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PubMed1998

Tropical myeloneuropathies revisited.

An interesting neurological syndrome, characterized by recurrent optic neuritis, cervical myelopathy from syringomyelia, paraparesis, amenorrhea-galactorrhea, and other endocrine problems, has been described among young black women in the French West Indies. The etiology remains unknown, but possible links with Devic's disease, acute disseminated encephalomyelitis, and neurotoxicity from quinolines in Annona muricata teas have been postulated. The largest epidemic of neuropathy in this century occurred in Cuba in 1991-1994. Clinical features and etiologic studies are reviewed. Its primary cause was nutritional. A similar epidemic was recently described in Tanzania. A number of infectious neuropathies and myopathies are reviewed, including leprosy, tuberculosis, hemorrhagic fevers (Ebola and Marburg filoviruses, Lassa, Argentinean and Bolivian arenaviruses), the human retrovirus human T-cell lymphotropic virus type I, Lyme disease and postimmunization neuropathies. The tropics continue to contribute interesting and important clinical conditions that may illuminate the etiopathiogenesis of other common disorders.

Cuba↗

PubMed1996

[Laparoscopic adrenalectomy. Experiences with 50 patients].

Fifty patients with adrenal tumors (18 men and 32 women, average age 51.8 years) underwent laparoscopic adrenalectomy from February 1992 to October 1995. Clinical diagnosis included pheochromocytoma in 3 patients, primary aldosteronism (including 1 with a 11-OH-corticosterone-producing tumor) in 15, Cushing's syndrome (including 7 with pre-Cushing's syndrome) in 13, non-functioning tumors in 17, 1 metastatic adrenal carcinoma, and 1 adrenal tuberculosis. Transperitoneal laparoscopic adrenalectomy was performed by the method reported previously. Extraperitoneal laparoscopic adrenalectomy was performed with the patient under general anesthesia in the lateral position. A working space was created by inserting a balloon dissector through a small skin incision. A total of four trocars were inserted. Three of the 50 patients were switched to open surgery, including 1 with metastatic adrenal carcinoma and 1 with adrenal tuberculosis. Laparoscopic tumor removal was successful in the other 47 patients. The average operating time and blood loss were 209 min and 177 ml, respectively. Blood loss was greater in the patients with pheochromocytoma. In patients with Cushing's syndrome, postoperative recovery tended to take longer. Postoperative complications occurred in 40% of the patients in this group, but all complications were minor and successfully treated without any surgical procedures. In the 10 patients undergoing retroperitoneal laparoscopic adrenalectomy, operative courses were excellent, excluding 1 patient with adrenal tuberculosis. Although laparoscopic adrenalectomy is considered to be appropriate for patients with pheochromocytoma and Cushing's syndrome, it appears unsuitable for the removal of malignant and inflammatory lesions.

Adrenal Cortex Hormones↗

PubMed1995

[The "vitamin D" endocrine and paracrine mediator in pulmonary granulomatosis].

This paper reports the recent data concerning the role of vitamin D in pulmonary granulomatous disease. Besides the well known action of 1,25-(OH)2D3 in producing hypercalcaemia in these patients, it is envisaged that 1,25-(OH)2D3 probably has an activating effect through a paracrine pathway on the formation and maturation of granulomas at the pulmonary level.

Calcitriol↗

PubMed2006

[Regulatory T cells].

