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Metwalley KA, Farghaly HS. Gynecomastia in adolescent males: current understanding of its etiology, pathophysiology, diagnosis, and treatment. Ann Pediatr Endocrinol Metab 2024; 29:75-81. [PMID: 38712491 PMCID: PMC11076233 DOI: 10.6065/apem.2346142.071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Revised: 08/23/2023] [Accepted: 10/04/2023] [Indexed: 05/08/2024] Open
Abstract
Gynecomastia (GM) is a common and continuously evolving condition that commonly occurs during adolescence. It is the source of significant embarrassment and psychological stress in adolescent males. GM is characterized by enlargement of the male breast due to the proliferation of glandular ducts and stromal components. The main cause of GM during adolescence is physiological or pubertal GM, which is primarily attributed to an imbalance between estrogen and androgen activity. Physiological GM is typically transient and resolves within several months, although it may take several years to resolve. GM may also be caused by other pathological conditions and could be indicative of an endocrine disease. It is crucial to understand the pathogenesis of GM to distinguish it from normal developmental variants due to pathological causes. The aim of this review is to highlight the significance of GM during adolescence in terms of potential etiologies, clinical and laboratory diagnoses, and current management.
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Affiliation(s)
| | - Hekma Saad Farghaly
- Department of Pediatrics, Faculty of Medicine, Assiut University, Assiut, Egypt
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2
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Saini J, Navin P, Rivera M, Bancos I. Gynecomastia in a Man With Adrenal Mass. JCEM CASE REPORTS 2024; 2:luad143. [PMID: 38192879 PMCID: PMC10773200 DOI: 10.1210/jcemcr/luad143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Indexed: 01/10/2024]
Abstract
Estrogen-secreting adrenocortical carcinoma (ACC) is exceedingly rare, representing 1% to 2% of all ACCs. We present a case of a 65-year-old man diagnosed with an estrogen-secreting, 4.3-cm right adrenal mass discovered during work-up for bilateral gynecomastia. Gynecomastia and hyperestrogenism resolved after laparoscopic adrenalectomy, and pathology was reported as adrenocortical adenoma. However, 5 years later, he again developed bilateral gynecomastia because of recurrent hyperestrogenism. Imaging revealed multiple metastases in the abdomen. Urine steroid profiling demonstrated increased androgen precursors, androgen metabolites, and glucocorticoid precursors. Ultrasound-guided biopsy of one of the metastases confirmed ACC. Initial therapy included debulking surgery with removal of metastatic lesions. Mitotane therapy was initiated 4 weeks later along with hydrocortisone for anticipated mitotane-induced adrenal insufficiency. Histopathology from the adrenalectomy specimen 5 years earlier was rereviewed and confirmed ACC. Estrogen-secreting adrenal tumors are exceedingly rare, and the majority are malignant. This case underlines the importance of making an initial accurate diagnosis of adrenal malignancy that allows better surgical planning and appropriate monitoring. Indeterminate imaging characteristics of the adrenal mass, as well as the presentation with estrogen excess, suggested an elevated risk for ACC. Initial pathology-based misdiagnosis illustrates the need for an expert adrenal pathologist to review these rare tumors.
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Affiliation(s)
- Jasmine Saini
- Division of Endocrinology, Metabolism, and Nutrition, Mayo Clinic, Rochester, MN 55905, USA
| | - Patrick Navin
- Division of Radiology, Mayo Clinic, Rochester, MN 55905, USA
| | - Michael Rivera
- Division of Anatomic Pathology, Mayo Clinic, Rochester, MN 55905, USA
| | - Irina Bancos
- Division of Endocrinology, Metabolism, and Nutrition, Mayo Clinic, Rochester, MN 55905, USA
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3
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Fargette C, Shulkin B, Jha A, Pacak K, Taïeb D. Clinical utility of nuclear imaging in the evaluation of pediatric adrenal neoplasms. Front Oncol 2023; 12:1081783. [PMID: 36733351 PMCID: PMC9886856 DOI: 10.3389/fonc.2022.1081783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Accepted: 12/30/2022] [Indexed: 01/18/2023] Open
Abstract
Adrenal neoplasms rarely occur in children. They can be diagnosed in the presence of endocrine, metabolic or neurological problems, an abdominal mass, more rarely an adrenal incidentaloma, or in the context of an adrenal mass discovered in the evaluation of childhood cancer including hematologic malignancy. According to standard medical practice, pediatric malignancies are almost always evaluated by 18F-fluorodeoxyglucose positron emission tomography with computed tomography ([18F]FDG PET/CT). Nuclear imaging using specific radiotracers is also an important tool for diagnosing and staging neuroblastoma, pheochromocytoma, hormone hypersecretion, or indeterminate adrenal masses. The Hippocratic oath "primum non nocere" encourages limitation of radiation in children per the ALARA concept (as low as reasonably achievable) but should not lead to the under-use of nuclear imaging because of the potential risk of inaccurate diagnosis or underestimation of the extent of disease. As in adults, nuclear imaging in children should be performed in conjunction with hormone evaluation and morphological imaging.
