms of cortical - sparing technique) should be rarely performed for unilateral PHEO; its potential utility is for cases with non-feasible total removal due to tumor anatomy (like advanced local disease) or bilateral adrenal involvement in hereditary syndromes (like MEN 2A, VHL), especially in children and young adults to overcome the need of life long glucocorticoid replacement due to chronic adrenal insufficiency. A meta-analysis focusing on recurrence after total adrenalectomy revealed a 3% ratio after 2 years in PHEO. The percent for partial procedure is more than 10% depending on study. In conclusion, a particular aspect in PHEO management is the recurrence after an adrenalectomy, typically after a partial procedure. Unless bilateral involvement or a clear diagnostic of a hereditary syndrome involving bilateral PHEO, partial adrenalectomy should be limited. [ABSTRACT FROM AUTHOR]

Acromegaly embraces typical complications of a pituitary tumor as well as GH (growth hormone) and IGF1 (insulin-like growth factor) excess-related cardio-metabolic and oncologic conditions; and associated medical, surgical treatment or even radiotherapy issues. We point out a few particular aspects concerning acromegaly issues amid COVID-19 pandemic. The review includes only full length, English published papers. One of the most important complications of long standing, untreated or un-responsive to therapy acromegaly is related to respiratory and otorhinolaryngology issues like sleep apnea; this becomes an important aspect causing pulmonary complications in patients with active coronavirus infection. In subjects who are not going through a COVID-19 infection, but they had a prior diagnostic of acromegaly, two main aspects of medical and surgical practice were noted: a massive reduction of surgical volume during the first year of pandemic, mostly during peak months of high infection rate in general population and the introduction of tele (digital) health care systems, of different protocols and various platforms mostly depending of medical center, rather than country or even continent related protocols. Associated central adrenal insufficiency requires a particular attention if COVID-19 positive. The data directly targeting the endocrinologists amid pandemic are very limited. ACROCOVID is a 2021 study that was internationally conducted based on a questionnaire that was applied to 84 endocrinologists (67% of them in Europe); 33% of acromegalic individuals had a delay on procedure because of insufficient COVID-19 assays and 54% of them due to inefficient provision for neurosurgery. Secondary diabetes mellitus (with a potential worsening in some patients due to pasireotide LAR) is at high risk for COVID-19 infection; the level of glycated hemoglobin A1c seems a good predictor at onset of infectious disease. Acromegaly might associate osteoporosis; coronavirus infection aggravates bone loss due to oxidative stress, inflammatory status, cytokine release, immobilization, glucocorticoid use. Acromegaly field concerning pandemic changes represents a complex, still ongoing matter involving both patients and multidisciplinary practitioners. [ABSTRACT FROM AUTHOR]

Scleroderma (systemic sclerosis) represents a challenging condition, usually requiring a multi-disciplinary team due to multi-organ involvement; it is mostly considered an autoimmune disease; the signature of the malady is the extensive fibrosis at the level of skin and multiple organs, associating endothelial/vessel damage and anomalies of immune response. We point out a few aspects concerning scleroderma-related osteoporosis. This is a literature review. Patients might associate low bone mineral density (the underling mechanisms are not entirely understood), thus an increased risk of fractures; so early recognition and treatment is mandatory for a better outcome. Some data showed that particularly vertebral fractures are prone to the condition. Almost half of individuals with the malady have osteoporosis (female prevalence, especially post-menopausal) and one third of them have an osteoporotic fracture. Older age and associated vitamin D deficiency increases the risk of fracture. Vitamin D has pleomorphic distribution, also targeting the immune modulation, cytokines puzzle, and the muscle-bone crosstalk in scleroderma. Hypovitaminosis D might be expected in these patients, while general D-supplementation has controversial benefits effects. Chronic inflammatory rheumatic conditions might benefit from the TBS use as fracture risk indicator through micro-architecture evaluation. It seems that patients with systemic sclerosis and malnutrition have lower TBS; high Dkk-1 serum levels (Dickkopf-1) is correlated with reduced TBS and advanced disease; TBS is correlated to the extent of microvascular complications; exposure to glucocorticoids (certain high-dose regimes) supplementary lowers TBS. Gastrointestinal complications are presented in 90% of patients with systemic sclerosis, involving fibrosis at any level which is a poor prognostic factor; malabsorption of nutrients and weight loss correlates with reduced bone formation while esophageal and gastric anomalies contraindicate the use of oral bisphosphonates for osteoporosis. Other abnormal elements of skeleton frame include: premature ovarian failure, serotonin system anomalies, chronic inflammation, potential side effects of immunosuppressant drugs. In patients with systemic sclerosis, the choices of medication targeting osteoporosis are limited; the use of intravenous bisphosphonates remains first line option (if renal function is adequate); the consideration of skin and esophageal anomalies is mandatory in the management of osteoporosis. Overall, the landscape of bone domain in systemic sclerosis is multi-leveled and some areas are still waiting for clear answers. [ABSTRACT FROM AUTHOR]