Regulatory T-cells are a subset of T cells that have beene extensively studied in modern immunology. They are important for the maintenance of peripheral tolerance, and have an important role in various clinical conditions such as allergy, autoimmune disorders, tumors, infections, and in transplant medicine. Basically, this population has a suppressive effect on the neighboring immune cells, thus contributing to the local modulation and control of immune response. There are two main populations of regulatory T cells - natural regulatory T cells, which form a distinct cellular lineage, develop in thymus and perform their modulatory action through direct intercellular contact, along with the secreted cytokines; and inducible regulatory T cells, which develop in the periphery after contact with the antigen that is presented on the antigen presenting cell, and their primary mode of action is through the interleukin 10 (IL-10) and transforming growth factor beta (TGF-alpha) cytokines. Natural regulatory T cells are activated through T cell receptor after contact with specific antigen and inhibit proliferation of other T cells in an antigen independent manner. One of the major difficulties in the research of regulatory T cells is the lack of specific molecular markers that would identify these cells. Natural regulatory T cells constitutively express surface molecule CD25, but many other surface and intracellular molecules (HLA-DR, CD122, CD45RO, CD62, CTLA-4, GITR, PD-1, Notch, FOXP3, etc.) are being investigated for further phenotypic characterization of these cells. Because regulatory T cells have an important role in establishing peripheral tolerance, their importance is manifested in a number of clinical conditions. In the IPEX syndrome (immunodysregulation, polyendocrinopathy and enteropathy, X-linked), which is caused by mutation in Foxp3 gene that influences the development and function of regulatory T cells, patients develop severe autoimmune reactions that involve autoimmune endocrine disorders (type 1 diabetes, thyroiditis), respiratory and nutritive allergy, eczema and severe infections. In different types of allergy (pollen allergy, dust mite, nutritive allergens, contact hypersensitivity, etc.) and autoimmune diseases (such as rheumatoid arthritis, multiple sclerosis and type 1 diabetes) a lower number or decreased functional capability of regulatory T cells have been described. In inflammatory conditions and infections, this cell population has an important task in restricting immune response and protecting the host from excessive damage. This ability of regulatory T cells can be used by some pathogens (Epstein Barr virus, Mycobacterium tuberculosis, Leishmania major, etc.) and tumor cells to avoid host response and therefore contribute to the development of some pathological conditions. The knowledge gained on the phenotype and function of regulatory T cells could be useful in many medical conditions. In allergy, autoimmune diseases and in transplant procedures in medicine it would be desirable to increase their function, thus to partially suppress the immune system activity. On the other hand, in some infections and tumors, it would be preferable to decrease the activity of regulatory T cells and boost the function of effector T cells. Regulatory T cells comprise a very active field of immunology, therefore monitoring and modulating of their activity is of great potential significance in a broad spectrum of clinical conditions. By developing and standardizing methods for their monitoring, it would be possible to follow additional parameters of certain clinical conditions and possibly utilize them in therapy.

Humans↗

PubMed2006

The effect of fertility control on the transmission of bovine tuberculosis in wild brushtail possums.

AIM: To determine the effect of fertility control on the rate of transmission of bovine tuberculosis (Tb), caused by Mycobacterium bovis, in brushtail possums (Trichosurus vulpecula). METHODS: At two study sites with a history of Tb infection in the resident possum population, a sample of adult male and female possums (n=50), determined by palpation to be Tb-free, was surgically sterilised by gonadectomy. A sample of untreated Tb-free male and female possums (n=54) served as controls. Each study site was trapped every 2 months over a 3-year period, and the Tb status of the individuals in the trial assessed. At the conclusion of the trial, all remaining experimental individuals were killed, necropsied and examined for characteristic lesions typical of Tb. The rate of transmission of Tb infection was estimated using the incidence of tuberculous cases in the experimental animals and comparing it between sites, sex and sterilisation treatment. RESULTS: Sterilisation by gonadectomy resulted in a reduction in the rate of transmission of Tb in male possums by 53%, but a corresponding increase in sterilised females for reasons that are still unclear. However, this interaction was statistically weak (p=0.10). When the sexes were combined, there was no overall effect of sterilisation on the rate of transmission of Tb (p=0.43). Sterility treatment notwithstanding, there was a highly significant difference in the rate of transmission between the sexes (p=0.01), being almost one order of magnitude higher in untreated males compared with untreated females. CONCLUSIONS: Although lacking strong statistical support, these results suggest that fertility control that targets endocrine control of fertility may provide some additional benefits for disease control over that achieved by reductions in population density, by reducing the rate of transmission of M. bovis in male possums. However, additional studies are needed to confirm the validity of these results. The large difference in the rate of transmission of M. bovis in untreated males compared with untreated females suggests that transmission of Tb among males may be an important driver of the dynamics of Tb infection in possums.

