sp endokrin case 2

8/18/2019 Sp Endokrin Case 2

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Student Project

Tumor with Ectopic Production of Hormone

Colorectal CancerSGD B8

Denpasar, Noem!er "8,"#$%


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Chapter-1: Introduction

last of "#th centur&,'ifest&le, lot of fast food, less

in ph&sical actiit& HealthPro!lems

cancer incidence is e(pected to

increase !& $##) to $8#) in thene(t $* &ears due to increases inlife e(pectanc&,

Colorectal cancer is a t&pe ofcancer is the third most in+ndonesia, the num!er of cases of$8-$##,### populations

MetabolicDisease


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Chapter-II: ContentDefniti

onEpidemiolo

.&

Risk

FactorPathogenesis

Diagnosis

Di. D

!tagingPre"enti

on

#reat$e

nt

Prognos


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on%pide$iol

og&

Risk

FactorPathogenesis

Diagnosis

Di. D

!tagingPre"enti

on

#reat$e

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Prognos

Si.n /S&mpotms

Need To !eConsidernum!er of colorectal cancer cases

in the 0nited States for "#$% are

'()*+, ne cases of coloncancer %#,### new cases of

rectal cancer

Colorectal cancer is a t&pe of

cancer is the third most in+ndonesia, the num!er of cases of1.* 1,,),,, population

$ 1orld Cancer 2eport "#$% 1orld Health 3r.ani4ation "#$% pp Chapter ** +SBN 5"86"#%"58" 7itroic, B Schae9er, D : 2iddell, 2 H ;irsch, 2 Tumor !uddin. in colorectal carcinoma? Time to

>

+s it ur.ent pro!lems A

2is@ factors

Colorectal cancer


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on%pide$iol

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How Can it Deeloped A

Produce the Ectopic

Hormone A

7ost colorectal cancers deelop slowl& oer seeral&ears Before a cancer deelops, a .rowth of tissue ortumor usuall& !e.ins as a nonFcancerous pol&p on the

inner linin. of the colon or rectum tumor is a!normaltissue and can !e !eni.n


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on%pide$iol

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Prognos $ Stephen Briet4@e, 7D, :CP, :CE 7ellitusEndicrinolo.&


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on%pide$iol

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Ectopic Hormone :rom Cancer Sel

%ctopic/C#0

Production

• +nappropriate secretion of CTH, althou.h uncommon, is animportant cause of mor!idit& and mortalit& in certain t&pes ofmali.nancies, The most common cause of ectopic CTHproduction is the e(pression of proopiomelanocortin


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on%pide$iol

og&Risk

FactorPathogenesis

Diagnosis

Di. D

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on#reat$e

ntPrognos

There are " @ind of cushin. s&ndrome ?

• +atro.enic cushin.Ks s&ndrome

7ore than $# million mericans receie

pharmacolo.ic doses of .lucocorticoidseach &ear, so iatro.enic cushin.Kss&ndrome must !e more common

•

Ectopic CTH s&ndrome !out $ percent of patients with

colorectal cancer hae ectopic CTHs&ndrome


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on%pide$iol

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• population !ased stud& in Denmar@ foundthat the from $ patients in an $$ &earperiod Ninet& nine patients had cushin.Lsdisease %8 had adrenal dependent cushin.Ls

disease $ had ectopic corticotropin


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on%pide$iol

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on%pide$iol

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on%pide$iol

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on%pide$iol

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ntPrognos Tomer C, +oannis SP 3had T, et al Mutant p53 Prolongs NF-kB Activation and Promotes Chronic Infammation andInfammation-Associated Colorectal Cancer Cancer Cell "#$6? "6


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on%pide$iol

og&Risk

FactorPathogenesis

Diagnosis

Di. D

!tagingPre"enti

on#reat$e

ntPrognos Tomer C, +oannis SP 3had T, et al Mutant p53 Prolongs NF-kB Activation and Promotes Chronic Infammation

and Infammation-Associated Colorectal Cancer Cancer Cell "#$6? "6


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on%pide$iol

og&Risk

FactorPathogenesis

Diagnosis

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ntPrognosGome4 2T, 3tero OD, Escalada P2, et al Carcinoma o$ the colon associated to ectopic AC!0 secretion An Med Interna %&&+' .)*.&, 5+(-5+)

