A case of lymphocytic hypophysitis associated with Rathke's cleft cyst / 대한내과학회지

Lymphocytic hypophysitis is a rare disorder characterized by focal or diffuse inflammatory infiltration and destruction of the pituitary gland. It has classically been described as affecting female patients during peripartum period and its pathogenesis has been attributed with autoimmunity. Pressure symptoms and visual impairment may arise from the sellar mass lesion, and mass effect, involvement of the pituitary stalk, and pituitary destruction may result in endocrine dysfunction. Rathke's cleft cyst is a cystic sellar or suprasellar lesion thought to originate from the remnants of Rathke's pouch. It is characteristically lined by a single layer of ciliated cuboidal or columnar epithelium. Although small asymptomatic Rathke's cleft cysts have been reported at autopsy in 2~26% of normal pituitary glands, symptomatic cysts are rare. In symptomatic Rathke's cleft cysts, the common presentations include headache, pituitary dysfunction, and visual loss caused by compression of the optic chiasm in the event of suprasellar extension. Recently we experienced a case of lymphocytic hypophysitis with Rathke's cleft cyst resected by transsphenoidal approach under the preoperative impression of pituitary adenoma. This coexistence is exceedingly rare event, and to our best knowledge, this may be the first case of lymphocytic hypophysitis with Rathke's cleft cyst in Korea.

A Case of Papillary Thyroid Microcarcinoma Presenting as a Contralateral Cervical Lymph Node Metastasis / 대한내분비학회지

Papillary carcinomas account for 85~90% of all thyroid cancers, with the tumor size considered an important prognostic factor. As the use of high-resolution ultrasonography and fine needle aspiration biopsy have increased, the diagnosis of papillary microcarcinomas of the thyroid gland; defined by the World Health Organization as being less than 1 cm in diameter, has increased. They are generally associated with an excellent prognosis, with distant metastasis being extremely rare. They usually remain clinically silent until their incidental histological diagnosis by autopsy or surgical material. The incidence discovered at autopsy varies between 3 and 36%. Cervical lymph node metastases from papillary microcarcinomas have often been discovered, which may be the first and sole manifestation of the disease, without clinical suspicion of a thyroid tumor. Herein, the case of a papillary thyroid microcarcinoma, diagnosed after a total thyroidectomy due to its first presentation as a contralateral cervical lymph node metastasis, without evidence of a clinical thyroid tumor, is described.

A Case of Cushing's Syndrome Complicating Pregnancy Adrenalectomized after Delivery / 대한내분비학회지

Pregnancy is rare in women with Cushing's syndrome, as the associated infertility is related to excess cortisol and/or androgen. However, approximately 100 such cases have been reported, with 50% due to an adrenal cortical adenoma. Establishing a diagnosis and cause can be difficult. Clinically, striae, hypertension and gestational diabetes are common features in pregnancy, with hypertension and diabetes being the most common signs of Cushing's syndrome in pregnant women. Furthermore, biochemically, a normal pregnancy is associated with a several fold increase in plasma cortisol, as the increased cortisol production rate also increases the cortisol binding protein. Untreated, the condition results in high maternal and fetal morbidity and mortality. An adrenal or pituitary adenoma should be excised, but a metyrapone, which is not teratogenic, has been effective in controlling many cases of excess cortisol. Here, a case of Cushing's syndrome, complicating a pregnancy due to an adrenal cortical adenoma, with thorough obstetric and medical management, including a metyrapone, which was adrenalectomized after delivery, is reported.

Analysis of Prognostic Factors Determining the Recurrences in Patients with Papillary Thyroid Cancer After Surgical Treatment / 대한내분비학회지

BACKGROUND: It is important to recognize the independent prognostic factors of papillary carcinoma of thyroid in therapeutic and follow up planning. However, its good prognosis and its low prevalence make it difficult to analyze prognostic factors determining patients survival in a relatively short period of time. We retrospectively investigated the independent prognostic factors for determining disease recurrence after surgery which, in adults, are known to be closely related to the prognosis of cancer. METHOD: We retrospectively reviewed the clinical records of 456 patients (male 70, female 381, unknown 5, mean age of 43.9+-12.9 years) who had visited the thyroid clinic in Seoul National University Hospital and analyzed the data with statistical software program. RESULTS: 1) At initial visit, chief complaint of the patients was abnormal neck mass in 90 percent. 2) In preoperative thyroid scan study, 82% showed cold area and 16% showed diffuse enlargement. 3) Of the 50 recurrent cases after surgery (11.5% of the total cases), 39 cases (78%) had recurred disease in neck area and 11 cases (22%) had recurrences at distant sites. (Lung 9 cases, Brain I case, Mediastinum 1case) 4) Statistically significant risk factors for recurrence after surgery were male sex, size of tumor (above 4.5cm in this study), extrathyroidal invasion of cancer, involvement of resection margin and no remnant ablation of thyroid tissue using radioiodine. CONCLUSION: Through retrospective study, we presented some clinical characteristics of papillary thyroid cancer in Korea and independent risk factors of cancer recurrences after surgery.

