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Endocrine DiseasesEndocrine DiseasesEndocrine DiseasesEndocrine Diseases
Th P th l i l B i f Di
QiaoQiao Li MD PhDLi MD PhD
The Pathological Basis of Disease- Graduate Course CMM5001Graduate Course CMM5001
QiaoQiao Li, MD, PhDLi, MD, PhDFaculty of MedicineFaculty of MedicineUniversity of OttawaUniversity of Ottawa
Qi Li@Qi [email protected]@[email protected]
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Outline
Endocrine System Adrenal Gland Adrenal Gland
• Anatomy & Histology• Steroid HormonesSteroid Hormones• Addison’s Disease• Cushing Syndromeg y• Clinical Case Presentation
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Endocrine Glands
Pineal gland
Hypothalamus
Pituitary gland
Endocrine glands • Pineal
y g
Thyroid gland
Parathyroid glands(on dorsal aspect of thyroid gland)
• Pituitary • Thyroid • Parathyroid
Thymus
Adrenal glands
• Adrenal Neuroendocrine organ
HypothalamusPancreas
Gonads
Hypothalamus Exocrine & endocrine
Pancreas, gonads, placenta Other
• Testis (male)• Ovary (female) Other
Thymus, heart, kidney etc.
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Characteristics
Originll l d i f th ith li ( ll th l )all glands arise from the epithelium (all three germ layers)
Microscopic Structure d l h ll f lli l & b d t ill icords, clumps, hollow follicles & abundant capillaries
Merocrine Secretion
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Endocrine Function
Controls & IntegratesG th d d l tGrowth and developmentMaintenance of electrolyte, water & nutrient balance of bloodRegulation of cellular metabolism & energy balanceMobilization of body defensesReproduction
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Homeostasis
Hypothalamus connectsi h d i i i inervous with endocrine via pituitary
Hypothalamic is controlled by neural connections negative feedback from hormones
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Homeostatic ImbalanceHomeostatic Imbalance
Increases risk of diseaseCauses changes associated with agingCauses changes associated with aging
control systems less efficient
most disease seen as a disturbance of homeostasis (homeostatic imbalance)
aging associated with progressiveaging associated with progressive decrease in our ability to maintain
homeostasis (greater risk for illness)
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The Summary
Hypothalamic Hormone Anterior Pituitary Hormone Target Organ
Thyrotropin-ReleasingHormone (TRH)
Thyroid-StimulatingHormone (TSH) Thyroid GlandThyroid GlandHormone (TRH) Hormone (TSH) Thyroid GlandThyroid Gland
Corticotropin-ReleasingHormone (CRH)
AdrenocorticoidtropicHormone (ACTH) AdrenalAdrenal GlandsGlands
Gonadotropin-ReleasingHormone (GnRH)
Folicle-Stimulating Hormone (FSH)Lutenizing Hormone (LH) Ovaries / TestesOvaries / Testeso o e (G ) ute g o o e ( ) O a es / estesO a es / estes
Prolactin-Inhibiting Hormone (PIH, Dopamine) Prolactin (PRL) BreastBreast
Growth Hormone-Releasing Hormone (GHRH) Growth Hormone
GHIH (Somatostatin) (GH, Somatotropin) LiverLiver
Anterior lobe
HypothalamusHypothalamic neurons synthesizeGHRH, GHIH, TRH, CRH, GnRH, PIH
Hypophyseal portal system
• Primary capillary plexus• Hypophyseal portal veins• Secondary capillary plexus
Superiorhypophyseal
artery
Anterior lobeof pituitary
QLGH, TSH, ACTH, FSH, LH, PRL
Anterior lobe of pituitary
• Secondary capillary plexus
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Adrenal Gland
•• Anatomy & Histology Anatomy & Histology •• Steroid HormonesSteroid Hormones•• Addison’s DiseaseAddison’s Disease•• Cushing SyndromeCushing Syndrome•• Clinical Case PresentationsClinical Case Presentations
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Adrenal Gland (Suprarenal)
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Adrenal Gland – in situ
Described as “accessory renal tissue”, “loose flesh” (left gland) by Claudius Galen (130-201) Depicted in 1552 by Bartholomeaus Eustachius on copper plateR d d b i i 1563