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Affiliation(s)
- Christelle Fargette
- Department of Nuclear Medicine, La Timone University Hospital, Centre Européen de Recherche en Imagerie Médicale (CERIMED), Aix-Marseille University, Marseille, France
| | - Barry Shulkin
- Department of Diagnostic Imaging, St. Jude Children’s Research Hospital, Memphis, TN, United States
| | - Abhishek Jha
- Section on Medical Neuroendocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, United States
| | - Karel Pacak
- Section on Medical Neuroendocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, United States
| | - David Taïeb
- Department of Nuclear Medicine, La Timone University Hospital, Centre Européen de Recherche en Imagerie Médicale (CERIMED), Aix-Marseille University, Marseille, France,*Correspondence: David Taïeb,
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4
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Rich JM, Duddalwar V, Cheng PM, Aron M, Daneshmand S. Feminizing Adrenocortical Tumor with Multiple Recurrences: A Case Report. Case Rep Oncol 2023; 16:1033-1040. [PMID: 37900824 PMCID: PMC10601808 DOI: 10.1159/000533835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Accepted: 08/24/2023] [Indexed: 10/31/2023] Open
Abstract
Feminizing adrenocortical tumors (FATs) are exceptionally rare primary adrenal neoplasms that cause high estrogen and low testosterone levels. They are most common in adult males, typically presenting with gynecomastia, hypogonadism, and weight loss. They are almost always malignant, with a poor prognosis and a high recurrence rate. We report a case of a 35-year-old man with an adrenal FAT with high estrogen (181 pg/mL) and low testosterone (37 ng/dL) who presented with gynecomastia, erectile dysfunction, subclinical Cushing syndrome, and pain localizing to different regions of the torso. There was no evidence of metastatic disease initially as seen by visualization of a well-marginated mass on computed tomography scan. Surgical resection of the FAT was performed, and the mass was confirmed to be a low-grade tumor. Clinical symptoms were resolved after surgery. Despite complete resection with negative margins, the patient subsequently had two separate local metastatic recurrences within a few years, treated with a combination of further surgery and medical intervention. This case highlights the unique features of an exceedingly rare adrenal tumor and stresses the importance of early detection and vigilant surveillance following resection due to high recurrence rates.
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Affiliation(s)
- Joseph M. Rich
- MD/PhD Program, USC-Caltech MD/PhD Program, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Vinay Duddalwar
- Department of Radiology, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
- USC Radiomics Laboratory, Keck School of Medicine, Department of Radiology, University of Southern California, Los Angeles, CA, USA
- Department of Urology, Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA, USA
| | - Phillip M. Cheng
- Department of Radiology, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Manju Aron
- Department of Pathology, Keck School of Medicine of USC, Los Angeles, CA, USA
| | - Siamak Daneshmand
- Department of Urology, Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA, USA
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Herbert SL, Ergezinger K, Sauer S, Kurz F, Schlaiß T, Wöckel A, Albert US. Prepubertal Idiopathic Unilateral Gynecomastia: Case Report and Literature Review. Breast Care (Basel) 2022; 17:573-579. [PMID: 36590144 PMCID: PMC9801404 DOI: 10.1159/000525096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Accepted: 05/05/2022] [Indexed: 01/04/2023] Open
Abstract
Introduction Gynecomastia is a benign proliferation of the glandular tissue of the breast in males. Depending on the age, it can be considered a physiological condition. Prepubertal unilateral gynecomastia is a rare phenomenon. There are only a few case reports described through the last few years. Case Presentation We report the clinical appearance and management of prepubertal idiopathic unilateral gynecomastia in a 9-year-old boy. We further include a literature review of 14 cases from 2011 to 2021. In contrast to pubertal gynecomastia, prepubertal gynecomastia and especially unilateral prepubertal gynecomastia are extremely rare conditions. Most cases remain idiopathic. Conclusion Chromosomal and genetic testing, as well as oncological, endocrine diagnostic and tests for liver and kidney function should be performed. In case of idiopathic prepubertal gynecomastia, surgery is an important part of therapy since patients suffer from their atypical and rare phenotype.
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Affiliation(s)
- Saskia-Laureen Herbert
- Department of Obstetrics and Gynaecology, University Medical Centre Würzburg, Würzburg, Germany
| | - Katrin Ergezinger
- Department of Pediatrics, University Medical Centre Würzburg, Würzburg, Germany
| | - Stephanie Sauer
- Department of Radiology, University Medical Centre Würzburg, Würzburg, Germany
| | - Florian Kurz
- Department of Pathology, University Medical Centre Würzburg, Würzburg, Germany
| | - Tanja Schlaiß
- Department of Obstetrics and Gynaecology, University Medical Centre Würzburg, Würzburg, Germany
| | - Achim Wöckel
- Department of Obstetrics and Gynaecology, University Medical Centre Würzburg, Würzburg, Germany
| | - Ute-Susann Albert
- Department of Obstetrics and Gynaecology, University Medical Centre Würzburg, Würzburg, Germany
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Sykes J, Ellis JL, Bukavina L, Koch CA, Wei S, Kutikov A. Estradiol-secreting adrenal oncocytoma in a 31-year old male. Urol Case Rep 2022; 44:102138. [PMID: 35784490 PMCID: PMC9241131 DOI: 10.1016/j.eucr.2022.102138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Revised: 05/31/2022] [Accepted: 06/16/2022] [Indexed: 11/21/2022] Open
Abstract
Oncocytic adrenocortical tumors (OAT) are rare and often are non-functional. We report a unique case of an estradiol-secreting adrenal oncocytoma in a 31-year-old male discovered upon an infertility and gynecomastia work-up. After resection of the 9 cm adrenal mass, the patient's estradiol levels normalized from 83.2 pg/ml to 19.0 pg/ml. Gonadotropins and serum dehydroepiandrosterone sulfate also normalized.