This is a narrative review of literature. We focus on the issue of identifying a parathyroid adenoma without anomalies of function (non-functioning parathyroid adenoma) which is incidentally detected or not, via routine neck ultrasound or through advanced imaging techniques which are mostly performed for other conditions (like assessment of a non-parathyroid oncological condition or emergencies – related neck exploration). The traditional diagnostic of primary hyperparathyroidism is exclusively a biological one based on high calcium and parathormone (PTH), and only a second step of assessment actually involves the localization procedures. However, the detection of a parathyroid tumor does not necessarily mean that it is associated with an over-secretion of PTH. Ultrasound is usually followed by Tc Sestamibi scintigram and/or computed tomography is order to refer the patient to parathyroidectomy in cases with biological confirmation of primary or renal hyperparathyroidism; yet, in cases with non-functioning profile, there is no clear indication of further imaging exploration. In conclusion, the identification of a parathyroid adenoma is rarely associated with a normal parathyroid function and this entity, which most probably is an incidentaloma, is not a subject of particular guidelines yet. Whether it is necessary to continue with other imaging techniques as typically seen in primary hyperparathyroidism is still an open issue, and so is the panel of indications to perform its surgical removal instead of serial follow-up. [ABSTRACT FROM AUTHOR]

Thyroid domain amid COVID-19 era has been involved in many ways, either in terms of patients with prior thyroid conditions who become COVID-19 positives, or coronavirus-induced de novo thyroid anomalies. This article represents a literature update on thyroid cancer (TC). The PubMed-based research includes a publication timeline regarding the first two years of pandemic (2020-2021). The general scientific interest on TC according to online research decreased during the first half of 2020 and got to the pre-pandemic level by the end of 2020. At the beginning of the pandemic, there was a delay in approaching the thyroid conditions, while telemedicine became a most useful tool, as seen in others areas of medicine. Post - 2020 lockdown medical presentation was associated with a more aggressive behavior of TC when compare to pre-pandemic data. Ongoing debates surround the topic of higher risk of COVID-19 infection in patients with a prior diagnostic of a thyroid malignancy in terms of having a higher risk of contracting the infection or an increased risk of developing a more severe form. There is not clear answer up to this point. Recent assets concerning TC field (non-COVID-19 data) that are released for the last two years concern the understanding of thyroid cancer genetics, the approach of shift from differentiated to anaplastic carcinoma, as well as evidence regarding new players in the oncological endocrinology like tyrosine kinase inhibitors for advanced forms of radioiodine refractory TC. For what we know so far, by the end of the second pandemic year, the patients with TC do not represent a fragile population when facing COVID-19 infection itself. However, the delay of adequate therapy amid restrictions is reflected in more severe malignancy behavior, while general concerns about the virus and pandemics increase the level of psychological and social stress. Case finding strategies to detect high risk patients as those on tyrosine kinase inhibitors with potential lung complications are needed. [ABSTRACT FROM AUTHOR]

Poorly differentiated/undifferentiated thyroid carcinoma represents a very severe type of malignancy with limited therapeutically resources. Fortunately, the diagnosis is very rare in general population; however, delayed presentation to a health care system might aggravate the evolution and during COVID-19 pandemic it was suggested an exacerbation of this phenomenon. This is a case report of a 56-year old lady diagnosed with poorly differentiated – undifferentiated thyroid carcinoma according to fine needle aspiration – based cytological exam. Despite having progressive large, neck mass with bone pain, asthenia, weight loss, and dysphagia since last months, she delayed the medical examination because of social anxiety amid COVID-19 pandemics. Poorly differentiated carcinoma still represents a sector of endocrinology with poor survival. Controversies around endocrine practice amid pandemic are still ongoing topics. [ABSTRACT FROM AUTHOR]