Animals↗

PubMedDate not supplied

[AIDS pathology: various critical considerations (especially regarding the brain, the heart, the lungs, the hypophysis and the adrenal glands].

Our studies on pathology of AIDS point to four major conclusions. 1) The brain is often directly affected by the HIV infection (with the characteristics of subacute microglial encephalitis with pathognomonic multinucleated giant cells) and then by opportunistic infections such as Cytomegalovirus, Herpes-virus, Papova-virus JC (with progressive multifocal leucoencephalopathy), Mycobacterium tuberculosis, Toxoplasma gondii, Cryptococcus neoformans, Candida albicans and Aspergillus fumigatus; opportunistic neoplasms (i.e. B cell lymphoma mostly pluricentric) could also developed. 2) The heart is frequently involved as well; perivascular sclerosis and myocytolysis are the hallmarks of a peculiar cardiomyopathy. 3) In the lung viral, bacterial, fungal an protozoan severe infections are frequently present: common are those caused by Cytomegalovirus and Pneumocystis carinii. Frequently thin fibrotic interalveolar septa are observed (with consequent alteration of hematosis). 4) Adrenal (most frequently) and pituitary may display necrotic-hemorragic areas (in adrenals chiefly due to Cytomegalovirus). These may be extensive enough to explain the occurrence of clinical syndromes of endocrine insufficiency.

Acquired Immunodeficiency Syndrome↗

PubMed1980

The endocrinology of breast cancer.

Endocrine studies relating to breast cancer are reviewed and the conclusion is reached that studies of hormone levels and hormone excretion to date are inconsistent and inadequate to explain the epidemiologic characteristics of the disease. A new paradigm termed the "estrogen window hypothesis" is introduced. Breast cancer risk is related to the duration of unopposed estrogen exposure during puberty and the early postmenarchial period and during the perimenopausal period. These two estrogen windows provide periods of maximum inducibility by environmental carcinogens. The hypothesis is supported by studies of the survivors of the atomic bomb blasts in Hiroshima and Nagasaki and of women having repeated fluoroscopy for management of tuberculosis. The hypothesis generates many testable conclusions. If verified, the hypothesis could lead to significant public health initiatives.

Adolescent↗

PubMed1999

A role for CD45RBlow CD38+ T cells and costimulatory pathways of T-cell activation in protection of non-obese diabetic (NOD) mice from diabetes.

Non-obese diabetic (NOD) mice spontaneously develop autoimmune insulin-dependent diabetes mellitus (IDDM). Infection of the animals with mycobacteria, or immunization with mycobacteria-containing adjuvant, results in permanent protection of NOD mice from diabetes and we have recently reported that the phenomenon is associated with increased numbers of interferon-gamma-producing T cells, possessing increased cytotoxic activity, and also with augmented numbers of activated immunoglobulin M-positive (IgM+) B cells. Here, we have investigated whether protection of NOD mice from IDDM was associated with changes on costimulatory pathways of T and B cells, namely CD28/CTLA-4-B7 and CD40-CD40 ligand (CD40L) and we also further characterized protective T helper (Th) cells with regards to the expression of the differentiation markers CD45RB and CD38. We report that Th cells involved in diabetes vaccination of NOD mice by mycobacterial infection seem to belong to CD45RBlo CD38+ phenotype. The protective effect of Mycobacterium avium infection is also associated with increased CD40L and CTLA-4- expressing Th cells and with the generation of a CD40- IgG+ B cells. Our data are consistent with induction by mycobacterial infection of regulatory CD45RBlo CD38+ Th cells with the ability to trigger deletion or anergy of peripheral self-reactive lymphocytes, with shutting down of IgG+ B-cell response. They also implicate a role for IgG+ B cells in the autoimmune aggression of the endocrine pancreas of NOD mice.

ADP-ribosyl Cyclase↗

PubMed2004

Male breast disorders in Jordan. Disease patterns and management problems.