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Affiliation(s)
- Jennifer Sykes
- Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
- Corresponding author.
| | - Jeffrey L. Ellis
- Department of Urology, Einstein Healthcare Network, Philadelphia, PA, USA
| | - Laura Bukavina
- Division of Urologic Oncology, Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - Christian A. Koch
- Department of Endocrinology, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - Shuanzeng Wei
- Department of Pathology, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - Alexander Kutikov
- Division of Urologic Oncology, Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA
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Gosavi V, Lila A, Memon SS, Sarathi V, Thakkar K, Dalvi A, Malhotra G, Prakash G, Patil V, Shah NS, Bandgar T. Clinical Spectrum of Adrenal Cushing's Syndrome and the Caution for Interpretation of Adrenocorticotrophic Hormone: A Single-Center Experience. Horm Metab Res 2022; 54:57-66. [PMID: 35130566 DOI: 10.1055/a-1735-3232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
UNLABELLED To describe the differences in presentation, biochemistry, and radiological evaluation of various etiologies of adrenal Cushing's syndrome (CS) from a single center. To emphasize caution for interpretation of plasma adrenocorticotropic hormone (ACTH), as a spuriously unsuppressed ACTH level by immunometric assay may lead to therapeutic misadventures in adrenal CS. DESIGN Retrospective, single-center, observational study. METHODS Fifty-eight adrenal CS patients [Adrenocortical carcinoma (ACC), n=30; Adenoma (ACA), n=15; Primary pigmented nodular adrenocortical disease (PPNAD), n=10; ACTH independent macronodular adrenal hyperplasia (AIMAH), n=3) evaluated at a tertiary care center in western India between January 2006 to March 2020 were included. Data on demography, clinical evaluation, biochemistry, imaging, management, histopathology, and outcome were recorded in a standard format and analyzed. RESULTS Cortisol secreting ACC presented at 38(1-50) years with abdominal mass in 26/30 (86.7%) and 16/30 (53.3%) had metastases at presentation. ACA with autonomous cortisol excess presented at 25(4.9-40) years with discriminating features of CS in 14/15 (93.3%), sex steroid production in 2/15, unenhanced HU <10 in only one, and relative washout >40% in 8/11 (72.7%). One ACA and eight ACC patients had plasma ACTH (by Siemens Immulite assay) > 20 pg/ml, despite hypercortisolemic state. CONCLUSIONS Cortisol-secreting ACC and ACA most often present with mass effects and florid CS, respectively. Baseline HU has low sensitivity to differentiate cortisol-secreting ACA from ACC. Plasma ACTH measured by Seimens Immulite is often unsuppressed, especially in ACC patients, which can be addressed by measuring ACTH by more accurate assays.
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Affiliation(s)
- Vikrant Gosavi
- Department of Endocrinology, Seth G. S. Medical College and KEM Hospital, Mumbai, India
| | - Anurag Lila
- Department of Endocrinology, Seth G. S. Medical College and KEM Hospital, Mumbai, India
| | - Saba Samad Memon
- Department of Endocrinology, Seth G. S. Medical College and KEM Hospital, Mumbai, India
| | - Vijaya Sarathi
- Department of Endocrinology, Vydehi Institute of Medical Sciences and Research Centre, Bangalore, India
| | - Kunal Thakkar
- Sterling Ramkrishna Speciality Hospital, Gandhidham, India
| | - Abhay Dalvi
- Department of Surgery, Seth G. S. Medical College and KEM Hospital, Mumbai, India
| | - Gaurav Malhotra
- Department of Nuclear Medicine, Bhabha Atomic Research Centre, Mumbai, India
| | - Gagan Prakash
- Department of Uro-oncology, Tata Memorial Hospital, Mumbai, India
| | - Virendra Patil
- Department of Endocrinology, Seth G. S. Medical College and KEM Hospital, Mumbai, India
| | - Nalini S Shah
- Department of Endocrinology, Seth G. S. Medical College and KEM Hospital, Mumbai, India
| | - Tushar Bandgar
- Department of Endocrinology, Seth G. S. Medical College and KEM Hospital, Mumbai, India
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Elnaw EAA, Ibrahim AAB, Abdullah MA. Feminizing adrenocortical adenoma in a girl from a resource-limited setting: a case report. J Med Case Rep 2021; 15:605. [PMID: 34930443 PMCID: PMC8690961 DOI: 10.1186/s13256-021-03203-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 11/08/2021] [Indexed: 11/10/2022] Open
Abstract
Background An adrenocortical tumor is a rare tumor in pediatrics, which can be functional or nonfunctional. Functional tumors present with virilization, feminization, or hypercortisolism. Feminizing adrenal tumors, though rare in pediatrics, need to be excluded in any child presenting with features of feminization.
