the pathological basis of disease · 2012. 2. 23. · endocrine diseases qiao li, md, phd dept of...
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Endocrine Diseases
Qiao Li, MD, PhD Dept of Pathology & Laboratory Medicine Faculty of Medicine University of Ottawa
[email protected] 613 562 5800 Ext. 8491
The Pathological Basis of Disease - Graduate Course CMM 5001
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• Endocrine System • Adrenal Gland
– Anatomy Histology & Function – Steroid Hormones – Addison’s Disease – Cushing Syndrome – Clinical Case Presentation
Outline
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• The Components • The Origin • The Microscopic Structure • Merocrine Secretion • Neuroendocrine System
Endocrine System
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• Anatomy, Histology & Function • Steroid Hormones • Addison’s Disease • Cushing’s Syndrome • Clinical Case Presentation
Adrenal Gland
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Adrenal Gland - Anatomy
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Adrenal Gland – Male Abdomen
The Internet Pathology Laboratory
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Adrenal Gland - CT
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Adrenal Gland - MRI
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Adrenal Gland – in situ
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Adrenal Gland – Gross
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Adrenal Gland – Cut Surface
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Adrenal Gland – Cross Section
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Capsule
Periadrenal fat Zona glomerulosa
Zona fasciculata
Zona reticularis
Medulla
Adrenal Gland – Low Power
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Adrenal Gland – Low & High Power
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Adrenal Gland
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• Anatomy, Histology & Function • Steroid Hormones • Addison’s Disease • Cushing’s Syndrome • Clinical Case Presentation
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Adrenal Cortex Steroids
glomerulosa Mineralocorticoids Aldosterone salt and water homeostasis
fasiculata Glucocorticoids Cortisol carbohydrate metabolism
reticularis Sex Steroids Androgens minimal effects
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O
O
CH2OH
O
O
Zone Class Representative Physiologic Effects
CH2OH
O
O O
CH
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Adrenal Steroidogenesis
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Adrenal Gland - Milestones
1552: Bartholomaeus Eustachius - adrenal glands on copper plates 1936: Edward Kendall and Tadeus Reichstein - isolation and synthesis of cortisone 1949: Edward Kendall and Philip Showalter Hench
- effects of cortisone and ACTH on arthritis 1950: Kendall, Reichstein & Hench - Nobel Prize “for their discoveries relating
to the hormones of the adrenal cortex, their structure and biological effects"
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Glucocorticoids & the Receptor
• Cortisol (hydrocortisone) the majority of glucocorticoid activity in most mammals • 90% of circulating cortisol binds to corticol binding
globulin (CBG), limiting the rate of metabolic clearance and the concentration fluctuation
• Enter cells by passive diffusion
Histone acetylation
TAFII250
RNA Pol II
p300/CBP
TBP
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Effects and Usage of Glucocorticoids
• Carbohydrate, proteins and fat metabolism increase gluconeogenesis muscle breakdown lipolysis
• Anti-inflammatory and immunosuppressive
• Medical Application: arthritis, dermatitis autoimmune diseases. fear phobic
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Control of Cortisol Secretion
Dr. Gary Farr
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Hypothalamus
ACTH
CRH
Cortisol
Pituitary
Adrenal Cortex
HPA Axis
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Adrenal Gland
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• Anatomy, Histology & Function • Steroid Hormones • Addison’s Disease • Cushing’s Syndrome • Clinical Case Presentation
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* General languor and debility * Remarkable feebleness of the heart's action * Peculiar change in the color of the skin
Chronic adrenocortical insufficiency progressive destruction of 90%of cortex
Addison’s Disease
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Extreme weakness and fatigue Unintentional weight loss Loss of appetite Darkening of the skin Low blood pressure, dizziness or fainting Craving for salt Nausea, diarrhea, vomiting Irritability, depression
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• Primary acute Hypocortisolism - Stress crisis - Rapid Steroids withdraw - adrenal hemorrhage
• Primary chronic Hypocortisolism - Autoimmune adrenalitis 60-70% - Infections TB 90% - Metastatic neoplasms - Genetic disorder
Primary Adrenocortical Insufficiency
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ACTH
CRH
Cortisol
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• Secondary Hypocortisolism - Hypothalamic pituitary disease
- Hypothalamic pituitary suppression
Secondary Adrenocortical Insufficiency
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ACTH
CRH
Cortisol
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Glucocorticoid replacement
