Objective: To describe a patient with isolated symptomatic pituitary metastasis from Renal Cell Carcinoma (RCC) in a horseshoe kidney. Case report: We report a case of 56-year-old man with RCC of a horseshoe kidney with symptomatic isolated pituitary gland metastasis. He initially presented to us for evaluation of a sellar mass. He complained of fatigue, 50-pound weight loss, anorexia, constipation and nonspecific abdominal pain for 4 months. CT head showed 2.6 cm × 1.8 cm × 2.5 cm sellar mass likely with bilateral cavernous sinus extension. Pituitary function evaluation revealed panhypopituitarism. CT abdomen/pelvis for the evaluation of abdominal pain showed 12.1 cm solid mass in the right renal moiety of a horseshoe kidney. Hydrocortisone and levothyroxine therapy led to cessation of weight loss, but unmasked diabetes insipidus requiring desmopressin therapy. Right heminephrectomy confirmed RCC. Soon after he complained of progressively worsening headache and visual disturbance. Histopathology from urgent trans-sphenoidal hypophysectomy revealed RCC. The patient began post-surgical radiotherapy, but eventually he declined further treatments. In the end, he was placed on hospice where he passed away. Conclusion: Symptomatic pituitary metastasis from RCC are rare and most of those occur in the setting of diffuse metastatic disease. They typically mimic signs and symptoms of non-functioning macroadenomas. They can be synchronous, metachronous or even the presenting lesion of the primary tumor. A pituitary mass in the setting of malignancy should raise suspicion for metastatic disease even though it is extremely rare.
Background Struma ovarii is a highly specialized and extremely rare monodermal ovarian teratoma that comprises 0.3 to 1% of all ovarian tumors. It consists of greater than 50% of mature thyroid tissue that is usually benign, but malignancy has been reported in up to 5- 23% of the cases. Even after surgery, recurrence rates of malignant struma ovarii can be as high as 35%. [1] Adjuvant thyroid targeting therapies such as radioiodine ablation after total thyroidectomy and TSH suppression therapy have been shown to reduce the risk of tumor recurrence similar to that of primary thyroid cancer. Case Description A 46-year-old healthy lady presented with a 3-month history of non-specific lower abdominal pain and inter-menstrual bleeding. An extensive review of systems was otherwise unremarkable. Ultrasound of the pelvis showed a 4 cm left adnexal mass. An MRI of the pelvis revealed a 2.2×3.6×2.4 cm solid, enhancing mass within the left ovary with an adjacent cystic component. Tumor markers including CEA, CA 19-9, and CA 125 were unremarkable. Due to suspicion for malignancy, she underwent laparoscopic left salpingo-oophorectomy and resection of the mass. Histopathology revealed papillary thyroid carcinoma approximately 1 cm in size with a background of struma ovarii. Immunohistochemistry staining showed positivity for thyroglobulin and Thyroid Transcription Factor-1 (TTF-1). BRAF mutation analysis was negative. An ultrasound of the thyroid gland disclosed two low-risk nodules. TSH was 1.070 mcIU/ml (0.450-4.500), and thyroglobulin level was 6.8ng/ml (1.5-38.5). We performed an Iodine-123 whole-body scan which was negative for abnormal radioiodine uptake. Based on these results, we classified this patients’ recurrence risk as low to intermediate. We initiated TSH suppression therapy with thyroid hormone to maintain TSH in the low normal range. We deferred total thyroidectomy and radioiodine ablation given the low recurrence risk. She will be monitored for recurrence with TSH and thyroglobulin panel at 6 and 12 months in the first year and then annually for at least the next ten years. Discussion Given the rarity of malignant struma ovarii, there are no consensus guidelines for identifying patients with a high recurrence risk who would benefit from thyroid targeting therapy. While some authors recommend total thyroidectomy and radioiodine ablation for all patients, a recent review [2] recommended an algorithm based on imaging, laboratory, and pathologic characteristics of the tumor to risk-stratify patients and treat them depending on their recurrence risk. Improved strategies for risk-stratification and follow-up are essential to provide optimal treatment for malignant struma ovarii patients without over-treating them. References 1. Yassa L, Sadow P, Marqusee E et al. Malignant struma ovarii. Nat Clin Pract Endocrinol Metab 2008; 4: 469-472. 2. Addley S, Mihai R, Alazzam M et al. Arch Gynecol Obstet 2021; 303(4): 863-870 Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.
Introduction There have been some case reports where patients presented with uncontrolled hyperglycemia without previous diagnosis of diabetes but very limited literature supporting the fact that COVID 19 infection can lead to the development of new onset Type 1 diabetes. Clinical Case A 30-year-old African American man presented to the office with a diagnosis of new onset DM towards the end of March 2021. He did not have any significant medical history other than prediabetes with a prior HbA1c of 6% and COVID 19 infection in 2020. He had no family history of DM. He was very sick with the COVID 19 infection and lost 20 pounds of weight around that time. He did not get hospitalized and did not have any blood work done. A couple of months after recovery from his COVID 19 illness he developed leg cellulitis. He decided to seek help for this problem and was started on some antibiotics and antifungals, but they did not help much. His leg swelling and pain did not improve so he went to the ER. At that time his work-up showed a HbA1c of 15.5%. Patient was also having polydipsia and polyuria by that time. He was given a new set of antibiotics and was discharged to follow-up with a primary care provider. His PCP started him on Metformin and Lantus insulin for new onset DM2. He was then referred to Endocrinologist for further management. At the time of his endocrine office visit his symptoms of polyuria and polydipsia had improved a lot.His Anti GAD 65 antibodies were positive with a value of 41 (neg <5). C-peptide level was 1.9 which was in the range (1.1-4.4). IAA–2 autoantibodies were positive with a value of more than 120 (neg<7.5). ZNT 8 antibodies and Insulin antibodies were negative. An increase in the number of antibodies is associated with a higher likelihood of type 1 DM. Only less than 3% of type 2 diabetics have positive antibodies. As per the laboratory interpretation our patient had type 1 diabetes. After starting insulin treatment, the HbA1c improved to 6.6% from 15.5%. Patient is currently on continuous glucose monitoring with insulin therapy and has a good glycemic control. Conclusion Our case highlights the importance that SARS-CoV-2 infection is an independent risk factor for the development of new onset type 1 DM and increased risk of complications in preexisting diabetics. There have been studies showing that patients who presented with DKA precipitated by COVID-19 infection had worse outcomes than patient's presenting with DKA without COVID-19 infection. Mortality was higher for COVID-19 in diabetic patients as well. Presentation: Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m.
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