Case presentation We report a case of a 4-year-old Sudanese girl who presented with gradually progressive bilateral breast enlargement and accelerated growth since the age of 6 months. The family had sought medical advice several times in numerous health facilities without much gain. Investigations showed pubertal luteinizing hormone levels, high estradiol E2, and dehydroepiandrosterone sulfate, with normal early morning cortisol level. Abdominal ultrasound revealed a right-sided hypoechoic suprarenal mass. Abdominal computed tomography scan showed a right adrenal mass. The diagnosis of feminizing adrenal neoplasm was confirmed and right adrenalectomy was done. Histopathological examination of the resected adrenal gland showed adrenocortical adenoma. The patient was started on gonadotrophin-releasing hormone agonist for secondary central precocious puberty. Conclusion Adrenocortical tumors, though rare in pediatrics, are a documented cause of precocious puberty; biochemical and imaging screening protocol should be adopted for patients with precocious puberty, even in a resource-limited setting, for early detection and treatment.
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Affiliation(s)
- Eman Abdalla Ali Elnaw
- The Endocrine Division, Department of Pediatrics and Child Health, Faculty of Medicine, University of Khartoum, P.O. Box 102, Khartoum, Sudan.
| | | | - Mohamed Ahmed Abdullah
- The Endocrine Division, Department of Pediatrics and Child Health, Faculty of Medicine, University of Khartoum, P.O. Box 102, Khartoum, Sudan
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Woszczyło M, Szumny A, Łyczko J, Jezierski T, Krzemińska P, Szczerbal I, Świtoński M, Niżański W, Dzięcioł M. The Case of Atypical Sexual Attractiveness in a Male Domestic Dog-A Case Study. Animals (Basel) 2021; 11:3156. [PMID: 34827888 PMCID: PMC8614462 DOI: 10.3390/ani11113156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 11/01/2021] [Accepted: 11/02/2021] [Indexed: 11/16/2022] Open
Abstract
During the ovarian cycle in domestic dogs, females do not accept males during the first days of estrus but become attractive to males from the beginning of proestrus, with this attractiveness persisting until the end of the estrus phase. It is believed that increased estradiol is responsible for the female attractiveness to the males. In this paper we describe the case of strong, but atypical attractiveness of a castrated male to various, adult, intact males, influenced by the emitted semiochemical signals. Any significant changes in the level of hormones typically involved in the process connected with estrus and responsible for sexual arousal in the males were assessed. The case animal was a 4 year old castrated male Border Collie that was extremely attractive to various males, which presented high levels of sexual arousal, with intensive sniffing and licking of the preputial area, specific vocalization, increased salivation and, finally, mating attempts. Clinical examination of the castrated male revealed a lack of testes in the scrotum and abdominal cavity confirmed by USG. Laboratory tests indicated basal levels of estradiol, testosterone, and progesterone (15.23 pg/mL, <0.05 ng/mL, 0.25 ng/mL), and sex was confirmed via cytogenetic and molecular analysis. Chemical analysis (HS-SPME) of the urine indicated a huge similarity to the profile obtained from a bitch in estrus, with an elevated level of acetophenone, which has been previously postulated in the literature as being a characteristic of the estrus phase in female domestic dogs. This case presented very atypical sexual attractiveness, particularly when taking into account the basal levels of hormones which, according to current knowledge, are responsible for the creation of attractiveness. As a hypothesis requiring verification, we propose the idea of involvement of other hormones in the creation of incidental attractiveness or increased production of compounds responsible for attractiveness (sex pheromones) resulting from metabolic events unrelated to reproductive processes. To our knowledge it is the first described case presenting this phenomenon, which, with more detailed study, could shed new light on the process of creation of sexual attraction in the domestic dog.
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Affiliation(s)
- Martyna Woszczyło
- Department of Reproduction and Clinic of Farm Animals, Wroclaw University of Environmental and Life Sciences, Plac Grunwaldzki 49, 50-366 Wrocław, Poland; (M.W.); (W.N.)
| | - Antoni Szumny
- Department of Chemistry, Wroclaw University of Environmental and Life Sciences, C.K. Norwida 25, 50-375 Wrocław, Poland; (A.S.); (J.Ł.)
| | - Jacek Łyczko
- Department of Chemistry, Wroclaw University of Environmental and Life Sciences, C.K. Norwida 25, 50-375 Wrocław, Poland; (A.S.); (J.Ł.)
| | - Tadeusz Jezierski
- Department of Animal Behaviour and Welfare, Institute of Genetics and Animal Biotechnology of Polish Academy of Sciences, Jastrzębiec, 05-552 Magdalenka, Poland;
| | - Paulina Krzemińska
- Department of Genetics and Animal Breeding, Faculty of Veterinary Medicine and Animal Science, Poznan University of Life Sciences, Wolynska 33, 60-637 Poznan, Poland; (P.K.); (I.S.); (M.Ś.)
| | - Izabela Szczerbal
- Department of Genetics and Animal Breeding, Faculty of Veterinary Medicine and Animal Science, Poznan University of Life Sciences, Wolynska 33, 60-637 Poznan, Poland; (P.K.); (I.S.); (M.Ś.)
| | - Marek Świtoński
- Department of Genetics and Animal Breeding, Faculty of Veterinary Medicine and Animal Science, Poznan University of Life Sciences, Wolynska 33, 60-637 Poznan, Poland; (P.K.); (I.S.); (M.Ś.)
| | - Wojciech Niżański
- Department of Reproduction and Clinic of Farm Animals, Wroclaw University of Environmental and Life Sciences, Plac Grunwaldzki 49, 50-366 Wrocław, Poland; (M.W.); (W.N.)
| | - Michał Dzięcioł
- Department of Reproduction and Clinic of Farm Animals, Wroclaw University of Environmental and Life Sciences, Plac Grunwaldzki 49, 50-366 Wrocław, Poland; (M.W.); (W.N.)