OBJECTIVE: To highlight the features and management problems of male breast disorders in an eastern country such as Jordan. METHODS: Data regarding 33 male patients who underwent surgery for breast diseases in the Department of Surgery at Jordan University of Science and Technology, Irbid, Jordan, between the year 1996 and 2002 were analyzed. RESULTS: Gynecomastia (45.5%), ductal carcinoma (18.2%), and lipoma (12.1%) were the most frequent lesions. Endocrine testing when the clinical diagnosis was physiologic gynecomastia was not yielding. Many features of male breast carcinoma in Jordan (symptomatology, male to female ratio, high education rate, age, diagnostic yield of fine-needle aspiration, histological type, and estrogen receptor status) did not depart from the experience of others. Delayed presentation is evident from the fact that 57% of tumors were stage III. Loco-regional control was achieved by modified radical mastectomy. Tamoxifen was used in 5 patients, and chemotherapy in 4 patients. The patient with stage I is still disease free 6 years after the diagnosis. The 5-year survival rate for stages II and III was zero. Rare lesions (cystic hygroma, cystic mastopathy, fibroadenoma, duct papilloma, tuberculosis, periductal mastitis, and the previously unreported primary primitive neuroectodermal tumor of the breast) accounted for the rest of the group. The patient with primary primitive neuroectodermal tumor of right breast was treated by mastectomy and adjuvant chemotherapy. He remains disease free 31 months after the diagnosis. CONCLUSION: Unawareness and the fact that male breast enlargement is considered a social stigmata are responsible for the delayed presentation. The value of fine needle aspiration cytology and mammography is not widely appreciated. The wide spectrum of potential pathologies calls for referring all patients to specialized breast units.

Adolescent↗

PubMed2006

[MRI pituitary stalk abnormalities: etiology aspects in 11 patients].

Newer techniques of magnetic resonance imaging (MRI) describe more accurately pituitary stalk abnormalities such as infections, infiltrative lesions and tumors. In absence of all the above mentioned etiological factors, genetics defects are suspected, mainly when other malformations are equally present. We attempt to show through 11 observations the variability of pathologies involving the pituitary stalk with their respective clinical and radiological features and associated endocrine abnormalities. This is a retrospective study of 7 men (67%) and 4 women (33%), mean age of 28 year (range: 15 to 53) in whom pituitary MRI was performed for hypopituitarism, diabetes insipidus or hyperprolactinemia. Three patients had brain MRI for an extra-pituitary condition. The pituitary MRI showed a stalk section in 3 cases (27%), atrophy in 1 case and thickening in 7 cases (67%). The pituitary stalk anomaly was associated with hyperprolactinemia in 3 cases (27%), central diabetes insipidus in 4 cases (36%), growth hormone deficiency in 4 cases (36%), adrenal insufficiency in 5 cases (45%), hypogonadism in 5 cases (45%) and hypothyroidism in one case (9%). Established diagnoses were: sellar metastasis in 2 cases (18%), Langerhans' histocytosis, tuberculosis and autoimmune hypophysitis respectively in 3 cases (9%). In 6 cases (54%), no clear etiology was found. Given the multitude of pituitary stalk pathologies, a detailed etiologic inquiry must be performed in order to detect elements able to reclassify an initially idiopathic disorder.

Adolescent↗

PubMed1979

Serum cholesterol and diseases in Nigerians.

A study of 3451 cholesterol determinations in different diseases was carried out. The mean cholesterol levels for male and female adults and children with different diseases were compared with values for their healthy counterparts. Sickle cell anemia, leukemia, liver cirrhosis, hepatosplenomegaly, tuberculosis, and diabetic, nutritional, ataxic, and tropical neuropathies in male and female adults were associated with reduced cholesterol level while in children malnutrition and anemia were the main causes of low cholesterol levels. Obesity and hypertension caused an elevated level but the mean values were within the range for adult Nigerians in the high income group. Only nephrotic syndrome in both adult and children was associated with a markedly increased cholesterol level in Nigerians of low income status.

Adolescent↗

PubMed1982

Drug-pyridoxal phosphate interactions.

