Recurrent primary hyperparathyroidism: a diagnostic and management dilemma

Summary Primary hyperparathyroidism requires a surgical approach to achieve a long-term cure. However, post-surgical recurrence significantly complicates the management of this condition. A number of causes for recurrent disease are well understood and several diagnostic modalities exist to localise the culprit parathyroid adenoma although none of them is efficacious in localisation of the recurrent lesion. In this case report, we highlight a novel causative mechanism and describe a unique diagnostic sequence that enabled curative treatment to be delivered. Learning points In the case described herein, we describe a novel location for a parathyroid adenoma causing recurrent PHPT. The case elucidates well the difficulties presented by such cases in terms of surgical planning and show the utility of PVS in such cases. Based on this case, we make the following recommendations: Meticulous care must be taken to prevent seeding of adenomatous tissue during primary excision. To consider the use of PVS in patients with discordant imaging in the setting of recurrent/persistent PHPT as a method to localise the causative adenoma. Same day PVS and surgery is a viable option for patients who either represent an anaesthetic risk or who are extremely anxious about the prospect of two separate procedures. Disordered calcium homeostasis is an important but forgotten cause of dysphagia which can be extremely debilitating for affected patients.

Tissue mRNA for S100A4, S100A6, S100A8, S100A9, S100A11 and S100P Proteins in Colorectal Neoplasia: A Pilot Study

S100 proteins are involved in the pathogenesis of sporadic colorectal carcinoma through different mechanisms. The aim of our study was to assess tissue mRNA encoding S100 proteins in patients with non-advanced and advanced colorectal adenoma. Mucosal biopsies were taken from the caecum, transverse colon and rectum during diagnostic and/or therapeutic colonoscopy. Another biopsy was obtained from adenomatous tissue in the advanced adenoma group. The tissue mRNA for each S100 protein (S100A4, S100A6, S100A8, S100A9, S100A11 and S100P) was investigated. Eighteen biopsies were obtained from the healthy mucosa in controls and the non-advanced adenoma group (six individuals in each group) and thirty biopsies in the advanced adenoma group (ten patients). Nine biopsies were obtained from advanced adenoma tissue (9/10 patients). Significant differences in mRNA investigated in the healthy mucosa were identified between (1) controls and the advanced adenoma group for S100A6 (p = 0.012), (2) controls and the non-advanced adenoma group for S100A8 (p = 0.033) and (3) controls and the advanced adenoma group for S100A11 (p = 0.005). In the advanced adenoma group, differences between the healthy mucosa and adenomatous tissue were found in S100A6 (p = 0.002), S100A8 (p = 0.002), S100A9 (p = 0.021) and S100A11 (p = 0.029). Abnormal mRNA expression for different S100 proteins was identified in the pathological adenomatous tissue as well as in the morphologically normal large intestinal mucosa.

Pituitary Apoplexy with raised intracranial pressure

Pituitary apoplexy in pre-existing pituitary adenomas occurs as a consequence of acute hemorrhage or infarction. Patients with pituitary apoplexy present with sudden onset headache, vomiting, clouding of consciousness and visual field defects or total oculomotor palsies without any prior diagnosis of pituitary tumor. In this case report, we report a case of 52 years female who presented to the emergency department with headache throughout her head and periorbital area with vomiting. Investigations revealed sellar cystic lesion suggestive of pituitary apoplexy with normal hormonal profile. She underwent endoscopic trans-nasal trans-sphenoidal surgery with complete resection of pituitary adenoma. Histopathological examination of tumor specimen showed large areas of necrosis with blood surrounded by the adenomatous tissue. Post-operatively she had cerebrospinal fluid rhinorrhea with persistent papilledema and hydrocephalus. Sellar floor repair along with theco-peritoneal shunt lead to good recovery.

CD31-positive microvessel density within adenomas of Lynch Syndrome patients is similar compared to adenomas of non-Lynch patients

Background and study aims Microsatellite instability accelerates colorectal cancer development in patients with Lynch syndrome (LS). Previous research showed that virtual chromoendoscopy increases detection of adenomas during colonoscopy surveillance of patients with LS. Because previous research revealed that Lynch patients have an increased vascular network in the oral mucosa, we hypothesized that increased vascularization of LS-associated adenomas is the cause of better detection with virtual chromoendoscopy. Patients and methods In this pilot study, patients with LS having a proven germline mutation were selected from two tertiary referral hospitals and non-LS patients from an outpatient colonoscopy center. Adenomas from patients with LS were exactly matched in size and histology with adenomas from non-LS patients. Initial adenoma diagnosis was confirmed by a specialist pathologist. All adenomas were stained with CD31 and adenomatous tissue was annotated by the specialist pathologist. Image analysis of CD31-positive microvessel density was conducted using FIJI software. Results Colonoscopy of 63 patients with LS and 24 non-LS patients provided 40 adenomas that could be exactly matched in size and histology. In image-analysis, the CD31-positive microvessel density (2.49 % vs. 2.47 %, P = 0.96), the average size of CD31-positive structures (514 μm2 vs. 523 μm2, P = 0.26) nor the amount of vascular structures per mm2 (183 vs. 176, P = 0.50) differed between adenomas of LS patients and non-Lynch patients. Conclusion The outcomes of this pilot case-control study did not provide further insights into the mechanism of increased adenoma detection in LS patients using virtual chromoendoscopy techniques.

