Adrenal Cushing 2 diagnoss treatment other syndromes

Diagnosis is based on clinical suspicion followed by measurement of plasma cortisol (5-25 ng/dl) a loss of diurnal variation (high value in the evening). A detailed evaluation is then required to differentiate between Hyperplasia or tumours of adrenal and ectopic ACTH syndrome the details of this differentiation are given in Table 3

The treatment ofendogenous cushings excess secretion of cortisol from adrenals is bilateral adrenalectomy

Minimal access route is used

NELSON’S SYNDROME

      Patients of Cushing’s Syndrome treated with total adrenalectomy later develop deep pigmentation of the skin and evidence of tumour in the pituitary. This is probably due to high levels of Melanin Secreting Hormone (M.S.H.) along with high ACTH.

2.5 CONN’S SYNDROME (PRIMARY ALDOSTERONISM)

      This syndrome is caused by an excess secretion of aldosterone by a secreting adrenal adenoma(70%). Bilateral adrenal hyperplasia (30%) and adenocarcinoma can also produce primary aldosteronism.

      The symptoms are due to hypertension, hypokalaemia and alkalosis. There is a weakness polydipsia intermitent paresthesia. Tetany and occasional paralysis also occur

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Adrenals Cushings clinical 1

2.2 CUSHING’S SYNDROME

Fig 32.3

      This syndrome is caused by excess endogenous or exogenous corticosteroids (glucocorticoids mainly). Nearly 80% of the endogenous variety is due to excess ACTH from the pituitary, leading to hyperplasia of the adrenal cortex. The rest of the lesions causing this syndrome are adenomas and carcinomas of the adrenal cortex. In some instances, there is a mixed picture of hyperadrenocorticism with some element of virilism.

      The typical patient show truncal obesity hypertrichosis (excess hair) and hypertension. The disease is commoner in females and affects all ages. The onset is gradual with lasitude and fatigability.

      The commonly observed clinical features seen in large number of cases are given in Table 32.1.

Table 32.1

Cushing’s Syndrome-Clinical Features In 711 Patients

_________________________________________________________________

      Central obesity               90%

      Hypertension                  87%

      Menstrual irregularity        80%

      Plethora                      80%

      Hirsuitism(in female)         79%

      Striae                        68%

      Weakness                      65%

      Osteoporosis                  64%

      Abnormal GTT                  55%

      Mental changes                42%

      Renal stones                  19%

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Adrenals anatomy

ADRENAL

1. ANATOMY

      Each adrenal gland weighs from 4-12 gms., the average being about 7 gms. in the adult.

The glands are superomedial to the upper poles of the kidneys.

* The right gland in its medial aspect is situated behind the vena cava

* The left gland is directly posterior to the tail of the pancreas. The arteries are from the renal, inferior phrenic and aorta (Fig. 32.1)

Fig 32.1

1.2 Veins

      On the right side, the hilar vein is short and wide and opens into the vena cava. On the left side, the hilar vein enters the left renal vein.

1.3 ADRENAL GLANDS

      There are two functional parts of the adrenal. The cortex and the medulla-with different embryologic origins. The cortex is derived from the fetal mesoderinal ridge and divided into zonaglomerulosa, zona fasciculata and zona reticular. These can be distinguished under the microscope.

1.3.1 The cortex secretes five principal hormones, all with steroids rings.

These are:

a) Corticosteroids

b) Mineralocorticoids

c) Androgens

d) Estrogens

e) Progesterones

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Thyroid carcinoma 1

13. CARCINOMA THYROID 

 a & b

      This is an uncommon cancer and the incidence 30-60 new cases per million population per year.

      In man there is convincing evidence regarding radiation exposure as an etiologic factor. Cancer seen in the young is usually of the differentiated variety in the old undifferentiated carcinoma is more common.

13.1 Differentiated Carcinoma

13.1.1 PAPILLARY CARCINOMA

      This occurs most often in those under the age of 40 years and accounts for more than 50% of all thyroid cancers and presents as a small hard slow growing nodule in the thyroid, and spreads most often to the cervical lymphnodes.

      Histopathologic examination shows the lining epithelium of the follicule arranged in papilary processes. On careful examination many show more than one focus of carcinoma in the thyroid. The metastasis in the lymphnodes also resemble thyroid with papillary formation
the follicule arranged in papilary processes. On careful examination many show more than one focus of carcinoma in the thyroid. The metastasis in the lymphnodes also resemble thyroid with papillary formation

FOLLICULAR CARCINOMA

      This carcinoma presents with a mass in the thyroid and occur ten years later (40-50 years). It appears as a follicular pattern on histopathologic examination and manifests its malignant nature in infiltrating into the blood vessels or the capsule of the tumour. Metastasis usually occur to bones and lungs by blood stream. There are no clinical feature to distinguish it except signsof local infiltration to structures (larynx; recurrent laryngeal nerve; carotid sheath).

13.2.1 TREATMENT Fig. 31.10a, 31.10b

      In cases where the diagnosis is established by aspiration cytology or biopsy, the treatment recommended is total thyroidectomy, this takes care of focal and multifocal origin of these carcinomas and also helps the future management of metastasis by radio iodide.

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