In this review it has been pointed out that vitamin B6 and its vitamers can be involved in many interactions with a number of drugs, as well as with the actions of various endocrines and neurotransmitters. Nutritional deficiencies, especially of vitamins and proteins, can affect the manner in which drugs undergo biotransformation, and thereby may also modify the therapeutic efficacy of certain drugs. The differences between nutritional vitamin B6 deficiency and the hereditary disorder producing pyridoxine dependency are discussed. In addition to a pyridoxine deficiency being able to adversely affect drug actions, the improper supplementation with vitamin B6 can in some instances also adversely affect drug efficacy. A decrease by pyridoxine in the efficacy of levodopa used in the treatment of Parkinsonism is an example. The interrelationships and enzymatic interconversions among pyridoxine vitamers, both phosphorylated and non-phosphorylated, are briefly discussed, particularly regarding their pharmacokinetic properties. The ways in which the normal biochemical functions of vitamin B6 may be interfered with by various drugs are reviewed. (1) The chronic administration of isoniazid for the prevention or treatment of tuberculosis can produce peripheral neuropathy which can be prevented by the concurrent administration of pyridoxine. An acute toxic overdose of isoniazid causes generalized convulsions, and the intravenous administration of pyridoxine hydrochloride will prevent or stop these seizures. (2) The acute ingestion of excessive monosodium glutamate will, in some individuals, cause a group of symptoms including among others headache, weakness, stiffness, and heartburn, collectively known as the 'Chinese Restaurant Syndrome.' These symptoms can be prevented by prior supplementation with vitamin B6. The beneficial effect is ascribed to the correction of a deficiency in the activity of glutamic oxaloacetic transaminase, an enzyme that is dependent on pyridoxal phosphate. Some interesting relationships are pointed out between vitamin B6, picolinic acid, and zinc. It is postulated that the intestinal absorption of zinc is facilitated by picolinic acid, a metabolite of tryptophan. The derivation of picolinic acid from tryptophan depends on the action of the enzyme kynureninase, which is dependent on pyridoxal phosphate; therefore, the adequate absorption of zinc is indirectly dependent on an adequate supply of vitamin B6. The formation of pyridoxal phosphate, on the other hand, appears to be indirectly dependent on Zn2++ which activates pyridoxal kinase.(ABSTRACT TRUNCATED AT 400 WORDS)

Animals↗

PubMed1980

[The initial stage of disease].

The many-year experience of comparing the clinical picture of human disease with its pathological picture indicates that man begins to be aware of the pathological process typical of a given disease in many cases after some, not infrequently long period after its initiation and against the background of already developed morphological changes of organs and tissues. This difference in the time between morphologically initial and clinically early manifestation of disease may be explained by the existence in the body of a strong system of compensatory-adaptive reactions directed to the preservation of homeostasis. When these reactions are disturbed, homeostasis is broken and the disease becomes clinically manifest. A disease may be diagnosed early only when it is recognized in this "latent" period. It is in this period that the damage ("break" according to Pavlov) of the regulating systems frequently far from the target organ occurs. Thus, hypertension arises when the centers regulating the constant level of arterial pressure are damaged, while the entire pathology of hypertension is the effect of this damage. Mammary cancer is the effect of dyshormonal damages occurring in endocrine glands. Many diseases of the stomach are associated with primary involvement of various parts of the central and vegetative nervous system. Damages of the immunocompetent system and disturbances of immunological homeostasis are primary in diseases of the connective tissue with immune disorders and determine their clinical pattern and morphology. The results of morphological investigations performed by modern methods indicate that there are no functional diseases and that each disease has its material substrate determined at all levels of organization beginning from molecular and subcellular and ending with systemic. The material substrate of disease is formed from alterations at the site of the initial lesion and alterations in the target organ in which this lesion is manifested externally. The task of the current medicine is to recognize the morphological and clinical essence of the initial period of disease as an entity which is very important for early diagnosis.

Diagnosis↗

PubMed2000

Lichenoid and granulomatous dermatitis.

