Contemporary radiologic imaging of renal cortical tumors.

Contemporary radiologic imaging has resulted in an increasing number of smaller renal cortical tumors being identified. The ability of imaging to classify these tumors is limited, although certain features may help classify the renal cortical neoplasm. The important role of radiologic imaging in tumor detection, characterization, staging, and follow-up of patients who have renal cortical tumors is reviewed in this article.

Genética molecular del cáncer renal: utilidad en pronóstico y posibilidades terapéuticas / Molecular genetics of renal cancer: usefulness in prognosis and therapeutic possibilities

El cáncer renal tiene una incidencia del 3% del total de las neoplasias en adultos, y puede ser tanto de origen hereditario como esporádico. Histológicamente se clasifica en 5 tipos principales. Las técnicas actuales de citogenética y biología molecular han permitido conocer con más detalle algunos de los sucesos genéticos iniciales que causa la patogenia de los tipos mayoritarios como, por ejemplo, que un defecto en el cromosoma 3p está implicado en el desarrollo del carcinoma de células claras (ccRCC) o que en un 13% de los RCC de tipo papilar está mutado el gen c-MET (cromosoma 7), y en el resto de cánceres de este tipo existe duplicación de este mismo cromosoma, o que, en los oncocitomas la pérdida de los cromosomas 1 y/o 14 podría representar el suceso inicial. Aparte de estos defectos, el conocimiento de otros genes y alteraciones cromosómicas implicados, junto con otros factores, permite definir de manera aproximada el pronóstico en cada caso. Debido a que este tipo de cáncer desarrolla metástasis rápidamente, las terapias actuales, como la cirugía y el uso de interleucina (IL) 2, son poco eficaces y sólo consiguen alargar en unos meses la supervivencia del paciente. Aunque se están ensayando nuevas terapias, es necesario un conocimiento más profundo de los procesos moleculares implicados para obtener el éxito deseado tanto en el diagnóstico precoz como en el pronóstico y el tratamiento de la enfermedad(AU)

Renal cancer has a 3% incidence of all neoplasms in adults and it can be of hereditary or sporadic origin. Histologically, it is classified into 5 main types. The current cytogenetic and molecular biology techniques allow some of the initial genetic events responsible for the main types of pathogenesis to be studied in more detail, such as the implication of a defect in chromosome 3p in the development of clear cell renal cell carcinoma (ccRCC), or the presence of the mutated c-MET gene (chromosome 7) in 13% of papillary RCCs and the presence of the same chromosome duplication in the rest of these types of cancer, or the loss of chromosomes 1 and/or 14 which could represent the initial event in oncocytomas. Apart from these defects, knowledge other genes involved and chromosomic defects, as well as other factors, may enable an approximate prognosis to be made in each case. As the metastatic process in this cancer type develops very early, the current therapies, such as surgery and the use of IL-2, are not very effective and they only manage to extend patient survival by a few months. Although newer therapies are being assessed, a deeper knowledge about the molecular processes involved is necessary to obtain the desirable success both in the early diagnosis, as well as the prognosis and treatment of the disease(AU)

[Differential diagnosis in visual field defects of glaucoma patients]. / Differenzialdiagnose bei glaukomatösen Gesichtsfeldausfällen.

In both cases optic disc neuropathy with perimetry defects and loss of vision is caused by a cerebral tumour. The progression of optic damage was stopped by resection of the tumor in both patients. We recommend the performance of a radiological examination in patients with visual field defects if the intraocular pressure is normal and thus glaucoma may not be the cause of the defects.

Utilidad de la citología en el diagnóstico y manejo de tumores renales y perirrenales del adulto / Usefulness of cytology in diagnosis and management of renal and perirenal tumors in adults