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10
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Mermejo LM, Carvalho FG, Molina CAF, Tucci S, Muglia VF, Elias J, Elias PCL, Castro M, Moreira AC. Estrogen-secreting adrenocortical tumor in a postmenopausal woman: a challenging diagnosis. Endocrinol Diabetes Metab Case Rep 2021; 2021:EDM200214. [PMID: 33845455 PMCID: PMC7983493 DOI: 10.1530/edm-20-0214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Accepted: 02/18/2021] [Indexed: 11/12/2022] Open
Abstract
SUMMARY Adrenocortical carcinoma (ACC) is a malignant disorder with rapid evolution and severe prognosis in adults and most produce cortisol and androgen. Estrogen-secreting adrenocortical carcinomas are extremely rare, especially in women, tend to be larger and have worse prognosis compared with other types of ACCs. We report the case of a 58-year-old woman who presented with bilateral breast enlargement and postmenopausal genital bleeding. She presented high estradiol (818 pg/mL - 25 times above upper normal limit for postmenopausal women) and testosterone (158 ng/dL - 2 times above upper normal limit) levels and no suppression of cortisol after overnight 1 mg dexamethasone test (12.5 µg/dL; normal reference value: < 1.8 µg/dL). The patient had no clinical features of cortisol excess. MRI showed a 12 cm tumor in the right adrenal. Clinical findings of bilateral breast enlargement and postmenopausal genital bleeding with no signs of hypercortisolism associated with hormonal findings of elevated estradiol and testosterone levels would indicate either an ovarian etiology or an adrenal etiology; however, in the context of plasma cortisol levels non-suppressive after dexamethasone test and the confirmation of an adrenal tumor by MRI, the diagnosis of an adrenal tumor with mixed hormonal secretion was made. The patient underwent an open right adrenalectomy and pathological examination revealed an ACC with a Weiss' score of 6. Estradiol and testosterone levels decreased to normal range soon after surgery. She was put on mitotane treatment as adjuvant therapy, but due to side effects, we were unable to up-titrate the dose and she never achieved serum mitotane dosage above the desired 14 µg/mL. The patient remained in good health without any local recurrence or metastasis until 5 years after surgery, when increased levels of estradiol (81 pg/mL - 2.5 times above upper normal limit) and testosterone (170 ng/dL - 2.1 times above upper normal limit) were detected. MRI revealed a retroperitoneal nodule measuring 1.8 × 1.2 cm. The pathological finding confirmed the recurrence of the estrogen-secreting ACC with a Weiss' score of 6. After the second procedure, patient achieved normal estrogen and androgen serum levels and since then she has been followed for 3 years. The overall survival was 8 years after the diagnosis. In conclusion, although extremely rare, a diagnosis of an estrogen-secreting ACC should be considered as an etiology in postmenopausal women presenting with bilateral breast enlargement, genital bleeding and increased pure or prevailing estrogen secretion. LEARNING POINTS Estrogen-secreting adrenocortical carcinomas are exceedingly rare in adults and account for 1-2% of adrenocortical carcinomas. Estrogen-secreting adrenal tumors can be present in females, but are even more rare, we found few cases described in the literature. In women, they present with precocious puberty or postmenopausal bleeding. Feminization in the context of an adrenal tumor is considered almost pathognomonic of malignancy. Feminizing ACCs tend to be larger and with worse prognosis compared with nonfeminizing ACCs.