BACKGROUND: The prototypic lichenoid eruptions, lichen planus (LP), lichenoid drug eruptions, secondary syphilis, and collagen vascular disease, are defined histologically by a band-like lymphocytic infiltrate in close apposition to the epidermis. We describe a novel form of lichenoid dermatitis with a granulomatous component. DESIGN: Skin biopsies from 40 patients demonstrating a band-like lymphocytic infiltrate with concomitant granulomatous inflammation were encountered over 4 years. Clinicians were contacted to elucidate underlying triggers and medical illnesses. RESULTS: A lichenoid dermatitis, a linear eruption, vasculitis, annular erythema, and erythroderma were among the clinical presentations. A drug-based etiology was implicated in 14 cases: the drugs included antibiotics, lipid-lowering agents, anti-inflammatory drugs, antihistamines, hydroxychloroquine sulfate, and angiotensin-converting enzyme inhibitors. Over one-third of patients with drug-related eruptions had other medical illnesses associated with cutaneous granulomatous inflammation, namely rheumatoid arthritis (RA), Crohn's disease, hepatitis C, diabetes mellitus, and thyroiditis. A microbial trigger was implicated in 12 patients in the context of infective id reactions to herpes zoster, Epstein-Barr virus (EBV), or streptococci, or active infections by Mycobacterium tuberculosis, M. leprae, fungi, and spirochetes. The remainder had hepatobiliary disease and RA without obvious exogenous triggers, cutaneous T-cell lymphoma (CTCL), and idiopathic lichenoid eruptions (i.e. LP, lichen nitidus, and lichen striatus). One patient with LP had underlying multicentric reticulohistiocytosis. The histiocytic infiltrate assumed one or more of five light microscopic patterns: (i) superficially disposed loose histiocytic aggregates; (ii) cohesive granulomata within zones of band-like lymphocytic infiltration with or without deeper dermal extension; (iii) a diffuse interstitial pattern; (iv) scattered singly disposed giant cells; and (v) granulomatous vasculitis. Additional features included lymphocytic eccrine hidradenitis in those patients with drug reactions, hepatobiliary disease, and antecedent viral illnesses, tissue eosinophilia and erythrocyte extravasation in drug hypersensitivity, granulomatous vasculitis in patients with microbial triggers, drug hypersensitivity or RA, and lymphoid atypia in lesions of CTCL or drug hypersensitivity. CONCLUSIONS: The cutaneous lichenoid and granulomatous reaction may reflect hepatobiliary disease, endocrinopathy, RA, Crohn's disease, infection, or a drug reaction. One-fifth of cases represent idiopathic lichenoid disorders. Lymphoproliferative disease or pseudolymphomatous drug reactions must be considered in those cases showing lymphoid atypia.

Adolescent↗

PubMed1976

The neuro-radiological examination of endocrine disorders of central origin in the child (precocious puberty, hypopituitarism).

The neuro-radiological findings in 38 cases of precocious puberty of central origin and 9 cases of hypopituitarism (craniopharyngiomas excepted), are reported. The radiological examination consisted of plain films of the skull and pneumo-encephalography. In the 9 cases with hypopituitarism radiological examination was normal in 4 and localised but quite diverse anomalies were discovered in 5. Out of 38 patients presenting with isosexual precocious puberty, 29 were female and 9 male. Out of the 29 girls, neuro-radiological examination was normal in 20 and showed a hypothalamic anomaly in 9. Out of the 9 boys, 8 had a hypothalamic anomaly, and only one examination was normal. In precocious puberty we found 1 ectopic pinealoma and 2 gliomas of the chiasma. In these three cases the clinical context and radiological examination made the diagnosis obvious. Masses were discovered in 7 (3 spongioblastomas and 4 heterotopias). In 2 cases (spongioblastomas) neurological symptoms were present and made an operation mandatory. In 5 cases (1 spongioblastoma, 4 heterotopias) precocious puberty was an isolated finding. It was not possible to make, on a clinical or radiological bases, a distinction between spongioblastoma and heterotopia. As time has passed the role of surgery has changed. Formerly, surgery aimed at excision of the lesion, but with advances in medical treatment surgical intervention is now directed towards biopsy and the histological study of lesions which may be treated by radiotherapy.

Adolescent↗

PubMed1976

Adjuvant disease induced by mycobacteria, determinants of arthritogenicity.

