Sp Endokrin Case 2
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Transcript of 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$e
nt
Prognos
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Chapter-II: ContentDefniti
on%pide$iol
og&
Risk
FactorPathogenesis
Diagnosis
Di. D
!tagingPre"enti
on
#reat$e
nt
Prognos
Si.n /S&mpotms
Need To !eConsidernum!er of colorectal cancer cases
in the 0nited States for "#$% 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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Chapter-II: ContentDefniti
on%pide$iol
og&
Risk
FactorPathogenesis
Diagnosis
Di. D
!tagingPre"enti
on
#reat$e
nt
Prognos
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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Chapter-II: ContentDefniti
on%pide$iol
og&
Risk
FactorPathogenesis
Diagnosis
Di. D
!tagingPre"enti
on
#reat$e
nt
Prognos $ Stephen Briet4@e, 7D, :CP, :CE 7ellitusEndicrinolo.&
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Chapter-II: ContentDefniti
on%pide$iol
og&Risk
FactorPathogenesis
Diagnosis
Di. D
!tagingPre"enti
on#reat$e
ntPrognos
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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Chapter-II: ContentDefniti
on%pide$iol
og&Risk
FactorPathogenesis
Diagnosis
Di. D
!tagingPre"enti
on#reat$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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Chapter-II: ContentDefniti
on%pide$iol
og&Risk
FactorPathogenesis
Diagnosis
Di. D
!tagingPre"enti
on#reat$e
ntPrognos
• 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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Chapter-II: ContentDefniti
on%pide$iol
og&Risk
FactorPathogenesis
Diagnosis
Di. D
!tagingPre"enti
on#reat$e
ntPrognos
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Chapter-II: ContentDefniti
on%pide$iol
og&Risk
FactorPathogenesis
Diagnosis
Di. D
!tagingPre"enti
on#reat$e
ntPrognos
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Chapter-II: ContentDefniti
on%pide$iol
og&Risk
FactorPathogenesis
Diagnosis
Di. D
!tagingPre"enti
on#reat$e
ntPrognos
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Chapter-II: ContentDefniti
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 andInfammation-Associated Colorectal Cancer Cancer Cell "#$6? "6
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Chapter-II: ContentDefniti
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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Chapter-II: ContentDefniti
on%pide$iol
og&Risk
FactorPathogenesis
Diagnosis
Di. D
!tagingPre"enti
on#reat$e
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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Chapter-II: ContentDefniti
on%pide$iol
og&Risk
FactorPathogenesis
Diagnosis
Di. D
!tagingPre"enti
on#reat$e
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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Chapter-II: ContentDefniti
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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Chapter-II: ContentDefniti
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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Chapter-II: ContentDefniti
on%pide$iol
og&Risk
FactorPathogen
esisDiagnos
isDi. D
!tagingPre"enti
on#reat$e
ntPrognos
/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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Chapter-II: ContentDefniti
on%pide$iol
og&Risk
FactorPathogen
esisDiagnos
isDi. D
!tagingPre"enti
on#reat$e
ntPrognos
Common s&mptom of colorectal cancerare?
• !dominal cramps
•
chan.e in !owel ha!its
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Chapter-II: ContentDefniti
on%pide$iol
og&Risk
FactorPathogen
esisDiagnos
isDi. D
!tagingPre"enti
on#reat$e
ntPrognos
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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Chapter-II: ContentDefniti
on%pide$iol
og&Risk
FactorPathogen
esisDiagnos
isDi. D
!tagingPre"enti
on#reat$e
ntPrognos 7oon face 7ultiple striae on s@in
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Chapter-II: ContentDefniti
on%pide$iol
og&Risk
FactorPathogen
esisDiagnos
isDi. D
!tagingPre"enti
on#reat$e
ntPrognos
+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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Chapter-II: ContentDefniti
on%pide$iol
og&Risk
FactorPathogen
esisDiagnos
isDi. D
!tagingPre"enti
on#reat$e
ntPrognos
• 2rine le"el o ree cortisol
• Dea$ethasone!uppression #est
• Plas$a Concentration o/C#0
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Chapter-II: ContentDefniti
on%pide$iol
og&Risk
FactorPathogen
esisDiagnos
isDi. D
!tagingPre"enti
on#reat$e
ntPrognos
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Chapter-II: ContentDefniti
on%pide$iol
og&Risk
FactorPathogen
esisDiagnos
isDi. D
!tagingPre"enti
on#reat$e
ntPrognos
!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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Chapter-II: ContentDefniti
on%pide$iol
og&Risk
FactorPathogen
esisDiagnos
isDi. D
!tagingPre"enti
on#reat$e
ntPrognos
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Chapter-II: ContentDefniti
on%pide$iol
og&Risk
FactorPathogen
esisDiagnos
isDi. D
!tagingPre"enti
on#reat$e
ntPrognos
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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Chapter-II: ContentDefniti
on%pide$iol
og&Risk
FactorPathogen
esisDiagnos
isDi. D
!tagingPre"enti
on#reat$e
ntPrognos
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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Chapter-II: ContentDefniti
on%pide$iol
og&Risk
FactorPathogen
esisDiagnos
isDi. D
!tagingPre"enti
on#reat$e
ntPrognos
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