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Affiliation(s)
- L M Mermejo
- Department of Internal MedicineHematology and Oncology, University of Sao Paulo Faculty of Medicine of Ribeirao Preto, Ribeirao Preto, São Paulo, Brazil
| | - F G Carvalho
- Department of Internal MedicineHematology and Oncology, University of Sao Paulo Faculty of Medicine of Ribeirao Preto, Ribeirao Preto, São Paulo, Brazil
| | - C A F Molina
- Department of Surgery and AnatomyHematology and Oncology, University of Sao Paulo Faculty of Medicine of Ribeirao Preto, Ribeirao Preto, São Paulo, Brazil
| | - S Tucci
- Department of Surgery and AnatomyHematology and Oncology, University of Sao Paulo Faculty of Medicine of Ribeirao Preto, Ribeirao Preto, São Paulo, Brazil
| | - V F Muglia
- Department of RadiologyHematology and Oncology, University of Sao Paulo Faculty of Medicine of Ribeirao Preto, Ribeirao Preto, São Paulo, Brazil
| | - J Elias
- Department of RadiologyHematology and Oncology, University of Sao Paulo Faculty of Medicine of Ribeirao Preto, Ribeirao Preto, São Paulo, Brazil
| | - P C L Elias
- Department of Internal MedicineHematology and Oncology, University of Sao Paulo Faculty of Medicine of Ribeirao Preto, Ribeirao Preto, São Paulo, Brazil
| | - M Castro
- Department of Internal MedicineHematology and Oncology, University of Sao Paulo Faculty of Medicine of Ribeirao Preto, Ribeirao Preto, São Paulo, Brazil
| | - A C Moreira
- Department of Internal MedicineHematology and Oncology, University of Sao Paulo Faculty of Medicine of Ribeirao Preto, Ribeirao Preto, São Paulo, Brazil
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Abstract
Background: Feminizing adrenal tumors are rare and generally malignant tumors usually seen in male adults and children. We report the case of a benign feminizing adrenal tumor in a male patient. To our knowledge, only 2 other cases of benign, estrogen-only-secreting adrenal tumors have been reported. Case Report: A 44-year-old male with a history of hypertension presented to his primary care physician with chest tenderness, fatigue, and erectile dysfunction. Hormonal workup and imaging identified an estrogen-only-secreting adrenal adenoma. The adenoma was removed via laparoscopic adrenalectomy, and the patient had a normal postoperative course. Pathologic findings were an adrenal cortical adenoma with a Weiss score of 0 and a Ki-67 score of 0%. At 6-month follow-up, the patient's symptoms had significantly improved, and his previously abnormal sex hormone levels were within normal limits. Conclusion: Given the ambiguity in distinguishing between malignant and benign feminizing adrenal tumors, we suggest that radiologic (via Hounsfield units), clinical (via trending hormone levels), and histopathologic (via Weiss and Ki-67 scores) findings are sufficient to confirm the benign nature of this commonly malignant tumor.
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Yalniz C, Morani AC, Waguespack SG, Elsayes KM. Imaging of Adrenal-Related Endocrine Disorders. Radiol Clin North Am 2020; 58:1099-1113. [PMID: 33040851 DOI: 10.1016/j.rcl.2020.07.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Endocrine disorders associated with adrenal pathologies can be caused by insufficient adrenal gland function or excess hormone secretion. Excess hormone secretion may result from adrenal hyperplasia or hormone-secreting (ie, functioning) adrenal masses. Based on the hormone type, functioning adrenal masses can be classified as cortisol-producing tumors, aldosterone producing tumors, and androgen-producing tumors, which originate in the adrenal cortex, as well as catecholamine-producing pheochromocytomas, which originate in the medulla. Nonfunctioning lesions can cause adrenal gland enlargement without causing hormonal imbalance. Evaluation of adrenal-related endocrine disorders requires clinical and biochemical workup associated with imaging evaluation to reach a diagnosis and guide management.
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Affiliation(s)
- Ceren Yalniz
- Department of Abdominal Imaging, Division of Diagnostic Imaging, The University of Texas MD Anderson Cancer Center, 1400 Pressler Street, Houston, TX 77030, USA
| | - Ajaykumar C Morani
- Department of Abdominal Imaging, Division of Diagnostic Imaging, The University of Texas MD Anderson Cancer Center, 1400 Pressler Street, Houston, TX 77030, USA
| | - Steven G Waguespack
- Department of Endocrine Neoplasia and Hormonal Disorders, The University of Texas MD Anderson Cancer Center, 1400 Pressler Street, Houston, TX 77030, USA
| | - Khaled M Elsayes
- Department of Abdominal Imaging, Division of Diagnostic Imaging, The University of Texas MD Anderson Cancer Center, 1400 Pressler Street, Houston, TX 77030, USA.
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13
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Walls CA, Smith WJ, Draus JM, Wagner LM. Case 4: Gynecomastia in a 15-year-old Boy. Pediatr Rev 2020; 41:206-209. [PMID: 32238551 DOI: 10.1542/pir.2018-0061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- Claci A Walls
- University of Kentucky College of Medicine, Lexington, KY
| | | | | | - Lars M Wagner
- Division of Pediatric Hematology/Oncology, University of Kentucky College of Medicine, Lexington, KY
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14
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Feminizing adrenal tumor with progesterone receptors. Med Clin (Barc) 2020; 156:100-101. [PMID: 32165004 DOI: 10.1016/j.medcli.2019.10.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Revised: 10/16/2019] [Accepted: 10/24/2019] [Indexed: 11/20/2022]
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15
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Tezuka Y, Yamazaki Y, Ono Y, Morimoto R, Omata K, Seiji K, Takase K, Kawasaki Y, Ito A, Nakamura Y, Harigae H, Sasano H, Satoh F. Unique Sex Steroid Profiles in Estrogen-Producing Adrenocortical Adenoma Associated With Bilateral Hyperaldosteronism. J Endocr Soc 2020; 4:bvaa004. [PMID: 32099947 PMCID: PMC7031070 DOI: 10.1210/jendso/bvaa004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Accepted: 01/20/2020] [Indexed: 01/27/2023] Open
Abstract
Because of its rarity, our understanding of steroidogenesis in estrogen-producing adrenocortical adenoma, including the response to adrenocorticotropic hormone (ACTH) stimulation, remains limited. A 65-year-old man was referred to us because of primary aldosteronism and a right adrenal tumor. Endocrinological evaluations revealed secondary hypogonadism due to hyperestrogenemia. Adrenal venous sampling (AVS) and subsequent liquid chromatography–tandem mass spectrometry (LC-MS/MS) indicated bilateral hyperaldosteronism and a right estrogen-producing adrenocortical tumor. He subsequently underwent right unilateral adrenalectomy, which resulted in clinical remission of hypogonadism. Subsequent histopathological analysis identified a right estrogen-producing adrenocortical adenoma and multiple, concomitant adrenocortical micronodules. Sequential evaluation of steroid profiles using LC-MS/MS revealed unique hormone production, including adrenal androgens, and less responsiveness to ACTH in the right estrogen-producing adrenocortical adenoma as compared to the nonneoplastic adrenal cortex. This case study revealed unique profiles of steroid production in estrogen-producing adrenocortical adenoma associated with concomitant primary aldosteronism. Sequential steroid profiling analysis using LC-MS/MS in combination with AVS can contribute to the diagnosis of various adrenal disorders.