Genetic, endocrine and immunological factors are probably involved in adjuvant polyarthritis. The nature of the vehicle and of the mycobacterial components administered also has a major influence. It was originally assumed that arthritogenicity and adjuvanticity of mycobacterial fractions such as wax D were intimately related. Our previous findings showed that the water soluble adjuvant (WSA) of M.smegmatis which could substitute for mycobacterial cells in Freund's complete adjuvant and induce delayed hypersensitivity was not arthritogenic in the Wistar rat. We have since observed that auto-immune diseases could be elicited by WSA. Therefore experiments were repeated using the very susceptible Lewis strain. The activity of cord factor and of various mycobacterial preparations suspended in mineral or in peanut oil was also evaluated in mice and in normal or hypophysectomized rats. Our present findings confirm the absence of arthritogenicity of WSA in the Lewis strain. They also indicate that cord factor with WSA does not suffice to induce a generalized adjuvant disease, but that a mycobacterial component which could be susceptible to lysozyme treatment is required also. However, the local inflammation of the injected limb was produced by a preparation of cord factor administered in mineral or even in peanut oil. This was observed in normal or hypophysectomized rats and in Swiss mice which were not susceptible to the generalized disease.

Animals↗

PubMed2002

[Surgical treatment of pheochromocytoma--personal experience].

UNLABELLED: The first description of the adrenal gland dates since 1563 by Eustachius in a study "Opscula anatomica". Despite earlier recognition of the presence of adrenals and division into cortex and medulla, the precise observations of Addison appeared in 1855 that the essential role of these glands was recognized in patients who died with adrenal destruction secondary to tuberculosis. Frankel first described a medulary adrenal tumour in 1886. In 1912 the pathologist Pick formulated the descriptive term pheochromocytoma. The first surgical removal of pheochromocytoma in Europe was performed by Rouks in 1926 and by Mayo in USA in 1927. The work of the later had greater impact. For a long period of time the Military Medical Academy is involved in clinical diagnosis and management of adrenal tumours. The first description of diagnosed pheochromocytoma was by Professor Ratibor Mitshitsh. The first surgical removal of pheochromocytoma in the Military Medical academy and in Yugoslavia was performed by Professor Isidor Papo. Over the period January 1974-December 2001, 268 patients with tumours of adrenal origin(93 patients/34.7%/had pheochromocytoma) underwent surgical treatment in the Military Medical Academy. Of our particular interest was the relation between the surgical approach to pheochromocytoma and the incidence and severe intraoperative and immediate postoperative complications. Although numerous studies favorise transabdominal and thoracic approach, our experience in flank approach is very favorable. By the lateral high intercostal approach above the eleventh costae we operated on 67 (72%) patients with only one (1.5%) major complication--cardiac arrest. With successful reanimation the patient survived. The transperitoneal approach was performed in 21 (22%) cases and we had 7 (33.1%) severe complications: one lethal outcome, cardiac arrest, injury of the aorta, injury of the VCI, postoperative bleeding that required relaparatomy and two splenectomies. The lethal outcome was the result of nonidentified ectopic retropancreatic pheochromocytoma that was not identified preoperatively and intraoperatively. At that time ultrasound, CT and MRI were not available. By transthoracic and posterior approach we operated on a small number of pheochromocytomas. DISSCUSSION: We analysed the advantages and disadvantages of some surgical approaches and our experience in these methods of management of pheochromocytoma and other adrenal tumours; we confirmed multiple advantages of flank intercostal approach above the eleventh costae compared to other approaches. This approach is simple, extrapleural and extraperitoneal. It offers a broad surgical field with the adrenal in its centre which permits an atraumatic operation with little risk of complications. CONCLUSIONS: The flank intercostal approach above the eleventh costae is indicated(option of choice) in unilateral pheochromocytoma and other unilateral adrenal tumours. The transabdominal approach is indicated in cases of bilateral pheochromocytomas, in cases of abdominal localization of ectopic pheochromocytomas, in tumours which involve the VCl and most of the left renal vein, and in patients with extremely large adrenal tumours. The thoracic approach is indicated in intrathoracic ectopic pheochromocytomas.

Adrenal Gland Neoplasms↗