The Diagnostic Value of a Low Dose (1ug) Rapid ACTH Stimulation Test to Assess the Adrenocortical Function / 대한내분비학회지

BACKGROUND: Insulin induced hypoglycemia has been used to assess the adrenocortical function, but may be hazardous. The standard rapid ACTH stimulation test has been advocated as a substitute but is sometimes insensitive. In this study, low dose (1ug) rapid ACTH stimulation test was compared to insulin induced hypoglycemia and standard dose (250ug) rapid ACTH stimulation. METHODS: 27 patients (14 men and 13 women) with pituitary disease and definite adrenocortical dysfunction (14 patients were confirmed by insulin induced hypoglycemia) and 23 controls (pituitary control: 3 men and 7 women, confirmed by insulin induced hypoglycemia, normal control: 8 men and 5 women) were studied. All subjects underwent rapid ACTH stimulation test with 2 different level of stimulation (1 and 250ug). Serum cortisol levels were measured at 0, 30 and 60 min after each dose of ACTH injection. A normal response was defined as a peak cortisol value of 497nrnol/L (18ug/dL) or above, RESULTS: During rapid ACTH stimulation study in controls, the peak serum cortisol level was significantly lower (690+-25lnmol/L (25.0+-9.1ug/dL) vs. 933+-257nmol/L (33.8+-9.3ug/dL); p0.1). None of these 27 patients showed normal response to low dose stimulation, but 2 of 27 did to standard dose. In controls, 19 of 23 showed normal response to low dose, and all of 23 did to standard dose (sensitivity 100% vs 92.5%, specificity 82.5% vs 100%). The results of low and high dose stimulation test agreed with those of insulin induced hypoglycemia (Kendalls g= 0.50 vs 0.92, p<0.01 vs 0.001). CONCLUSIONS: The results of a low dose (1ug) rapid ACTH stimulation test showed good correlation with those of the standard dose (250ug) rapid ACTH stimulation test and insulin induced hypoglycemia. Thus it may be used in screening for the diagnosis of adrenal insufficiency.

The Incidence of Thyroid Autoantibody in Subacute Thyroiditis and the Clinical Characteristics of Greeping Thyroiditis / 대한내분비학회지

Background: Subacute thyroiditis is a spontaneously resolving inflammatory disorder of thyroid gland, usually associated with painful goiter and short-lived thyrotoxicosis. Although its etiology is yet to be established, much evidence suggests viral infections and genetic factors play important roles. Usually, both lobes of thyroid gland are involved simultaneously, but in some patients one lobe is involved first and the other later(creeping thyroiditis), Thyroid autoantibodies which might appear probably due to inflammatory release of thyroid antigens, are found in a variable number of patients with subacute thyroiditis. However there have been few detailed reports on their incidence in Korean patients with subacute thyroiditis. So, we were to see the elinical characteristics of patients with subacute thyroiditis with special regards to the incidence of thyroid autoantibodies and to the incidence and characteristics of creeping thyroiditis, Methods: We reviewed the clinical records of 85 patients with subacute thyroiditis(7 men and 78 wornen, meam age of 43+9 years) who had visited the thyroid clinic in Seoul National University Hospital between 1986 and 1994. Results: At initial visit, the incidenees of thyroid autoantibodies were as follows: anti- microsomal antibody 7.8%, anti-thyroglobulin antibody 22.1%, and thyratropin binding inhibitor inununglobulin 6.3%. During the follow-up period, thyroid autoantibodies appeared most frequently between the first and the second month after initial visit. Compared to those with non-creeping thyroiditis, the patients with creeping thyroiditis(21.4%) had nonspecific systemic sy~rnptoms more frequently(89% vs. 42%, p<0.05). They required steroid therapy more ftequently(89% vs. 52%, p <0.05), and needed longer duration of treatment(9.3+6.2weeks vs, 4.7+3.7weeks, p<0.05). The incidence of abnormalities in liver function and the incidence of thyroid autoantibodies were higher in non-creeping thyroiditis group. Conclusion: In accordance with previous reports, thyroid autoantibodies were detected in only a small portion of Korean patients with subacute thyroiditis. Rather different clinical manifestations and different incidences of thyroid autoantibodies between ereeping group and non-creeping group suggest differences in the pathogenetic mechanisms between those two groups. However, there is need for further study to validate such observation and to elucidate the mechanisms.