Colorectal cancercell

M 7elanoc&testimulatin.hormone

M Corticotropinreleasin.hormone

M CTH

M P37C

M Ectopic production of CTH hormone


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on%pide$iol

og&Risk

FactorPathogenesis

Diagnosis

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ntPrognosrant4a :S, Giusi +:, 1im EC, et al Integral anal"sis o$ p53 and its value as prognostic $actor in sporadic colon cancer BMC Cancer %&.3'.3*1, %22-%((

;aplan 7eier plots for CSS accordin. to p*6 functionalit&


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on%pide$iol

og&Risk

FactorPathogenesis

Diagnosis

Di. D

!tagingPre"enti

on#reat$e

ntPrognos Tomer C, +oannis SP 3had T, et al Mutant p53 Prolongs NF-kB Activation and Promotes Chronic Infammationand Infammation-Associated Colorectal Cancer Cancer Cell "#$6? "6


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on%pide$iol

og&Risk

FactorPathogen

esisDiagnos

isDi. D

!tagingPre"enti

on#reat$e

ntPrognos Tomer C, +oannis SP 3had T, et al Mutant p53 Prolongs NF-kB Activation and Promotes Chronic Infammationand Infammation-Associated Colorectal Cancer Cancer Cell "#$6? "6


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on%pide$iol

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esisDiagnos

isDi. D

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/na$nesis? Basic :our and sacred seen

$ Present illness

a 3nset

! 'ocation

c Chronolo.&

d Ruantit&

e Rualit&

f :actor a..raate and e(tenuate. ccompan&in. s&mptoms

" Past illness

6 :amil& histor&

% Social histor&


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on%pide$iol

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Common s&mptom of colorectal cancerare?

• !dominal cramps

•

chan.e in !owel ha!its


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esisDiagnos

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The s&mptoms of ectopic CTH are as !elow?

• 1ea@ muscle

• :luid retention

• +ncreased s@in pi.mentation

• Dia!etes• +ncreased !lood pressure

• +ncreased !lood .lucose

• +ncreased urination

•

n(iet&• :ati.ue round, red and full face


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on%pide$iol

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esisDiagnos

isDi. D

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ntPrognos 7oon face 7ultiple striae on s@in


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on%pide$iol

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esisDiagnos

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+f patient is suspected with colorectalcancer after anamnesis and ph&sicale(amination, then further tests areneeded for conIrmation such as?

• Colonoscop&

• Si.moidoscop&

• Biops&

• 72+, CT scan• :ecal 3ccult Blood Testin.

• Tumor 7ar@er test


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on%pide$iol

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• 2rine le"el o ree cortisol

• Dea$ethasone!uppression #est

• Plas$a Concentration o/C#0


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on%pide$iol

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!tage-, The tumor is er& small,in the inner part of colon/ rectum The therap&

can !e sur.er&

!tage-1 The tumor cells inadeinto the other la&er of

the intestine !ut not outof the colon

!tage-3spread out of the colonand rectum !ut do notreach the l&mph node

!tage-+

tumor cellshae spread outinto the nearestl&mph node !utdo not reach theother or.ans

The possi!letherapies aresur.er&,

chemotherap&,and radiation

!tage-4

The tumor cellshae !eenspread into theother or.anssuch as lierand lun. Thepossi!letherapies aresur.er&,

chemotherap&,radiation, and' P :ieldin., P rsenault, P H Chapuis, d@@ $55$ Clinicopathological staging $or colorectal cancer' An

International ocumentation 4"stem *I4, and an International Comprehensive Anatomical !erminolog" *ICA!,


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on%pide$iol

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Depends on tumor si4e, sta.e ofdia.nosis, location of the tumor, ris@ ofthe cancer returnin. and ph&sical healthof the patient There are 6 t&pes of

treatments?a= Sur.er& helps to reliee s&mptoms

!= Chemotherap&Fshrin@ tumors,reliee s&mptoms and help people

lie lon.er " t&pes of chemotherap&?$= djuant chemotherap& and "=

Neoadjuant chemotherap&


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on%pide$iol

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c= Biolo.ical therap& F uses theimmune s&stem to I.ht cancer

$= to help lessen the side e9ects

of other treatments !& usin.natural !od& su!stances

"= dru.s to stren.then the!od&Ls immune s&stem and

!oost its own defences6= Common dru.ss?