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for Medical Education
Reproduced by prints in 1563
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Adrenal Gland – Male Abdomen
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Adrenal Gland - CT
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Adrenal Gland - MRI
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Adrenal Gland – Gross
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Adrenal Gland – Cut Surface
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Adrenal Gland – Cut Surface
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Adrenal Gland – Cross Section
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Adrenal Gland – Medulla
Chromaffin cellsChromaffin cells
Catecholamines- epinephrine
i h i- norepinephrine
Ganglion cells
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Adrenal Gland
•• Anatomy & Histology Anatomy & Histology •• Steroid HormonesSteroid Hormones•• Addison’s DiseaseAddison’s Disease•• Cushing SyndromeCushing Syndrome•• Clinical Case PresentationsClinical Case Presentations
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Adrenal Cortex
Three layers of cortex produce three corticosteroids Zona glomerulosa - mineralocorticoids Zona glomerulosa mineralocorticoids Zona fasciculata - glucocorticoids Zona reticularis - gonadocorticoids
CapsuleZona
glomerulosa
Hormonessecreted
Aldosterone
g
Cor
tex
Zonafasciculata
Adrenal gland• Medulla• Cortex
Kid
Cortisolandandrogens
Med
ulla
Zonareticularis
Adrenalmedulla
Kidneyandrogens
Epinephrineandnorepinephrine
Photomicrograph (115x)Drawing of the histology of theadrenal cortex and a portion ofthe adrenal medulla
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Adrenal Gland – Low Power
Capsule
Periadrenal fatZona glomerulosa
Zona fasciculata
Zona reticularis
Medulla
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Adrenal Gland – Low & High Power
HP
sinusoid
HP-zrHP-zf
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Adrenal Cortex Steroids
Zone Class Representative Physiologic Effects
glomerulosa mineralocorticoids aldosterone salt and water homeostasis
fasiculata glucocorticoids cortisol carbohydrate metabolism
reticularis sex steroids androgens & estrogen minimal effects
O CH2OH O
CH2OH O
O CH
O O O
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Adrenal Steroidogenesis
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Glucocorticoids & the Receptor
CortisolCortisol (hydrocortisone) (hydrocortisone) the majority of the majority of glucocorticoidglucocorticoid activity in most mammalsactivity in most mammals
90% f i l ti90% f i l ti ti lti l bi d tbi d t ti lti l bi dibi di 90% of circulating 90% of circulating cortisolcortisol binds to binds to cortisolcortisol binding binding globulin (CBG), for transportation, also limiting the rate globulin (CBG), for transportation, also limiting the rate of metabolic clearance & the concentration fluctuationof metabolic clearance & the concentration fluctuation
E t ll b i diff iE t ll b i diff i Enter cells by passive diffusionEnter cells by passive diffusion
Histone acetylationp300/CBP
TAFII250
RNA Pol IITBP
RNA Pol II
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Effects & Usage of Effects & Usage of Glucocorticoids
Carbohydrate, proteins and fat metabolismCarbohydrate, proteins and fat metabolismgluconeogenesisgluconeogenesisg gg gmuscle breakdownmuscle breakdownlipolysislipolysis
AntiAnti--inflammatory and immunosuppressiveinflammatory and immunosuppressive
Medical Application:Medical Application:arthritis, dermatitisarthritis, dermatitisautoimmune diseases autoimmune diseases fear phobicfear phobicfear phobicfear phobic
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Control of Cortisol Secretion
Hypothalamus
HPA Axis
y
ACTH
CRH
Anterior Pituitary
ACTH
Adrenal Cortex
Cortisol
Dr. Gary Farr
