Increased risk of unfavorable metabolic outcome during short-term follow-up in subjects with nonfunctioning adrenal adenomas.

OBJECTIVE: To demonstrate long-term changes in the prevalence of several types of metabolic derangements in subjects with nonfunctioning adrenal adenomas. SUBJECTS AND METHODS: 273 subjects with adrenal adenomas, including 231 with nonfunctioning adenoma and 42 with subclinical Cushing's syndrome (sCS), were evaluated with respect to anthropometric and laboratory characteristics and prevalence of type 2 diabetes mellitus (T2DM), hypertension, dyslipidemia, metabolic syndrome (MS), prediabetes and cardiovascular disease (CVD). Median duration was 24 months. Follow-up data of 114 participants with nonfunctioning adrenal adenomas are also presented while those of 117 were missing. Follow-up data regarding changes in anthropometric and laboratory parameters and prevalence rates of metabolic disturbances were obtained from the medical records. RESULTS: The prevalence rates for both patients with nonfunctioning adenoma and sCS were: dyslipidemia: 161 (59%), hypertension: 147 (54%), MS: 128 (47%), prediabetes: 62 (23%), T2DM: 49 (18%), and CVD: 21 (8%). Hypertension and CVD were prevalent in subjects with sCS compared to participants with nonfunctioning adenoma. In follow-up, body mass index (p = 0.005), systolic blood pressure (p < 0.001), waist circumference (p = 0.005), homeostasis model assessment (p = 0.046), high-sensitivity C-reactive protein (p = 0.023), total cholesterol (p < 0.001) and low-density lipoprotein cholesterol (p < 0.001) and prevalence of hypertension (p < 0.001), dyslipidemia (p < 0.001), prediabetes (p < 0.001) and MS (p < 0.01) significantly increased in subjects with nonfunctioning adenoma. CONCLUSION: The data showed that nonfunctioning adrenal adenomas were associated with the development or deterioration of atherosclerotic risk factors. Therefore, follow-up and management strategies should be developed to decrease atherosclerotic morbidity in those individuals.

Is there an association between non-functioning adrenal adenoma and endothelial dysfunction?

BACKGROUND AND AIM: Subtle changes in hypothalamic- pituitary-adrenal (HPA) axis of subjects with nonfunctioning adrenal adenoma may be associated with endothelial alterations. We sought to investigate endothelial function, visceral adiposity and osteoprotegerin (OPG) and interleukin- 18 (IL-18) levels in subjects with non-functioning adrenal adenomas. SUBJECTS AND METHODS: The adenoma group included 40 subjects without clinical and subclinical findings of hypercortisolism or other adrenal gland disorders. Twenty-two body mass index-matched controls were also enroled. The patients and control subjects underwent hormonal evaluation and assessment of anthropometric and metabolic parameters. Endothelial function was assessed with flowmediated dilatation (FMD) of the brachial artery and intima media thickness (IMT) of common carotid arteries. Visceral adipose tissue area was measured by computed tomography. Plasma OPG and serum IL-18 levels were also measured. RESULTS: When compared with healthy controls, the adenoma group had elevated systolic blood pressure, post-dexamethasone suppression test cortisol and reduced DHEAS. Visceral adipose tissue area and IMT of common carotid arteries were comparable. In the adenoma group, FMD of the brachial artery was significantly impaired and IL-18 level was significantly elevated. Visceral adipose tissue area was independently related with FMD. Homeostasis model assessment (HOMA) was the independent factor associated with visceral adipose tissue area. Cortisol, DHEAS and visceral adipose tissue area were independently associated with HOMA. CONCLUSIONS: We achieved evidence that could be attributable to endothelial alterations in subjects with non-functioning adrenal adenomas. Impaired FMD appeared to be a consequence of subtle changes in HPA axis in terms of elevated cortisol and reduced DHEAS as these conditions were known to disturb endothelial-dependent vasodilatation.

Prospective evaluation of tumor size and hormonal status in adrenal incidentalomas.