Introducción: El uso cada vez mas extendido de tumorectomías, nefrectomías parciales y tratamientos no quirúrgicos de tumores renales ha supuesto un renovado interés en el uso diagnóstico de la citología. Ya sea de forma preoperatoria, a través de la punción aspiración con aguja fina (PAAF), o durante el análisis intraoperatorio, la citología ofrece la posibilidad de un diagnóstico morfológico específico. En esta revisión se actualiza la información concerniente al valor diagnóstico de la citología de tumores renales. Material y métodos: Se ha revisado la bibliografía relativa a las descripciones citológicas de masas renales. Para ello se ha procedido tanto a búsqueda computerizada en la base de datos Medline, como a búsqueda bibliográfica manual. Del mismo modo se incluye la experiencia de los autores tanto en la PAAF de estas lesiones como en el uso intraoperatorio de la citología. Resultados: Entre las neoplasias con presentación citológica más característica destacan el carcinoma renal de células claras y el carcinoma renal papilar. El carcinoma cromófobo y el oncocitoma renal pueden mostrar similitudes, si bien la experiencia acumulada en los últimos años refleja que su diferenciación es posible en la mayoría de los casos. Para el diagnóstico de angiomiolipoma, carcinoma urotelial y metástasis en riñón, la información clínica y de imagen resulta es de gran interés para el patólogo. La integración de dichos datos suele permitir un diagnóstico específico. Conclusión: En general, la citología refleja con fidelidad las características histológicas de las neoplasias renales, permitiendo en muchos casos un diagnóstico específico. Ante la cada vez más frecuente situación de “incidentaloma” renal, consideramos muy apropiado el uso diagnóstico de la citología. La naturaleza mínimamente invasiva de la PAAF y la posibilidad de realización de análisis citológico rápido durante estudios intraoperatorios ofrecen importante información para el manejo terapéutico de estos pacientes

Introduction: The use more and more extended of tumorectomy, partial nephrectomy and nonsurgical treatments of renal tumors has supposed a renewed interest in the diagnosis use of cytology. Whether during preoperative period, through the puncture aspiration with fine needle (PAAF), or during the intraoperative analysis, the cytology offers the possibility of a specific morphologic diagnosis. In this revision the information concerning the diagnostic value of the cytology in renal tumors is updated. Material and methods: The references related to renal masses cytological descriptions has been reviewed. For this purpose we have searched both with computer in Medline data base and also manually. In the same way we include authors experience as much in the PAAF of these lesions as in the intraoperative use of the cytology. Results: Between neoplasias with more cytological typical presentation are the clear cell renal and papillary carcinomas. The chromophobe and oncocytoma can show similarities, although the accumulated experience in the last years reflects that its differentiation is possible in most of the cases. For the diagnosis of angiomyolipoma, urothelial carcinoma and kidney metastasis, the clinical and image information are of great interest for the pathologist. The integration of these data usually allows a specific diagnosis. Conclusion: Generally, cytology reflects with accuracy the histological characteristics of renal neoplasias, allowing in many cases a specific diagnosis. We consider much appropriated the use of cytology, due to the more and more frequent situation of “incidentaloma”. The PAAF minimum invasive nature and the possibility of performing a fast cytological analysis during intraoperative studies offer important information for the therapeutic management of these patients

[A case of GH and TSH secreting pituitary macroadenoma]. / Przypadek makrogruczolaka przysadki wydzielacego hormon wzrostu i tyreotropin.

A case of GH and TSH secreting pituitary macroadenoma is reported. A 45-year-old female presented clinical features of acromegaly (the abnormal growth of the hands and feet, with lower jaw protrusion), diabetes mellitus, hypertension, nodular goiter and hyperthyroidism of unclear origin. NMR pituitary imaging revealed intra and extrasellar tumor. The laboratory examinations showed very high plasma levels of GH and IGF-1 and normal level of TSH coexisting with high plasma levels of free thyroid hormones. Pharmacological pretreatment with somatostatin analogues caused the substantial reduction of GH and TSH plasma levels. Histological and immunohistochemical examination of the tissue obtained at transsphenoidal surgery showed GH and TSH secreting adenoma. The laboratory examinations after surgery showed normal GH and IGF-1 plasma levels and reduced insulin requirement, what indicates radical operation. The very low plasma levels of TSH and free thyroid hormones after surgery and immunohistochemical examination suggest central hyperthyroidism due to TSH secreting pituitary tumor (thyrotropinoma).

[The strange case of a patient affected by acromegaly with osteoporomalacia without hypogonadism]. / Lo strano caso di un paziente affetto da acromegalia con osteoporomalacia senza ipogonadismo.

Acromegaly is a rare disease that, in the majority of cases, is due to the presence of a benign growth hormone (GH)-producing tumor of the pituitary. Growth hormone has profound effects on linear bone growth, bone metabolism, and bone mass. In acromegaly, the skeletal effects of chronic GH excess have been mainly addressed by evaluating bone mineral density (BMD). Most data were obtained in patients with active acromegaly, and apparently high or normal BMD was observed in the absence of hypogonadism. The Autors describe a case of patient affected by acromegaly without hypogonadism with serious osteoporosis and biological signs of osteomalacia.