Technical Features of Robot-Assisted Prostatectomy in Patients with Very Enlarged Prostates

Introduction. According to scientific studies, adenocarcinoma coincides with adenomatous tissue within the same prostate gland in 10–83.3 % of cases (including incidental cancer). Clinical situations in which the adenoma reaches a significant size (typically greater than 80 cm3 ) and thus creates considerable difficulties for surgeons occurs in not more than in 8–10 % of all cases of prostatectomy. Given the limitations of external beam radiotherapy and brachytherapy related with prostate volume and poor quality of urination, radical prostatectomy in this group of patients remains the treatment of choice. Features of adenoma, such as large median and lateral lobes, the presence of cystostomy and bladder stones, significantly complicate operational benefits. When an enlarged prostate is one of the factors prior to surgery, robotic technology may have certain advantages.The main goalof this work is to demonstrate the technical advantages of robot-assisted prostatectomy associated with enlarged prostate.Results and discussion. We describe the anatomical landmarks and possible surgical methods for overcoming different variations of benign hyperplasia of the prostate using robot-assisted prostatectomy. This information is particularly useful to surgeons aiming to master robotic surgical platforms. Robot-assisted prostatectomy can be effectively used in the treatment of prostate cancer associated with benign prostatic hyperplasia, and patients can have confidence in the results of such an operation.Conclusion. If a surgeon is sufficiently experienced, robot-assisted prostatectomy may become the method of choice in the treatment of patients with enlarged prostates.

Role of Bone Marrow-Derived Stem Cells in Polyps Development in Mice with ApcMin/+Mutation

We explored the hypothesis that an altered microenvironment (intestinal adenomatous polyp) could modify the differentiation program of bone marrow-derived stem cells (BMSCs), involving them in colon carcinogenesis. Sublethally irradiated 8-week-old femaleApcMin/+mice were transplanted with bone marrow (BM) cells obtained from either male age-matchedApcMin/+(Apc-Tx-Apc) or wild type (WT) (WT-Tx-Apc) mice. At 4 and 7 weeks after transplantation, BM-derived colonocytes were recognized by colocalization of Y-chromosome and Cdx2 protein (specific colonocyte marker). Polyp number, volume, and grade of dysplasia were not influenced by irradiation/transplantation procedures since they were similar in both untreated femaleApcMin/+and Apc-Tx-Apc mice. At 4 and 7 weeks after transplantation, a progressive significant reduction of polyp number and volume was observed in WT-Tx-Apc mice. Moreover, the number of WT-Tx-Apc mice with a high-grade dysplastic polyps significantly decreased as compared to Apc-Tx-Apc mice. Finally, at 4 and 7 weeks after transplantation, WT-Tx-Apc mice showed a progressive significant increase of Y+/Cdx2+ cells in “normal” mucosa, whereas, in the adenomatous tissue, Y+/Cdx2+ cells remained substantially unvaried. Our findings demonstrate that WT BMSCs do not participate in polyp development but rather inhibit their growth. The substitution of genotypically altered colonocytes with Y+/Cdx2+ cells probably contributes to this process.

Secondary erythrocytosis in patient with acromegaly

A 53-year old man with acromegaly was referred for neurosurgical treatment. At admission: growth hormone (GH) 240 ME/l at all time points of glucose tolerance test, IGF-1 - 415,1 ng/ml, brain MRI showed pituitary adenoma 34×32×27 mm extending suprasellar, deforming and displacing optic chiasm, parasellar to both cavernous sinuses and surrounding left internal carotid artery. Clinical blood tests revealed marked erythrocytosis - 6.1×1012, Hb - 200 g/l, HCT - 62%; urobilinigen 50 mmol/l was found in urine; otherwise the tests were normal. For exclusion of erythraemia the patient underwent trepanobiopsy of bone marrow which showed normal haemopoesis and suggested a secondary nature of erythrocytosis. In preoperative period 1100 ml of blood were evacuated by phlebotomy in 4 sessions, which resulted in reduction of erythrocyte count to 5,1×1012, Hb 160 g/l, HCT 50% and disappearance of urobilinigen. The patient was then operated by transnasal approach with debulking of most adenomatous tissue but without biochemical remission of acromegaly (GH 92-99 at glucose tolerance test). A week after surgery - erythrocytes 4,5×1012, Hb - 141 g/l, HCT - 44,1%. The patient was prescribed a octreotide depo (Sandostatin LAR) injections 20 mg/mth and at 6 months from operation was feeling well, with clinical remission of acromegaly and normalization of IGF-1 and all blood count parameters.

Hypoglycemic Syndrome in a Patient with Proinsulin-Only Secreting Pancreatic Adenoma (Proinsulinoma)

We describe an unusual case of hypoglycemic syndrome in a 69-year old woman with a proinsulin-only secreting pancreatic endocrine adenoma. The clinical history was highly suggestive of an organic hypoglycemia, with normal or relatively low insulin concentrations and elevated proinsulin levels. Magnetic resonance and computed tomography of the abdomen showed a 1 cm pancreatic nodule and multiple accessory spleens. The diagnosis was confirmed by selective angiography, showing location and vascularization of the nodule, despite no response to intra-arterial calcium. After resection, the hypoglycemic syndrome resolved. The surgical specimen was comprised of a neuroendocrine adenomatous tissue with high proinsulin immunoreactivity. Study of this unusual case of proinsulinoma underlines (i) the need to assay proinsulin in patients with hypoglycemia and normal immunoreactive insulin, (ii) the differential diagnosis in the presence of accessory spleens, (iii) the unresponsiveness to intra-arterial calcium stimulation, and (iv) the extensive evaluation needed to reach a final diagnosis.