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Research Milestones
* 1552: * 1552: BartholomaeusBartholomaeus EustachiusEustachius- Depicted adrenal glands on copper plate
* 1656: * 1656: Thomas Wharton Thomas Wharton - Adrenals took something from the nerves and secreted it into the circulation
* 1936: * 1936: Edward Kendall and Edward Kendall and TadeusTadeus ReichsteinReichstein- Isolation and synthesis of cortisone
* 1949:* 1949: Edward Kendall and Philip HenchEdward Kendall and Philip Hench 1949: 1949: Edward Kendall and Philip HenchEdward Kendall and Philip Hench-- Effects of cortisone and ACTH on rheumatoid arthritisEffects of cortisone and ACTH on rheumatoid arthritis
* 1950: Nobel Prize to * 1950: Nobel Prize to Kendall, Reichstein & HenchKendall, Reichstein & Hench"for their discoveries relating to the hormones of the adrenal cortex, their structure and biological effects"
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Adrenal Gland
•• Anatomy & Histology Anatomy & Histology •• Steroid HormonesSteroid Hormones•• Addison’s DiseaseAddison’s Disease•• Cushing SyndromeCushing Syndrome•• Clinical Case PresentationsClinical Case Presentations
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Addison’s DiseaseAddison’s Disease
* General languor and debility* Remarkable feebleness of the heart's action* P li h i th l f th ki* Peculiar change in the color of the skinChronic adrenocortical insufficiency
progressive destruction of 90%of cortexprogressive destruction of 90%of cortex extreme weakness and fatigue extreme weakness and fatigue unintentional weight lossunintentional weight lossloss of appetiteloss of appetiteloss of appetite loss of appetite darkening of the skindarkening of the skinlow blood pressure, low blood pressure, dizziness or faintingdizziness or faintingcraving for saltcraving for salt
Thomas Addison 1855
craving for saltcraving for saltnausea, diarrhea, vomitingnausea, diarrhea, vomitingirritability, depression irritability, depression
Thomas Addison 1855
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Primary Adrenocortical Insufficiency
Primary Chronic Primary Chronic HypocortisolismHypocortisolism-- Autoimmune Autoimmune adrenalitisadrenalitis 6060--70%70% CRH-- Infections (TB, AIDS)Infections (TB, AIDS) TB 90%TB 90%-- Metastatic Metastatic neoplasmsneoplasms-- Genetic disorderGenetic disorder
(Addison’s disease)(Addison’s disease)ACTH
(Addison s disease)(Addison s disease)
Primary Acute Primary Acute HypocortisolismHypocortisolism-- Stress crisis Stress crisis (chronic AI)(chronic AI)-- Rapid Steroids withdrawRapid Steroids withdraw-- adrenal adrenal hemorrhagehemorrhage
Cortisol
QL
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Secondary Adrenocortical Insufficiency
Secondary Secondary HypocortisolismHypocortisolism CRH
-- Hypothalamic pituitary diseaseHypothalamic pituitary disease
-- Hypothalamic pituitary suppressionHypothalamic pituitary suppression ACTHyp p y ppyp p y pp
Cortisol
QL
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Managements
Glucocorticoid replacement CRH
Mineralocorticoid replacement Prevent adrenal crisis ACTH
Medic alert bracelet
Cortisol
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PrognosisPrognosis
For people with Addison’s Disease i t 1930 90% di d ithi 5 prior to 1930, 90% died within 5 years from 1930, much better prognosis since 1950, normal life span
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Adrenal Gland
•• Anatomy & Histology Anatomy & Histology •• Steroid HormonesSteroid Hormones•• Addison’s DiseaseAddison’s Disease•• Cushing SyndromeCushing Syndrome•• Clinical Case PresentationsClinical Case Presentations
QL
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Causes of Cushing Syndrome
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Cushing’s Disease
Excessive Endogenous Excessive Endogenous CortisolCortisol-- ACTH dependent:ACTH dependent: CRHACTH dependent: ACTH dependent:
* Pituitary adenoma * Pituitary adenoma (70(70--80%)80%)
** Small cell carcinomaSmall cell carcinoma ACTH
-- ACTH independent ACTH independent * Cortical tumor* Cortical tumor
Administration of Administration of GlucocorticoidsGlucocorticoids-- The most common causeThe most common cause Cortisol
Cushing’s Disease
QL
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Ectopic ACTH Secretion
Excessive Endogenous Excessive Endogenous CortisolCortisol-- ACTH dependent:ACTH dependent: CRHACTH dependent: ACTH dependent:
* Pituitary adenoma* Pituitary adenoma* Small cell carcinoma * Small cell carcinoma (10%)(10%)
ACTH
-- ACTH independent ACTH independent * Cortical tumor* Cortical tumor
Administration of Administration of GlucocorticoidsGlucocorticoids-- The most common causeThe most common cause Cortisol
QL
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Adrenal Defects
Excessive Endogenous Excessive Endogenous CortisolCortisol-- ACTH dependent:ACTH dependent: CRHACTH dependent: ACTH dependent:
* Pituitary adenoma* Pituitary adenoma* Small cell carcinoma* Small cell carcinoma ACTH
-- ACTH independent ACTH independent * Cortical tumor * Cortical tumor (10(10--20%)20%)
Administration of Administration of GlucocorticoidsGlucocorticoids-- The most common causeThe most common cause Cortisol
QL
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Exogenous CS
Excessive Endogenous Excessive Endogenous CortisolCortisol-- ACTH dependent:ACTH dependent: CRHACTH dependent: ACTH dependent:
* Pituitary adenoma* Pituitary adenoma* Small cell carcinoma* Small cell carcinoma ACTH
CRH
-- ACTH independent ACTH independent * Cortical tumor* Cortical tumor
Administration of Administration of GlucocorticoidsGlucocorticoids-- The most common causeThe most common cause Cortisol
QL
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Cushing Syndrome
Excessive Endogenous Excessive Endogenous CortisolCortisol-- ACTH dependent:ACTH dependent: CRHACTH dependent: ACTH dependent:
* Pituitary adenoma* Pituitary adenoma (Cushing’s Disease)(Cushing’s Disease)
* Small cell carcinoma* Small cell carcinoma ACTH
-- ACTH independent ACTH independent * Cortical tumor* Cortical tumor
Administration of Administration of GlucocorticoidsGlucocorticoids-- The most common causeThe most common cause Cortisol
H C hi 1912Harvey Cushing 1912
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Adrenal Gland – Gr / CSN d l C ti l H l iNodular Cortical Hyperplasia
Confluent Nodules
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Adrenal Gland – Low PowerN d l C ti l H l iNodular Cortical Hyperplasia
Nodule
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Adrenal Gland – High PowerN d l C ti l H l iNodular Cortical Hyperplasia
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Adrenal Gland, cortical adenoma i C hi S d G / CSin Cushing Syndrome – Gr / CS
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Adrenal Gland, cortical adenoma - LP
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Adrenal Gland - Tumor
CT
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Adrenal Gland - Mass
MRI : in-phase sequence
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Adrenal Gland - Adenoma
MRI : out-of-phase sequence
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Clinical ManifestationsClinical Manifestations
•• Moodiness, depression 75Moodiness, depression 75--80%80%•• Moon face 85%Moon face 85%Moon face 85%Moon face 85%•• Facial plethora 75%Facial plethora 75%•• OsteoprosisOsteoprosis 75%75%•• TruncalTruncal obesityobesity (buffalo hump)(buffalo hump) 8585--90%90%• Skin Skin striaestriae (abdomen)(abdomen) 50%50%• Menstrual abnormalities 70%Menstrual abnormalities 70%•• Weakness and fatigability 85%Weakness and fatigability 85%
Hi iHi i %%•• HirsutismHirsutism 75%75%•• Hypertension 75%Hypertension 75%•• Glucose intolerance / diabetes 70 / 20%Glucose intolerance / diabetes 70 / 20%
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Screening Tests