Clinical and endocrine aspects of pituitary tumors.

OBJECTIVE: To study the clinical spectrum and endocrine profile of pituitary tumors presenting to a tertiary care endocrine center. METHODS: Retrospective analysis of clinical and hormonal data of patients with pituitary tumors admitted in the Endocrinology Department of Sher-i-Kashmir Institute of Medical Sciences, Srinagar, Kashmir India between January 1989 and December 1998. RESULTS: Over a period of one decade, 75 subjects were diagnosed to have pituitary tumors. Somatotroph adenoma was the most common pituitary mass lesion seen (44/75) and followed in the decreasing order of frequency, by non-functioning pituitary tumor (12/75), prolactinoma (11/75) and corticotroph adenoma (8/75). Overall there was a male preponderance (male to female ratio was 41:34). Subjects with somatotroph adenoma presented with classical features of acromegaly: mean fasting and post glucose suppression growth hormone levels were 34.04+/-11.67 and 36.47+/-6.64 ng/ml. Eleven subjects (9 females and 2 males) had prolactinoma; females presented with the classical symptom complex of amenorrhea-galactorrhea while males presented with headache, visual disturbances and impotence. The 12 subjects with nonfunctioning pituitary tumors presented with features of mass lesion. Of the 8 subjects (6 females and 2 males) with corticotroph adenomas, 2 were confirmed to have periodic hormonogenesis. CONCLUSION: In an endocrine center, functioning pituitary tumors are more often seen than non-functioning tumors.

[Mental changes in course of pituitary gland tumour--a case study]. / Zmiany psychiczne u chorego z guzem przysadki mózgowej--opis przypadku.

The aim of this paper is to present a case of a 59-year old patient diagnosed with a pituitary gland tumour. The psychiatric examination at the day of admission to the clinic suggested the manic episode was based upon the disseminated organic brain lesion. The patient presented mood elevation, carefree joviality, excitement, loss of social inhibition, inability to sustain attention. In course of the clinical observation and diagnostic progress the pituitary gland tumour was revealed and neurosurgical treatment was applied. The psychopathological course of the disorder was not typical for the established location. The psychopathological syndrome that was presented by the patient gave the global clinical impression of frontal and temporal lobes' dysfunction. This case report supports the present neurobiological opinions criticizing the direct relation of the location to the function within the central nervous system.

Synchronous subarachnoid drop metastases from a pituitary adenoma with multiple recurrences. Case report.

The authors report the case of a 49-year-old man with synchronous drop metastases from a multiply recurrent somatotroph pituitary adenoma. The metastatic lesions were found in the subarachnoid space of the cauda equina and foramen magnum 18 years after the initial diagnosis of the disease. Five transsphenoidal resections had previously failed to cure the sellar tumor. Two of these, performed 4 and 5 years before the patient's current presentation, had been complicated by cerebrospinal fluid rhinorrhea that necessitated lumbar drainage. Resections of the two subarachnoid lesions, separated by 14 months, removed pathologically aggressive pituitary adenomas. There were no signs of local recurrence or subarachnoid dissemination of disease during the postoperative follow-up periods, which lasted 18 and 4 months, respectively. Previous cases of subarachnoid spread of a pituitary adenoma have been associated with multiple intracranial metastases, multiple intraspinal metastases, or widely disseminated disease. This case demonstrates that subarachnoid metastasis of a pituitary adenoma, particularly when it follows multiple operations, is not invariably widely disseminated or associated with a very poor prognosis.

Subclinical Cushing's disease accompanied by malignant hypertension and diabetes mellitus.

A 53-year-old woman was admitted because of hypertension and diabetes mellitus. Elevated diastolic blood pressure, hypertensive retinopathy and renal dysfunction indicated malignant hypertension. Adrenocorticotropic hormone (ACTH) and cortisol levels were high although there were no Cushingoid features. One mg dexamethasone administration decreased neither ACTH nor cortisol levels. Brain magnetic resonance imaging revealed a left pituitary tumor (7 mm x 6 mm). Upon removal, the tumor showed positive ACTH staining by immnohistochemistry, and was diagnosed as pituitary ACTH-secreting adenoma (Cushing's disease). Her blood pressure, renal function, blood glucose and hormone levels subsequently improved. Malignant hypertension and deteriorated diabetes mellitus may have been due to subclinical Cushing's disease.

Simultaneous treatment of a pituitary adenoma and an internal carotid artery aneurysm through a supraorbital keyhole approach.