BACKGROUND: Because of the increased use of imaging interventions, more subjects have been diagnosed with adrenal incidentaloma in recent years. AIM: To evaluate the risk of mass enlargement, hormone hypersecretion and development of adrenal carcinomas during short-term followup. SUBJECTS AND METHODS: There were 317 subjects with incidentally discovered adrenal tumors in the registry. Forty subjects were excluded because of clinically overt hormone secretion at diagnosis and subjects with complete data were included in radiological (no.=150) and hormonal (no.=150) follow- up. Radiological evaluation was performed with computed tomography (CT) and/or magnetic resonance imaging (MRI). There were 143 subjects with adrenal adenomas and 7 subjects with other tumor types (cyst or myelolipoma). Median follow-up duration was 24 months. RESULTS: Increase in tumor size was detected in 25 subjects (17.4%) with adenomas and 1 subject with adrenal myelolipoma (14.3%). Decrease in tumor size was found in 7 subjects (4.8%) with adrenal adenomas. One patient was diagnosed with adrenocortical carcinoma during follow-up. In subjects with non-functioning adrenal adenoma (NFA, no.=120) or subclinical Cushing syndrome (sCS) (no.=30), no subject developed clinically overt hormone hypersecretion, while 8 (6%) subjects in the NFA group developed sCS. Tumor diameter and follow-up duration were significantly higher in subjects who developed sCS. CONCLUSION: In conclusion, we demonstrated that, despite being infrequent, adrenal tumors may increase in size, develop overt or subclinical hormone secretion or feature malignant transformation. Therefore, radiological and hormonal follow-up should be recommended to the patients. More investigations are needed for the establishment of long-term follow-up protocols.

Non-functioning adrenal incidentalomas are associated with elevated D-dimer levels.

AIM: Although the majority of adrenal incidentalomas (AI) are non-functioning, studies evaluating metabolic disturbances in this particular group are limited. The objective of this study is to investigate metabolic syndrome components and levels of plasma von Willebrand factor (VWF), fibrinogen, and D-dimer in subjects with non-functioning AI. SUBJECTS AND METHODS: Forty-five subjects without clinical and subclinical findings of hypercortisolism or other adrenal gland disorders and 37 healthy controls were enrolled. The patients and controls underwent hormonal evaluation including morning cortisol, ACTH, post-dexamethasone suppression test (DST), morning cortisol, DHEAS, and urinary free cortisol. Anthropometric and metabolic parameters and body composition were assessed and fibrinogen, D-dimer, and VWF were measured. RESULTS: When compared with healthy controls, subjects with AI had significant elevations in several metabolic and anthropometric parameters, uric acid, post-DST cortisol, and D-dimer. When compared with body mass index-matched controls, blood pressure (p=0.004), uric acid (p=0.009), post-DST cortisol (p=0.014), and D-dimer (p=0.045) remained significantly elevated. We demonstrated weak correlations between D-dimer and other metabolic and anthropometric variables. Morning cortisol was demonstrated as an independent variable associated with homeostasis model assessment levels in subjects with AI (beta=410, p=0.004). CONCLUSION: Individuals with clinically and hormonally inactive adrenal adenomas feature insulin resistance and a variety of metabolic disturbances. The subtle cortisol autonomy seems to be associated with insulin-resistant state. D-dimer elevation in AI group was a consequence of insulin-resistant state associated with subtle cortisol autonomy rather than a direct effect of cortisol secretion.

Small cell neuroendocrine carcinoma of the endometrium and laparoscopic staging: a clinicopathologic study of a case and a brief review of the literature.

