discussion-presentation82

ID

• A 27 year old woman , from Astara , single , first born
• Source of history is the patient herself and was reliable

Chief complaint and HPI

• CC: adrenal mass, weight gain
• HPI: our patient is a 27-year-old woman who has been referred to endocrine clinic following adrenal mass
• Since the age of 25 year (1396 ) she has been suffered from weight gain(9kg) during 3month, acne, hirsutism, plethora, mood disorder and purplish striae, proximal muscle weakness , recurrent  infections , depression, moon face, suicide thoughts.
• she was referred to endocrinologist in Isfahan.
• In  work-up :diagnosis of Cushing's syndrome
• Evaluation: cortisol :19.5 ug/dl             (3.7-19.4) 
• Low dose dexa test : cortisol  36.3 ug/dl
• ACTH :42.8 pg/ml         cortisol 8 AM : 33.6 ug/dl          (5-21)
• Low dose dexa : 28.4 ug/dl
• UFC????

R/o: ectopic cushing

• Plan: high dose dexa ,chest CT , Pituitary MRI
• Brain MRI with and w/o contrast : Pituitary gland and hypothalamic area are normal
• high dose dexa test : cortisol : 23.64     ACTH: 46.98   calcitonin >2000
• Chest CT with contrast : a 2cm-mass in inlet of thorax
• Thyroid sonography : normal size, volume, parenchymal echo, Right lobes =>>16cc , many heterogenous  hypoechoic nodules, greater diameter 24mm     left lobes=>>12cc, a nodule 20mm      no lymphadenopathy
• FNA of thyroid bilateral nodules was consistent with medullary thyroid carcinoma.
• Whole body scan with Tc-Octreotide :

      1.   thyroid nodule of right lobe,

      2.   foci of abnormal radiotracer activity in the anatomical regions of both adrenals (more right adrenal)

      3.  no abnormal radiotracer uptake is noticed in mediastinum

• Abdomen and pelvic CT: right adrenal mass , diameter: 15 mm , hypodense , wash out < 40% (23.8) , 55-60 Hounsfield

Bilateral nodular hyperplasia should be considered in this case and hypodense mass may be a metastasis or part of nodular hyperplasia

• Panel of pheochromocytoma : normal
• T3:89      T4: 6.4     TSH :1.3
• Metanephrin : 142
• Normetanephrin : 274
• Epinephrin : 9.3
• Norepinephrin : 40.3
• At the age of 26 year she has been operated (Total thyroidectomy + radical lymph node dissection) at “Alzahra” hospital in Esfahan  96/05/10.
• Pathology : MTC; tumor size : 3cm in greater dimension      
• Margin : free of tumor
• Capsular invasion : present
• 9 cervical lymph nodes are involved by tumor 
• Staging : PT2 N1a Mx (at least stage lll)