ACTA ENDOCRINOLOGICA (BUC)

Thyroiditis developing post pituitary surgery in a case of TSH secreting tumor has been reported, albeit rarely. A 46 year old female was treated as a case of hypothyroidism for almost five years, however, TSH levels remained unsuppressed in spite of increasing thyroxine doses. A cyclic pattern of TSH with T3 secretion was observed after stopping thyroxine, though T4 levels were normal. T3 suppression test revealed a non suppressed TSH and MRI sella revealed a pituitary mass with Grade 1 cavernous sinus invasion. With a diagnosis of TSH secreting tumor, the patient was initiated on octreotide therapy. TFT normalized within 4 days of initiation of octreotide, tumor size reduced by about 30% within 2 months of therapy and goiter size reduced to almost half with octreotide therapy. Anti TPO levels which were initially negative became positive within a month of octreotide therapy and FNAC thyroid revealed thyroiditis. To the best of our knowledge, this is the second case report of development of thyroiditis after octreotide therapy. The immunomodulatory role of TSH and somatostatin may have a role in the development of thyroiditis in this case.

Objective. Ectopic parathyroid adenoma is an uncommon cause of primary hyperparathyroidism. Apart from the usually described sites of ectopic parathyroid adenoma, anecdotal case reports of undescended parathyroid adenoma along the carotid artery have been described. Methods. We report a rare case of a 4 cm large parathyroid adenoma within the carotid sheath. Results. A 27-year-old lady presented with severe bony pains, history of height loss, fracture of left shaft femur following trivial trauma and renal calculi. On evaluation she had hypercalcemia with elevated iPTH suggestive of primary hyperparathyroidism. Ultrasound of neck and 99mTc sestamibi SPECT/CT incorrectly localised the lesion as right inferior parathyroid adenoma leading to a failed initial surgery. Later CECT of the neck identified adenoma posterior to right common carotid artery which was confirmed on repeat surgery and the patient was cured. Conclusion. Ectopic parathyroid adenomas are both difficult to localise and are a common cause of failed initial parathyroid surgery. Surgeons should exercise caution while removing a visually normal parathyroid gland. In case of any discordance with the pre-operative localization, a meticulous systematic dissection using the conventional approach should be performed and the possibility of an undescended gland in the carotid sheath should be considered.

Context and objective. Somatostatin analogues and cinacalcet have been suggested to have some role in managing hypophosphatemia. This report highlights challenges in managing surgically incurable tumor induced osteomalacia (TIO) with somatostatin analogues and cinacalcet. Patient and methods. A twenty-two year old patient with severe osteomalacia was diagnosed to have TIO due to left hemipelvis tumor (June 2013). Partial surgical removal of tumor (due to its proximity to neurovascular bundles), led to transient remission for 6 weeks. Clinical worsening in spite of maximum tolerable phosphate and calcitriol dose led to trial of octreotide. Acute improvement in phosphate following subcutaneous octreotide 100 mcg was the basis for use of long acting depot octreotide, which was associated with maximal improvement for 4 months, followed by reduced efficacy. Repeated MRI revealed an increase in residual tumor size. Reevaluation revealed very a high parathyroid hormone. Cinacalcet titrated to 90 mg/day induced hypoparathyroidism, improved hypophosphatemia but caused symptomatic hypocalcemia. Cinacalcet at lower doses (30mg/day), though well tolerated, was less effective in improving hypophosphatemia. There was a near 10-fold reduction (2406 to 246RU/ml) in C-terminal FGF-23 levels with cinacalcet. Reduction in phosphate and calcitriol requirements with cinacalcet may contribute to decreased FGF-23. There was no decrease in tumor size. Conclusion. Octreotide and cinacalcet are effective in controlling hypophosphatemia over short periods. Progressive nature of TIO leading to an increased disease severity, tachyphylaxis may explain decreased efficacy of octreotide, higher cinacalcet requirement, poor tolerability, thus limiting their role in long-term management of TIO.