Mineralocorticoid replacement
Prevent adrenal crisis
Medic Alert bracelet
Management
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ACTH
CRH
Cortisol
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For people with Addison’s Disease
* prior to 1930, 90% died within 5 years
* from late 1930, much better prognosis
* since late 1950, normal life span
Prognosis
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• Anatomy, Histology & Function • Steroid Hormones • Addison’s Disease • Cushing’s Syndrome • Clinical Case Presentation
Adrenal Gland
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• Excessive Endogenous Cortisol - ACTH independent: cortical tumor - ACTH dependent:
* Pituitary adenoma * Small cell carcinoma
• Administration of Glucocorticoids - The most common cause
Cushing’s Syndrome
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ACTH
CRH
Cortisol
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Causes of Cushing’s Syndrome
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• Excessive Endogenous Cortisol - ACTH independent: cortical tumor - ACTH dependent:
* Pituitary adenoma * Small cell carcinoma
• Administration of Glucocorticoids - The most common cause
Causes of Cushing’s Syndrome
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ACTH
CRH
Cortisol
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• Excessive Endogenous Cortisol - ACTH independent: cortical tumor - ACTH dependent:
* Pituitary adenoma * Small cell carcinoma
• Administration of Glucocorticoids - The most common cause
Causes of Cushing’s Syndrome
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ACTH
CRH
Cortisol
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• Excessive Endogenous Cortisol - ACTH independent: cortical tumor - ACTH dependent:
* Pituitary adenoma * Small cell carcinoma
• Administration of Glucocorticoids - The most common cause
Causes of Cushing’s Syndrome
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ACTH
CRH
Cortisol
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• Excessive Endogenous Cortisol - ACTH independent: cortical tumor - ACTH dependent:
* Pituitary adenoma * Small cell carcinoma
• Administration of Glucocorticoids - The most common cause
Causes of Cushing’s Syndrome
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ACTH
CRH
Cortisol
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• Central Obesity (trunk & upper back) 85-90% • Moon face 85% • Weakness and fatigability 85% • Hirsutism 75% • Hypertension 75% • Plethora 75% • Glucose intolerance / diabetes 70 / 20% • Osteoprosis 75% • Moodiness, irritability or depression 75-80% • Menstrual abnormalities 70% • Skin striae (sides of lower abdomen) 50%
Clinical Manifestations
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24-hour urine free cortisol level am & pm cortisol * for loss of diurnal rhythm, Hall mark Low-dose Dex suppression * identify Cushing's Syndrome High-dose Dex suppression * identify Cushing’s Disease
Screening Tests
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ACTH
CRH
Cortisol
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Low-dose Dex suppression Day 1: 1 mg of Dex is given at 11 pm Day 2: 0.5 mg of Dex every 6 hrs for 48 hrs High-dose Dex suppression Day 1: a baseline cortisol measured at am 8 mg of Dex is given at 11 pm Day 2: 2 mg of Dex every 6 hrs for 48 hrs. blood cortisol at 8 am on day 2 urinary cortisol for 3 days
Dexamethasone Suppression Test
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ACTH
CRH
Cortisol
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• Is ACTH independent?
• If ACTH dependent * pituitary or ectopic
• Source of hormone overproduction * MRI pituitary * CT adrenals, chest, abdomen
Determining the Etiology
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ACTH
CRH
Cortisol
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Adrenal Gland - Adenoma
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Adrenal Gland - Mass
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Adrenal Gland - Adenoma
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Surgical Therapy
Radiotherapy
Medical therapy adrenal enzyme blockers
The management
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ACTH
CRH
Cortisol
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Adrenal Gland
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• Anatomy, Histology & Function • Steroid Hormones • Addison’s Disease • Cushing’s Syndrome • Clinical Case Presentation
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Adrenal Gland – Gr / CS Nodular Cortical Hyperplasia
Confluent Nodules
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Nodule
Adrenal Gland – Low Power Nodular Cortical Hyperplasia
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Adrenal Gland – High Power Nodular Cortical Hyperplasia
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Adrenal Gland, cortical adenoma in Cushing’s syndrome – Gr / CS
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Adrenal Gland, cortical adenoma - LP
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Adrenal Gland - Comparison
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Resources
• Pathologic Basis of Disease Robbins & Cotran 7th Edition
• Basic Pathology Robins 7th Edition
• Handbook of Clinical Pathology 2nd Edition
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