Small cell neuroendocrine (NE) carcinoma is one of the most aggressive tumors that arise in the female genital tract. Small cell carcinoma of the endometrium (SCCE) is an extremely rare disease. Because of its rarity, the only clinical reports are limited to case studies, and therefore, clinical behavior and optimal treatment modalities are not well defined. To the best of our knowledge, we present the first case of SCCE staged by laparoscopic approach. A 54-year-old parous woman admitted with intermittent vaginal spotting. On physical examination, she had a 4- x 3-cm mass fungating out of the cervical os. Magnetic resonance imaging showed an endometrial mass of 25 x 30 x 50 mm in dimensions, invading less than 50% of the depth of the myometrium at the uterine fundus. Pathologic examination revealed undifferentiated malign NE tumor of endometrium of small cell type. The patient underwent laparoscopic hysterectomy, bilateral salpingo-oophorectomy, and laparoscopic pelvic and para-aortic lymphadenectomy. The disease was surgically staged as IB. Histologically, tumor cells were monotone, with scanty, ill-defined cytoplasm and hyperchromatic nuclei. Immunohistochemically, tumor showed positive immunoreactivity for P16, neuron-specific enolase, and synaptophysin. She underwent pelvic external radiation and brachytherapy postoperatively. Patient has no evidence of disease after 26 months of follow-up. Small cell NE carcinoma of the endometrium is an extremely rare and aggressive disease. With the availability of skilled endoscopic surgeons, laparoscopic management of women, even with SCCE in early stage, can be a feasible option.

Pyelovenous fistula: a rare cause of hematuria.

A 72-year-old female who was admitted to our urology clinic with painless intermittent macroscopic hematuria existing for 3 months with no other voiding symptom was diagnosed with left pyelovenous fistula. Although a rare condition, pyelovenous fistula should be kept in mind when the cause of macroscopic hematuria cannot be diagnosed with routine radiological examinations, and retrograde pyelography should be the method of choice for the diagnosis in this rare condition.

The combined use of brachial artery flow-mediated dilatation and carotid artery intima-media thickness measurements may be a method to determine vasculogenic erectile dysfunction.

The aim of this study was to investigate the relationship between penile color Doppler sonography (CDS) findings and sonographic endothelial parameters in patients with erectile dysfunction (ED), including intima-media thickness (IMT) of common carotid arteries (CCA) and flow-mediated dilatation (FMD) of brachial artery. Fifty-six ED patients were included in the study. Penile CDS, IMT of CCA and FMD of brachial artery were performed in all patients. According to penile CDS findings, 27 (48%) patients had non-vasculogenic and 29 (52%) patients had vasculogenic ED. Among 29 patients, 17 (30%) patients had cavernous veno-occlusive disease (CVOD) and 12 (22%) patients had arterial/combined insufficiency (AI). Median (interquartile range) FMD values of non-vasculogenic ED, CVOD and AI were 12.50 (6.54)%, 12.82 (7.41)% and 6.25 (7.17)%, respectively. FMD was found to be impaired significantly in AI group when compared to the other groups. FMD values of CVOD group were lower when compared to non-vasculogenic group, but the difference was not statistically significant. IMT values of vasculogenic ED patients were higher than non-vasculogenic ED patients (P<0.05). Although IMT values were higher in AI group when compared to CVOD, the difference was not statistically significant. The combined use of IMT and FMD established the diagnosis of vasculogenic ED with 100% sensitivity and 59.2% specificity. The positive predictive value was 72%, negative predictive value 100% and accuracy 80%. The combined use of brachial artery FMD and carotid arteries IMT measurements may be suggested as an alternative method to evaluate vasculogenic ED.

Cushing's syndrome due to ectopic CRH secretion by adrenal pheochromocytoma accompanied by renal infarction.

Ectopic production of corticotropin-releasing hormone (CRH) by a pheochromocytoma is an infrequent cause of Cushing's syndrome. We report the case of a 43-year-old man with Cushing's syndrome due to a CRH-producing adrenal pheochromocytoma. The patient had clinical and biochemical evidence of hypercortisolism in conjunction with high ACTH levels and non-suppressible serum cortisol levels on low-dose and high-dose dexamethasone suppression testing. In addition to these clinical features of one month's duration, the patient developed symptoms of pheochromocytoma including headache, hypertension that was resistant to conventional therapy and excessive sweating. Biochemical testing confirmed elevated 24-hour urinary catecholamines and metabolites. Abdominal CT revealed a 4.5 x 4 x 3.5 cm mass in the left adrenal gland. He underwent elective left adrenalectomy. Light microscopic and immunochemical studies revealed a pheochromocytoma that contained immunoreactive CRH and was negative for ACTH. Plasma ACTH and dexamethasone supression tests normalized after surgery. This is an unusual case of a CRH-secreting pheochromocytoma. This was complicated by renal infarction, illustrating further the complexity of Cushing's syndrome in a patient with pheochromocytoma caused by CRH hypersecretion.