We aim to update the pandemic literature concerning thyroidectomies for benign and malign conditions. The inclusion criteria: PubMed published papers, the key words of research are “thyroidectomy” or “thyroid surgery” or “endocrine surgery” and “coronavirus”, “pandemic” or “COVID-19”. The reduction of thyroid ultrasound and fine needle aspiration is reflected in a lower volume of indications for surgery depending on the phases of pandemic and the rate of infections in general population. Imperative surgical approach is needed in cases with poor prognostic like poorly differentiated, undifferentiated, anaplastic and medullary carcinoma, while cases with well differentiated carcinoma originating from follicular cells associate a less aggressive behavior, thus the overall prognostic might not be affected if surgery is postponed. During the period of times with severe restrictions and high infection rates in general population, the delay of surgical procedures was unavoidable, thus scores of assigning the moment of operation were introduced as PAPS (Physician Assigned Priority Scoring) and MeNTS (Medically Necessary Time Sensitive). The need of assessing post-thyroidectomy complications is essential in situations when telemedicine is not a solution as severe cases of hypocalcemia, vocal folds damage, local liquid collections, etc. In conclusion, scores validation is still needed. Critical preoperatory decision takes into consideration the pandemic circumstances (COVID-19 status of the patient and of the health workers involved in the procedure). Use of digital health care systems might reduce the pre- and post-operatory burden. Overall, a reduction of thyroid surgery volume was registered during the first year of pandemic all over the world, while the procedure itself seems safe for the patient from a point of view related to the risk of coronavirus cross-infection. We aim to update the pandemic literature concerning thyroidectomies for benign and malign conditions. The inclusion criteria: PubMed published papers, the key words of research are “thyroidectomy” or “thyroid surgery” or “endocrine surgery” and “coronavirus”, “pandemic” or “COVID-19”. The reduction of thyroid ultrasound and fine needle aspiration is reflected in a lower volume of indications for surgery depending on the phases of pandemic and the rate of infections in general population. Imperative surgical approach is needed in cases with poor prognostic like poorly differentiated, undifferentiated, anaplastic and medullary carcinoma, while cases with well differentiated carcinoma originating from follicular cells associate a less aggressive behavior, thus the overall prognostic might not be affected if surgery is postponed. During the period of times with severe restrictions and high infection rates in general population, the delay of surgical procedures was unavoidable, thus scores of assigning the moment of operation were introduced as PAPS (Physician Assigned Priority Scoring) and MeNTS (Medically Necessary Time Sensitive). The need of assessing post-thyroidectomy complications is essential in situations when telemedicine is not a solution as severe cases of hypocalcemia, vocal folds damage, local liquid collections, etc. In conclusion, scores validation is still needed. Critical preoperatory decision takes into consideration the pandemic circumstances (COVID-19 status of the patient and of the health workers involved in the procedure). Use of digital health care systems might reduce the pre- and post-operatory burden. Overall, a reduction of thyroid surgery volume was registered during the first year of pandemic all over the world, while the procedure itself seems safe for the patient from a point of view related to the risk of coronavirus cross-infection. [ABSTRACT FROM AUTHOR]

In 2021, the scientific community was marked by the introduction of vaccine against COVID-19. This is major step in overcoming the pandemic, but it does not mean that several side effects or precautions are not related to the immunization; however, the current level of statistical evidence concerning potential negative effects is low, as logically expected at this point. We aim to introduce a female case who was confirmed with subacute thyroiditis after COVID-19 vaccination. Prompt recognition of subacute thyroiditis avoids unnecessary investigations, hospitalizations or even exposure to antibiotics as seen in this case. Early intervention with anti-inflammatory medication releases the symptoms. The association with vaccine against COVID-19 might be incidental or not; more evidence is needed but as far as we might think nowadays, the connection is possible, thus the importance of specific awareness. [ABSTRACT FROM AUTHOR]