We describe a case in which an incidental left carotid aneurysm was found during the preoperative evaluation of a pituitary adenoma. After magnetic resonance imaging (MRI) and angiography delineated their characteristics, we chose to treat both lesions simultaneously through a left supraorbital keyhole approach. The aneurysm clipping was followed by intracapsular resection of the tumor that was identified later as a non-secretory adenoma. The postoperative course was uneventful. This case shows that in carefully selected patients it is possible to treat successfully concurrent conditions through a minimally invasive approach, with the well known advantages of low morbidity and a short hospital stay.

Galactorrhea may be clue to serious problems. Patients deserve a thorough workup.

Three cases of nonphysiologic hyperprolactinemia associated with pituitary disease evidenced by galactorrhea are presented. Two patients had significant pituitary disease associated with low-level prolactin elevations. The third patient had only a history of infertility and expressible galactorrhea on examination. This patient was found to have high prolactin levels and a locally invasive pituitary tumor. Physicians need to be aware of the serious conditions associated with galactorrhea so that appropriate diagnostic studies can be done and treatment instituted.

Retinitis pigmentosa in association with acromegaly: a case report.

Retinal abnormalities, unrelated to visual pathway compression, in acromegalic patients were originally described by Small in 1972 (Smail JM. Primary pigmentary degeneration of the retina and acromegaly in a case of pituitary adenoma. Br J Ophthalmol 1972; 56: 25-31). He illustrated a case of primary pigmentary degeneration of the retina occurring in a patient with a chromophobe adenoma of the pituitary gland. To the best of our knowledge this remains the sole, published case of this association. We report on two male patients, with an acromegalic appearance, one caused by a pituitary adenoma, the other associated with a Rathke's cleft cyst, presenting to our department of ophthalmology with the clinical picture of pigmentary degeneration of the retina.

[Diagnosis and surgical treatment of pituitary microadenoma].

OBJECTIVE: Through the experiences of clinic picture and the radiologic characteristics of eleven cases of micropituitary adenomas, the early diagnosis and surgical indications were discussed. METHODS: Intensified CT and MRI were used to compare their significances in the diagnosis of micropituitary adenomas. Kaltai incision of the nares and transsphenoidal approach were adopted in these cases. RESULTS: The bulging of the upper border of the pituitary gland and the shifting position of the pituitary stalk observed in the intensified MRI are the pathognomonic signs for the diagnosis of micropituitary adenoma. The operation was stopped due to hemorrhage in one case. The average following up was 3.2 years past operative death in the second month in one case, operative failure in one case and loss of following up in one case. CONCLUSION: Strict selection of surgical indications must be done necessary after careful study of MRI.

Pituitary tumours.

This report describes the presentation, pre-operative findings, surgical management and follow-up results of 20 pediatric patients with pituitary adenomas. The most common presenting complaints encountered were, headache and decrease in visual acuity. Among the patients with endocrine problems, majority had frank Cushing's disease (30%). Nine patients (45%) were endocrinally normal. The most common, histological type of pituitary tumour encountered in this series was the Chromophobe adenoma. One patient died following surgery. Radiation therapy was given in all post operative cases. Response to radiation therapy has been satisfactory on follow up. The generally encouraging results we have observed following the multi-disciplinary treatment, confirms the findings reported by other workers.

A case of nonfunctioning pituitary adenoma resembling so-called silent corticotroph adenoma.

It has been indicated that some subsets of clinically nonfunctioning pituitary adenoma exhibit immunohistochemical and ultrastructural features of somatotroph or corticotroph cells, which are described as silent somatotroph and corticotroph adenomas, respectively. We here describe a 70-year-old woman with nonfunctioning pituitary adenoma presenting with visual disturbance. None of the pituitary hormones show abnormal finding. Magnetic resonance imaging study revealed a pituitary tumor which developed inferiorly into the sphenoidal sinus. Tumor resection was performed by a transsphenoidal approach, and resulted in a partial resection of the tumor. The specimen indicated chromophobic adenoma. Immunohistochemical examination revealed a characteristic distribution pattern of cytokeratin staining for ACTH cell adenoma, although immunostaining for ACTH was only weakly positive. After the operation, only ACTH secretion was impaired, requiring replacement therapy with glucocorticoid. Bromocriptine was administered in order to prevent the recurrence of the tumor. It remains to be elucidated whether the present case could be classified as silent corticotroph adenoma, which was originally indicated to have aggressive characteristics, i.e., progressive visual defect, high incidence of infarction and frequent recurrence.