Evaluation of ureteral jet dynamics in pediatric kidney stone formers: A cross-sectional study.

INTRODUCTION: The risk of kidney stone formation increases with urinary stasis, which is associated with decreased peristaltism. The relationship between nonobstructive kidney stone formation and ureteral jet dynamics, which can be measured with Doppler ultrasonography (US) and provide information about ureteral peristaltism, has been demonstrated in adults. OBJECTIVE: To investigate the relationship between ureteral jet dynamics, which provide information about ureteral peristaltism, and stone formation in children. STUDY DESIGN: Children admitted to Dokuz Eylul University Hospital with flank pain, and asymptomatic age-matched children for the control group, were prospectively enrolled and underwent Doppler US for diagnostic reasons and bilateral ureteral jet flow measurements. Children diagnosed with unilateral nonobstructive lower pole kidney stones formed Group 1, and the control group, without any evidence of stone disease, formed Group 2. Ureteral jet dynamics were compared between the affected renal units in Group 1, and healthy renal units in Group 1 and Group 2. RESULTS: A total of 32 children were included for each group. The mean average jet flow-rate (JETave (cm/second)) in affected renal units in Group 1 was found to be significantly lower than in the healthy renal units in Group 1 and left and right healthy renal units in Group 2 (P < 0.05). The continuous JETpattern rate in affected renal units in Group 1 was found to be significantly higher compared with healthy renal units in Groups 1 and 2 (P = 0.012) (Table). The odds ratio for kidney stone formation was 5.6 for renal units with JETave <9.5 cm/s when compared with renal units with JETave ≥9.5 cm/s. DISCUSSION: In a recent study, it was demonstrated in adults that low ureteral jet flow-rate and continuous JETpattern were significantly higher in affected renal units. The findings in children were also similar to adults: the mean JETave was significantly lower and determination rate of continuous flow pattern was significantly higher in affected renal units. CONCLUSIONS: Children with low JETave and continuous JETpattern as a sign of decreased ureteral peristaltism are at an increased risk of kidney stone formation. However, it is vital that further studies are conducted to elaborate on this topic.

Imaging of acute pancreatitis and its complications. Part 2: complications of acute pancreatitis.

The Atlanta classification of acute pancreatitis was introduced in 1992 and divides patients into mild and severe groups based on clinical and biochemical criteria. Recently, the terminology and classification scheme proposed at the initial Atlanta Symposium have been reviewed and a new consensus statement has been proposed by the Acute Pancreatitis Classification Working Group. Major changes include subdividing acute fluid collections into "acute peripancreatic fluid collection" and "acute post-necrotic pancreatic/peripancreatic fluid collection (acute necrotic collection)" based on the presence of necrotic debris. Delayed fluid collections have been similarly subdivided into "pseudocyst" and "walled of pancreatic necrosis". Appropriate use of the new terms describing the fluid collections is important for management decision-making in patients with acute pancreatitis. The purpose of this review article is to present an overview of complications of the acute pancreatitis with emphasis on their prognostic significance and impact on clinical management and to clarify confusing terminology for pancreatic fluid collections.

Imaging of acute pancreatitis and its complications. Part 1: acute pancreatitis.

Acute pancreatitis is an acute inflammatory disease of the pancreas that may also involve surrounding tissues or remote organs. The Atlanta classification of acute pancreatitis was introduced in 1992 and divides patients into mild and severe groups based on clinical and biochemical criteria. Recently, the terminology and classification scheme proposed at the initial Atlanta Symposium have been reviewed and a new consensus statement has been proposed by the Acute Pancreatitis Classification Working Group. Generally, imaging is recommended to confirm the clinical diagnosis, investigate the etiology, and grade the extend and severity of the acute pancreatitis. Ultrasound is the first-line imaging modality in most centers for the confirmation of the diagnosis of acute pancreatitis and the ruling out of other causes of acute abdomen, but it has limitations in the acute clinical setting. Computed tomography not only establishes the diagnosis of acute pancreatitis, but also enables to stage severity of the disease. Magnetic resonance imaging has earned an ever more important role in the diagnosis of acute pancreatitis. It is especially useful for imaging of patients with iodine allergies, characterizing collections and assessment of an abnormal or disconnected pancreatic duct. The purpose of this review article is to present an overview of the acute pancreatitis, clarify confusing terminology, underline the role of ultrasound, computed tomography and magnetic resonance imaging according to the proper clinical context and compare the advantages and limitations of each modality.