The Localization of Microadenoma with Sella Imaging Study and Inferior Petrosal Sinus Sampling in Cushing's Disease / 대한내분비학회지

Background: Inferior petrosal sinus sampling(IPSS) is known to be useful for the differential diagnosis of ACTH-dependent Cushings syndrome and for the preoperative lateralization of pituitary microadenoma. We tried to analyze the relative value of IPSS in localization of microadenoma as compared with sella imaging study including computerized tomogram(CT) or magnet resonance imaging(MRI) in Cushings disease. Methods: We reviewed the clinical records of 21 patients with Cushings disease who underwent IPSS and the radiologic study such as sella CT or sella MRI preoperatively followed by transsphenoidal microsurgery. By pathologic examination including immunohistochemistry and postoperative clinical and biochemical evaluation we confirmed the diagnosis of Cushings disease due to pituitary microadenoma in all 21 cases. Results: Sella CT or sella MRI detected microadenoma in 57.1% of cases( =12/21), while recently available dynamic MRI did so in 7 out of S cases. With IPSS the diagnosis of Cushings disease was possible in 90.5% of cases(= 19/21), but accurate lateralization of microadenoma was achieved in only 63.2% of cases( =12/19). IPSS precisely localized the pituitary microadenoma in 6 out of 9 cases whose lesion were not detected by the radiologic study. Of 7 cases in which IPSS failed to localize microadenoma, the radiologic study detected the lesion in 6 cases. Of 5 cases in which IPSS and the radiologic study showed a discrepancy in location of microadenoma, the radiologic study correctly localizaed the lesion in 4 cases and IPSS did so in one case. Conclusion: IPSS is not more reliable than sella imaging study for preoperative localization of microadenoma in Cushings disease. However it might have a complementary role, especially when sella imaging study failed to visualize the lesion.

A Case of Thyroid Anaplastic Cancer with Intestinal Metastasis / 대한내분비학회지

Thyroid anaplastic cancer is one of the most malignant neoplasms encountered in human. These tumors usually present as rapidly enlarging neck mass in old patients who may or may not have had a previously recognized goiter. The distant metastases of anaplastic cancer eventually occur in about 50% patients, mostly in the lung and bone and are an important prognostic factor, substantially reducing survival time.A 66-year old man visited out hospital because of rapidly growing anterior neck mass and hoarseness. He was diagnosed as thyroid anaplastic cancer with lymph node and lung metastasis and received combined chemotherapy and radiation therapy. On the 8th hospital day, severe abdominal pain developed and exploratory laparotomy was conducted. During operation, two intestinal mass were discovered, one of which was perforated. The microscopic examinations showed that undifferentiated malignant cells were infiltrated in the wall of small bowel. We report this case because we first experienced thyroid anaplastic cancer with intestinal metastasis.

A Clinical study on the diagnesis and Treatment of Cushing's Disease / 대한내분비학회지

Bilateral inferior petrosal sinus sampling(IPSS) is known to be useful for the differential diagnosis of ACTH-dependent Cushing's syndrome and for the preoperative localization of pituitary microadenomas.To evaluate the usefulness of IPSS, we performed the procedure in the 17 cases of ACTH-dependent Cushing's syndrome including 2 cases of macroadenomas, 6 of them with CRH stimulation test. A inferior petrosal sinus-to-peripheral ACTH ratio of 2:1 or greater(3:1 after CRH stimulation) indicates a pituitary source of ACTH hypersecretion, and a ratio of the ACTH level in one inferior petrosal sinus to the ACTH level in the other of 1:4 or greater lateralizes the microadenomas to that half of the pituitary gland.With these criteria, we diagnosed Cushing's disease in 15 of 17 cases of ACTH-dependent Cushing's syndrome, and localized the lesion in 8 of 13 cases of microadenoma.In conclusion, IPSS with CRH stimulation has high diagnostic accuracy in the differential diagnosis of ACTH-dependent Cushing's syndrome, but still has the limitations on the localization of microadenoma.

Activation of phosphatidylinositol 4, 5-biphosphate(PIP2) cascade by thyroid stimulating antibody / 대한내분비학회지

No abstract available.