Estrogen-secreting adrenocortical tumor in a postmenopausal woman: a challenging diagnosis

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.

Effect of chemical and mechanical degradation on surface roughness of three glass ionomers and a nanofilled resin composite

Nanofillers have been incorporated into glass ionomer (GI) restorative materials to improve their mechanical and surface properties. The aim of this present laboratory study was to compare the superficial roughness (Ra) of nanofilled GI (Ketac N100) with that of conventional GI (Fuji IX GP), resin-modified GI (Vitremer), and a nanofilled resin composite (Filtek Supreme) after pH cycling and toothbrush abrasion. Ten specimens of each material were made using Teflon molds, which were polished using aluminum-oxide abrasive disks. Three measurements of Ra were made of each specimen to serve as baseline values. The specimens were submitted to pH cycling for 10 days in a demineralization solution for six hours (pH 4.3) and were then stored in remineralization solution for 18 hours (pH 7.0). Ra measurements were recorded after the pH cycling. Specimens were then submitted to toothbrush abrasion in a brushing machine with a 200g load for 30,000 cycles at 250 cycles/min. The Ra values were then recorded. The surface morphology of specimens from each group was analyzed using a scanning electron microscope. Data were analyzed by analysis of variance, Tukey, and t-tests. After toothbrushing, only Fuji IX GP (1.10 ± 0.80) showed Ra values that were statistically different from those of the other materials evaluated. Ketac N100 (0.68 ± 0.16) showed intermediate Ra values, but it did not differ statistically from the results associated with Vitremer (1.04 ± 0.46) and Filtek (0.30 ± 0.15). Ketac N100 showed intermediate values of superficial roughness among the conventional glass ionomer cement, resin-modified glass ionomer cements, and the nanofilled resin after chemical and mechanical degradation.

MCNP simulation to optimise in-pile and shielding parts of the Portuguese SANS instrument

A Small Angle Neutron Scattering instrument is being installed at one end of the tangential beam tube of the Portuguese Research Reactor. The instrument is fed using a neutron scatterer positioned in the middle of the beam tube. The scatterer consists of circulating H2O contained in a hollow disc of Al. The in-pile shielding components and the shielding installed around the neutron selector have been the object of an MCNP simulation study. The quantities calculated were the neutron and gamma-ray fluxes in different positions, the energy deposited in the material by the neutron and gamma-ray fields, the material activation resulting from the neutron field and radiation doses at the exit wall of the shutter and around the shielding. The MCNP results are presented and compared with results of an analytical approach and with experimental data collected after installation.

Guidelines for the implementation ofXYvariable-geometry converging multichannel collimation in a specific SANS facility

A detailed analysis of the performance of a SANS instrument with variable-geometry converging multichannel collimation is carried out. Count-rate gains relative to conventional SANS arrangements obtained by using theXYvariable-geometry converging multichannel collimator either as a single unit or in association with similar units are discussed.

Intensity and resolution effects in converging multichannel collimators for SANS by Monte Carlo simulation

A study of the contribution of the individual channels of a converging multichannel collimator to the operation of the device is carried out by means of a Monte Carlo computer simulation. The simulation shows that the coupling between the divergence of the incident neutron beam and the inclination of the individual CMC channel axis relative to the beam direction modulates the channel performance as far as intensity and resolution of the transmitted neutrons are concerned. While this does not impair in any significant way the usefulness of the device, the results are helpful to the designer.

A contribution to the practical implementation of a variable-geometry converging multichannel collimator for SANS

The feasibility of constructing a variable-geometry converging multichannel collimator consisting of interlaced planes of thin neutron-absorbing strips is discussed. A process is reported for producing strips of a composite material incorporating gadolinium oxide as the neutron absorber with the required mechanical and neutron-absorbing properties.

[Use of digitalis in elderly patients admitted to a geriatric unit at a general hospital]

PURPOSE

To determine the prevalence of digoxin use as well as its indications in elderly patients at the time of admission to a geriatric unit of a general hospital.

METHODS

One hundred and thirty elderly patients aged 65 and over (mean age = 80 +/- 9 years), 100 women and 30 men were consecutively investigated. Each patient was submitted to a thorough clinical investigation, laboratory work-up, chest X-ray, electrocardiogram and doppler echocardiogram. The use of digoxin was considered appropriate, questionable or inappropriate.

RESULTS

At the time of admission to the geriatric unit 27.6% of the patients were receiving digoxin. The indication was considered appropriate in 36.1%, questionable in 11.1% and inappropriate in 52.7%.

CONCLUSION

We found a high prevalence of digoxin use in elderly patients admitted to a geriatric unit of a general hospital. In most cases its indications were considered inappropriate or questionable. Due to the increased risk of digitalis intoxication in this age group the drug should be prescribed under more strict indications.

[Intracranial cavernous angioma]

Clinical, radiological and histopathological features of eight cases of symptomatic cavernous angioma are presented. Five patients were being evaluated for seizure, two for mass lesions and one for intracranial hemorrhage. CT and/or MRI detected the lesion in all cases, but there is not a characteristic image for cavernous angioma. Good results were obtained by microsurgical approach to these malformations in seven patients with only one patient suffering a worsening of neurological status after surgery.

Solving the problem of SANS instrument optimization

The problem of the optimization of small-angle neutron scattering instruments installed at steady neutron sources is discussed. The optimum solution is shown to be that in which full use is made of either the available luminous area of the source or the available hall space and not necessarily that corresponding to the equal-flight-paths design. Design criteria and their implementation are discussed taking into account space constraints on the instrument's layout. It is shown that the performance of currently operating SANS facilities can be substantially improved by following the optimization procedure proposed by the authors.

[Surgical treatment of acute pancreatitis: experience at a general hospital]

The authors present a study of 15 cases of necrotizing acute pancreatitis treated surgically at the Surgery Department of the University Hospital of the University of São Paulo. All patients in the series were submitted to exploratory laparotomy with sequestrectomy and drainage. Etiology, sex, age, complications, and Ranson prognostic criteria were compared to mortality. Overall mortality was 33%.