Effects of sildenafil on ocular perfusion demonstrated by color Doppler ultrasonography.

The aim of this study was to investigate the effects of sildenafil on ocular hemodynamics by color Doppler ultrasonography (CDU). In all, 38 patients with erectile dysfunction diagnosed by International Index of Erectile Function (IIEF) and Sexual Health Inventory of Men (SHIM) scores were included into the study. After taking 100 mg of oral sildenafil citrate, all patients underwent CDU examination of central retinal artery at 60 and 75 min and CDU examination of cavernosal artery at 20, 60 and 75 min. All of the side effects during and after the test were also recorded. The mean cavernous artery peak systolic flow velocity increased significantly after sildenafil. However, no significant change was determined in central retinal artery flow parameters including peak systolic flow velocity, end-diastolic flow velocity, resistive index, pulsatility index, volume and diameter. Five patients experienced ocular side effects. No significant change was observed in retinal artery CDU measurements of patients having ocular side effects. Sildenafil has no effect on ocular hemodynamics on the basis of CDU. Ocular side effects may be the result of other changes in retinal photoreceptors rather than the ocular circulation.

Subclavian artery aneurysm with oesophagoarterial fistula.

Aneurysms of the subclavian artery are rare. Fistula formation between the subclavian artery and the oesophagus has been described in aberrant subclavian artery and oesophageal foreign body. However, a fistula between a non-aberrant subclavian artery aneurysm and the oesophagus has not been previously reported. In this report, an unusual case of subclavian artery aneurysm with a fistula to the oesophagus causing intractable haematemesis is presented with the angiographic findings.

Orbital varices: imaging findings and the role of color Doppler sonography in the diagnosis.

The orbital varices are infrequent intraorbital masses, which cause intermittent, positional exophthalmos. They have low venous pressure inside which causes difficulties in detection by routine protocols of nearly all imaging modalities. Color Doppler sonography is a simple procedure that can easily detect orbital varices which avoids further evaluation in non-complicated patients. We report the imaging findings of a case of orbital varix and discuss the role of color Doppler sonography in the diagnosis and follow-up.

Color doppler sonography in the follow-up of giant glutealaneurysm embolization.

False aneurysm of the gluteal artery is uncommon and may develop secondary to penetrating gluteal injury or pelvic trauma. The use of color Doppler sonography may allow the initial diagnosis of gluteal pseudoaneurysms and provide information about the success of the interventional radiological procedures. In this study, color Doppler sonographic examination demonstrated the failure of the endovascular treatment of a giant superior gluteal artery pseudoaneurysm. The second intervention of super-selective coil embolization provided optimal thrombosis and eliminated the need for open surgery.

Lipoma of the pancreas: MRI findings.

Lipomas of the pancreas are very rare. Focal fatty infiltration of the pancreas is an entity that should be differentiated from a pancreatic lipoma. In this report the MRI findings of an incidentally found pancreatic lipoma are presented and the role of MRI in the differentiation of pancreatic lipoma and focal fatty infiltration of the pancreas is discussed.

CT findings of non-functioning neuroendocrine pancreatic tumors.

Neuroendocrine tumors are rare neoplasms of the pancreas, representing 0.5% of all pancreatic tumors. Approximately, one-third of neuroendocrine tumors are hormonally inactive and called non-functioning neuroendocrine tumors. As these tumors remain clinically silent in their course of growth, they may attain great sizes without causing apparent clinical findings and commonly present in advanced stage. We report three cases of non-functioning neuroendocrine tumors with large sizes and discuss the radiological findings.