!eaci4uma!


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on%pide$iol

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1ith prompt and appropriate treatment,the pro.nosis for a person with colorectalcancer is hopeful The surial rate forpeople with colorectal cancer depends

on the e(tent of the cancer at the time ofdia.nosis and the indiidualLs responseto treatmentSeeral factors determine how well aperson will do after treatment forcolorectal cancer The& include? Sta.e ofthe cancer, The num!er of l&mph .landsinoled, +f the cancer has spread toother or.ans, and Rualit& of the sur.er&


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Chapter-III: Conclusion


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Chapter-III: Conclusion


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Case !tud&-1N+ Tsa!ed4e, C 2a&, 7 Hale Ectopic

CTH s&ndrome? a clinical

challen.e OE7DS "#$$$


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Histor&

• "5F&earFold woman with a si(Fmonthhistor& of human immunodeIcienc& irus


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Ph&sical E(am

• Normotensie Cushin.oid &oun. woman with centralobesit& and $oon acies

• Purple striae oer her an@s and thi.hs

• :acial acne

• Bruisin. on her forearms• H&perpi.mentation of her e(tensor surfaces on her

upper and lower lim!s

• si.niIcant right inguinal l&$ph node was

palpa!le, which was I(ed and nontender• 3n rectal e(amination a orr&ing ulcer was noted on

her anus

• Th&roid e(amination was normal


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'a! test


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'a! Test6o #est 7alue 6or$al 7alue

$ Serum Potassium "6 mmol-l


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+ma.in.

• CT scan of thea!domenreealed a locall&

in"asi"e rectaltu$or

• n o!structie

rectal tumor wasidentiIed !&si.moidoscop&and !iops& wasta@en


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Histopatholo.&

• Histopatholo.ical e(amination showedulceration o the s8ua$ous epitheliu$

• %tensi"e infltration of the perianal softtissue !& discohesie nests of small cells withh&perchro$atic nuclei hain. Inel& stippledchromatin with a saltFandFpepperFli@eappearance

• !$all) eosinophilic nucleoli ere present The cells also had a moderate amount of palestainin. c&toplasm 9ccasional $itoses wereidentiIed to.ether with focal necrosis


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+mmunohistochemistr& showed paranuclear, dotF

li@e, positie stainin. for the pan@eratins 7N: $$and E$-6, to.ether with positie c&toplasmic

stainin. for s&naptoph&sin, chromo.ranin and/C#0 in the $alignant cells


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Dia.nosis and treatment

• This patient can !e dia.nosed as anectopic CTH production caused !&neuroendocrine carcinoma

• Neuroendocrine carcinoma can !econIrmed !& ima.in. and histolo.&e(amination

• +t is unclear whether H+ infectionitself has a direct e9ect on thedeelopment of anal cancer


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The ectopic CTH production can !eseen !&?

• 2andom serum cortisol was in e(cessof " #5 nmol-l

• drenocorticotropic hormone


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Ectopic hormone production conIrmed!&?

• +mmunohistochemistr& e(aminationthat show CTH in the mali.nantcells

•

Patients ph&sical appearance isCushin. s&ndrome appearance thatcaused !& hi.h CTH leel that made

hi.h cortisol leel• la!ile emotion can !e caused !& hi.h

cortisol leel


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Treatment and pro.nosis

• H&po@alemic still occur despitea..ressie potassium replacementtherap&

• Despite a..ressie supportie andspeciIc therap&, the disease coursewas complicated !& nosocomial

sepsis and septic shoc@, temperaturespi@es, h&potension and the patienteentuall& succum!ed


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Case !tud&-32 Seh.al, 1 7cha&leh, et al Oournal of3ncolo.& denocarcinoma of Colon

Presentin. as Cushin.Ls S&ndrome "#$#


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6*F&earFold woman present with $ monthhistor& of a!dominal pain, wei.ht .ain


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Pictures

Ph i l E d


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Ph&sical E(am and'a!orator& data

Pulse rate (*$inute /C#0 43, pg$

;lood pressure 1


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Treatment

• CTH supressiontherap&

• S&stemic

chemotherap&• 7et&rapone and

etomidate wereused durin. this

period fortreatment ofh&percortisolism

• ri.hthemicolectom& andintra!dominallaa.e perforated cecum

and intraa!dominala!cess

sp endokrin case 2

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