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Affiliation(s)
- Yuta Tezuka
- Division of Nephrology, Endocrinology and Vascular Medicine, Tohoku University Hospital, Sendai, Miyagi, Japan
| | - Yuto Yamazaki
- Department of Pathology, Tohoku University Hospital, Sendai, Miyagi, Japan
| | - Yoshikiyo Ono
- Division of Nephrology, Endocrinology and Vascular Medicine, Tohoku University Hospital, Sendai, Miyagi, Japan
| | - Ryo Morimoto
- Division of Nephrology, Endocrinology and Vascular Medicine, Tohoku University Hospital, Sendai, Miyagi, Japan
| | - Kei Omata
- Division of Nephrology, Endocrinology and Vascular Medicine, Tohoku University Hospital, Sendai, Miyagi, Japan
| | - Kazumasa Seiji
- Department of Diagnostic Radiology, Tohoku University Hospital, Sendai, Miyagi, Japan
| | - Kei Takase
- Department of Diagnostic Radiology, Tohoku University Hospital, Sendai, Miyagi, Japan
| | - Yoshihide Kawasaki
- Department of Urology, Tohoku University Hospital, Sendai, Miyagi, Japan
| | - Akihiro Ito
- Department of Urology, Tohoku University Hospital, Sendai, Miyagi, Japan
| | - Yasuhiro Nakamura
- Division of Pathology, Faculty of Medicine, Tohoku Medical and Pharmaceutical University Hospital, Sendai, Miyagi, Japan
| | - Hideo Harigae
- Division of Nephrology, Endocrinology and Vascular Medicine, Tohoku University Hospital, Sendai, Miyagi, Japan
| | - Hironobu Sasano
- Department of Pathology, Tohoku University Hospital, Sendai, Miyagi, Japan
| | - Fumitoshi Satoh
- Division of Nephrology, Endocrinology and Vascular Medicine, Tohoku University Hospital, Sendai, Miyagi, Japan.,Division of Clinical Hypertension, Endocrinology and Metabolism, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
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16
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Siraj M, Tolofari S, Yow L, Sinclair A, Javed S, Mukherjee R, Bell R, Lynch N, Counsell A, Pollard A, Lewis P, Adeyoju A. ‘Adrenal incidentalomas’; Rationalising assessment in the urology multi-disciplinary team meeting. JOURNAL OF CLINICAL UROLOGY 2019. [DOI: 10.1177/2051415818808893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The combination of an aging population and the continual technological advances in modern imaging techniques have contributed to the increased detection of asymptomatic incidental lesions. The definition of an adrenal ‘incidentaloma’ is an asymptomatic lesion (⩾1 cm) detected on imaging following a suspected alternative primary diagnosis. The majority of these adrenal incidentalomas, may be benign and non-functioning, however, a proportion of these lesions may be either malignant or ‘hyperfunctioning’ (hormone-producing). As such, these incidental and asymptomatic lesions can provide the urologist with a diagnostic dilemma. In this article we aim to review the current literature with reference to common clinical scenarios often encountered as part of the urology multi-disciplinary team meeting. The overall aim is to rationalise and standardise an approach to these often challenging scenarios.
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Affiliation(s)
| | | | - Lina Yow
- Glan Clwyd District General Hospital, UK
| | | | - Saqib Javed
- Royal Liverpool and Broadgreen NHS Foundation Trust, UK
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17
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Calcaterra V, Clerici E, Ceolin V, Regalbuto C, Larizza D. Gynecomastia after euthyroidism restoration in a patient with type 1 diabetes and Graves' disease. Clin Case Rep 2018; 6:1481-1484. [PMID: 30147887 PMCID: PMC6099052 DOI: 10.1002/ccr3.1565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2018] [Revised: 03/30/2018] [Accepted: 04/14/2018] [Indexed: 11/06/2022] Open
Abstract
In patients with autoimmune disease, gynecomastia should not be considered as 1 of the first signs of hyperthyroidism, rather it is a breast pathology that can be present even when euthyroidism restoration is achieved. It is unknown whether the autoimmune nature of thyroid disorders or simply the hyperthyroidism effects breast changes.