2424--hour urine free hour urine free cortisolcortisol levellevel
am & pm am & pm cortisolcortisol levellevel* * circadian circadian rhythmrhythm, a hall mark hall mark
QL
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DST (Dex Suppression Test)
LowLow--dose dose DexDex suppressionsuppressionCRH
** identify Cushing Syndrome identify Cushing Syndrome
HighHigh--dose dose DexDex suppressionsuppression ACTHgg* identify Cushing’s Disease* identify Cushing’s Disease
Cortisol
QL
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Low Dose DST
LowLow--dose DSTdose DSTDay 1:Day 1: 1 mg of 1 mg of DexDex at 11 pmat 11 pmDay 2:Day 2: bloodblood cortisolcortisol at 8 amat 8 am
CRHDay 2:Day 2: blood blood cortisolcortisol at 8 amat 8 am
0.5 mg of 0.5 mg of DexDex every 6 hrs for 48 hrsevery 6 hrs for 48 hrs2424--hr hr urinary urinary cortisolcortisol for 3 daysfor 3 days** identify Cushing Syndromeidentify Cushing Syndrome
ACTH
identify Cushing Syndrome identify Cushing Syndrome
HighHigh--dose DSTdose DSTDay 1:Day 1: a baseline a baseline cortisolcortisol at amat am
8 f8 f DD t 11t 118 mg of 8 mg of DexDex at 11 pm at 11 pm Day 2:Day 2: blood blood cortisolcortisol at 8 amat 8 am
2 mg of 2 mg of DexDex every 6 hrs for 48 hrs.every 6 hrs for 48 hrs.2424 hr urinaryhr urinary cortisolcortisol for 3 daysfor 3 days
Cortisol
2424--hr urinary hr urinary cortisolcortisol for 3 daysfor 3 days** identify Cushing's Diseaseidentify Cushing's Disease
QL
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High Dose DST
LowLow--dose DSTdose DSTDay 1:Day 1: 1 mg of 1 mg of DexDex at 11 pmat 11 pmDay 2:Day 2: bloodblood cortisolcortisol at 8 amat 8 am
CRHDay 2:Day 2: blood blood cortisolcortisol at 8 amat 8 am
0.5 mg of 0.5 mg of DexDex every 6 hrs for 48 hrsevery 6 hrs for 48 hrs2424--hr hr urinary urinary cortisolcortisol for 3 daysfor 3 days** identify Cushing Syndromeidentify Cushing Syndrome
ACTH
identify Cushing Syndrome identify Cushing Syndrome
HighHigh--dose DSTdose DSTDay 1:Day 1: a baseline a baseline cortisolcortisol at amat am
8 f8 f DD t 11t 118 mg of 8 mg of DexDex at 11 pm at 11 pm Day 2:Day 2: blood blood cortisolcortisol at 8 amat 8 am
2 mg of 2 mg of DexDex every 6 hrs for 48 hrs.every 6 hrs for 48 hrs.2424--hr urinaryhr urinary cortisolcortisol for 3 daysfor 3 days
Cortisol
2424--hr urinary hr urinary cortisolcortisol for 3 daysfor 3 days** identify Cushing's Diseaseidentify Cushing's Disease
QL
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Determining the Etiology
Is ACTH dependent?Is ACTH dependent? If ACTH dependentIf ACTH dependent CRH If ACTH dependentIf ACTH dependent
* pituitary or ectopic* pituitary or ectopic
Source of overproductionSource of overproduction ACTH
* MRI pituitary* MRI pituitary* CT adrenals, chest, abdomen* CT adrenals, chest, abdomen
Cortisol
QL
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Managements
Surgical TreatmentSurgical Treatmentl il i d l td l t CRHlaparoscopic laparoscopic adrenalectomyadrenalectomy
Medical Treatment Medical Treatment d l bl kd l bl k
ACTH
adrenal enzyme blockersadrenal enzyme blockers
Cortisol
QL
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Adrenal Gland
•• Anatomy & Histology Anatomy & Histology •• Steroid HormonesSteroid Hormones•• Addison’s DiseaseAddison’s Disease•• Cushing SyndromeCushing Syndrome•• Clinical Case PresentationsClinical Case Presentations
QL
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Adrenal Gland - Comparison
The Internet Pathology Laboratory
for Medical Education
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Resources
•• Pathologic Basis of DiseasePathologic Basis of DiseaseR bbi &R bbi & C tC t 77thth EditiEditiRobbins & Robbins & CotranCotran 77thth EditionEdition
•• Basic Pathology Basic Pathology R b 7R b 7thth EdEdRobins 7Robins 7thth EditionEdition
•• Handbook of Clinical PathologyHandbook of Clinical Pathology22ndnd EditionEdition
QL