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Affiliation(s)
- Valeria Calcaterra
- Pediatric Endocrinology UnitDepartment of Maternal and Children's HealthFondazione IRCCS Policlinico S. Matteo and University of PaviaPaviaItaly
| | - Edoardo Clerici
- Pediatric Endocrinology UnitDepartment of Maternal and Children's HealthFondazione IRCCS Policlinico S. Matteo and University of PaviaPaviaItaly
| | - Valeria Ceolin
- Pediatric Endocrinology UnitDepartment of Maternal and Children's HealthFondazione IRCCS Policlinico S. Matteo and University of PaviaPaviaItaly
| | - Corrado Regalbuto
- Pediatric Endocrinology UnitDepartment of Maternal and Children's HealthFondazione IRCCS Policlinico S. Matteo and University of PaviaPaviaItaly
| | - Daniela Larizza
- Pediatric Endocrinology UnitDepartment of Maternal and Children's HealthFondazione IRCCS Policlinico S. Matteo and University of PaviaPaviaItaly
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Chentli F, Chabour F, Bouchibane D, Nouar N. Feminizing Adrenocortical Carcinoma Without Gynecomastia. Oman Med J 2017; 32:349-351. [PMID: 28804590 DOI: 10.5001/omj.2017.66] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Malignant feminizing adrenocortical tumors are exceedingly rare. Their main presentation is gynecomastia. In these estrogen secreting tumors (with or without other adrenocortical hormones) lack of gynecomastia is exceptional as in our case. A 44-year-old man presented with abdominal pain. Radiological assessment revealed a tumor measuring 120 × 95 mm in the retroperitoneal area with numerous metastases. Pathological examination pleaded for an adrenal origin with a Weiss's score of 5. Six months later, the tumor relapsed, and he had a second surgery and was sent for hormone assessment. Clinical examination showed a skinny man with severe fatigue. He had no Cushingoid features. Gynecomastia and galactorrhea were absent. Penile length, testicular volume, and body hair growth were normal. Several cutaneous nodules were present. Biological assessment showed high morning plasma cortisol, which failed to be suppressed by treatment with 2 mg dexamethasone. Plasma estradiol and 17OH progesterone levels were high, but his testosterone levels were low. Radiological exploration showed numerous metastases: pleural, pulmonary, retroperitoneal, and abdominal. He was treated with classical chemotherapy, but he died four months after diagnosis.
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Affiliation(s)
- Farida Chentli
- Department of Endocrine and Metabolic Diseases, Bab El Oued Teaching Hospital, Algiers, Algeria
| | - Fadila Chabour
- Department of Endocrine and Metabolic Diseases, Bab El Oued Teaching Hospital, Algiers, Algeria
| | - Djafer Bouchibane
- Department of Radiology, Benimessous Teaching Hospital, Algiers, Algeria
| | - Nouria Nouar
- Department of Pathology, Benimessous Teaching Hospital, Algiers, Algeria
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Sansone A, Romanelli F, Sansone M, Lenzi A, Di Luigi L. Gynecomastia and hormones. Endocrine 2017; 55:37-44. [PMID: 27145756 DOI: 10.1007/s12020-016-0975-9] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2016] [Accepted: 04/26/2016] [Indexed: 12/28/2022]
Abstract
Gynecomastia-the enlargement of male breast tissue in men-is a common finding, frequently observed in newborns, adolescents, and old men. Physiological gynecomastia, occurring in almost 25 % of cases, is benign and self-limited; on the other hand, several conditions and drugs may induce proliferation of male breast tissue. True gynecomastia is a common feature often related to estrogen excess and/or androgen deficiency as a consequence of different endocrine disorders. Biochemical evaluation should be performed once physiological or iatrogenic gynecomastia has been ruled out. Non-endocrine illnesses, including liver failure and chronic kidney disease, are another cause of gynecomastia which should be considered. Treating the underlying disease or discontinuing medications might resolve gynecomastia, although the psychosocial burden of this condition might require different and careful consideration.
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Affiliation(s)
- Andrea Sansone
- Department of Experimental Medicine, Section of Medical Pathophysiology, Food Science and Endocrinology, Sapienza, University of Rome, Viale Regina Elena 324, 00161, Rome, Italy.
| | - Francesco Romanelli
- Department of Experimental Medicine, Section of Medical Pathophysiology, Food Science and Endocrinology, Sapienza, University of Rome, Viale Regina Elena 324, 00161, Rome, Italy
| | - Massimiliano Sansone
- Department of Experimental Medicine, Section of Medical Pathophysiology, Food Science and Endocrinology, Sapienza, University of Rome, Viale Regina Elena 324, 00161, Rome, Italy
| | - Andrea Lenzi
- Department of Experimental Medicine, Section of Medical Pathophysiology, Food Science and Endocrinology, Sapienza, University of Rome, Viale Regina Elena 324, 00161, Rome, Italy
| | - Luigi Di Luigi
- Department of Movement, Human and Health Sciences, Unit of Endocrinology, University of Rome "Foro Italico", Largo Lauro de Bosis 15, 00135, Rome, Italy
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