The document provides a comprehensive outline of various endocrine disorders, particularly focusing on Cushing syndrome and Addison's disease, along with tumor markers and growth hormone deficiency. It discusses diagnostic approaches, including various tests and their interpretations, for identifying these disorders. Additionally, it includes case studies and suggestions for establishing a growth clinic to address hormone deficiencies in children.

1. Pakistan Society Of Chemical Pathologists
Distance Learning Programme In Chemical Pathology
Lesson No 18
Miscellaneous Endocrine Disorders and
Tumour Markers
(Short Name: MEDTM)
BY
Surg Commodore Aamir Ijaz
MCPS, FCPS, FRCP (EDIN)
Professor Of Pathology /
Consultant Chemical Pathologist
Bahria University Medical & Dental College /
PNS SHIFA Karachi 1

2. BCQs
2

3. Q 1: The most common cause of Cushing Syndrome is:
a. Adrnocortical Hyperplasia
b. Cushing disease
c. Ectopic ACTH secretion
d. Iatrogenic
e. Pseudo-Cushing Syndrome
d.Iatrogenic
3

4. Slides on CUSHING SYNDROME and ADDISON
DISEASE were Initially Prepared by
Dr Mehreen Hassan (PNS SHIFA)
4

5. Cushing’s Syndrome
Iatrogenic is most common cause. Other causes are:
ACTH dependent:
• Cushing’s disease (70%)
• Ectopic ACTH (15%)
ACTH independent:
• Adrenal hyperplasia (10%)
• Adenoma or carcinoma
5

6. Q 2: A 54 y male is having Cushing Syndrome. His cortisol and other steroid
profile is as following:
• Serum Cortisol: Increased
• Serum DHEAS: Markedly increased
• Urinary 17-ketosteroids : Markedly Increased
• Serum Aldosterone: Low
• Aldosterone precursors : Increased
What is the most probable cause of Cushing Syndrome in this patient?
a. Adrenocortical Carcinoma
b. Adrenal Adenoma
c. Bilateral ACTH-independent macronodular hyperplasia
d. Ectopic cortisol secretion
e. Primary pigmented nodular adrenocortical disease
a.Adrenocortical Carcinoma
6

7. Adrenocortical Carcinoma
• Can present as Hirsutism
• Characterised by increased metabolites of
Cortisol and Aldosterone
• Increased DHEAS
7

8. Q 3: A 36 y old Registered Nurse is performing night duty for the
last 2 years with the habit of going to bed at 0800 h in the morning.
She has developed some features suggestive of Cushing Syndrome
and referred to you for appropriate investigations.
At what time of the day (24 h) you will like to collect her sample:
a. Afternoon (1500 h)
b. Early evening (1900 h)
c. Mid day (1200 h)
d. Midnight (0000 h)
e. Morning (0900)
e.Morning (0900)
8

9. Timing of Cortisol Sampling
For Cushing Syndrome (CS):
• Late Evening Sample : To see the loss of Diurnal
variation i.e. higher cortisol in the evening
• Exact Time: One hour after usual sleeping time.
(True for Serum or Salivary Cortisol timing).
For Addison Disease (AD):
• Morning sample at 0800 h.
9

10. Q 4: A 32 y pregnant lady has been referred to you for
investigation of Cushing Syndrome. As per recent Guidelines which
of the following should be the first line tests in this patient?
a. 48-h, 2 mg/d Dexamethasone Suppression test (DST)
b. Late evening Salivary cortisol
c. Midnight Sleeping Serum Cortisol
d. Overnight 1mg DST
e. Urinary Free Cortisol
e.Urinary Free Cortisol
10

11. Urinary Free Cortisol (UFC)
• 24 h urine sample is required
• Better test in Pregnancy and patients on OCP
due to increased CBGs in these conditions
• Should NOT be done in patients with renal
impairment
• In pregnancy Dexamethasone test should NOT
be done
11

12. First line Tests for CS
• Late evening Salivary Cortisol
• Urinary Free Cortisol (UFC)
• 1 mg Dexmamethasone Test (DMT)
12

13. Evening Serum cortisol (1 h after sleep)
• Done for confirmation of CS
• Can be done in two ways:
• Sleeping: Difficult to perform but better method
• Wakening: Also quiteuseful
13

14. • Stress
• Obesity
• Depression
• High estrogen state
• Glucocorticoid resistance syndrome
• Drugs (phenytoin, phenobarbital etc)
Pseudo-Cushing Syndrome
14

15. Low-dose dexamethasone suppression test
• Oral administration of 0.5 mg
dexamethasone every 6h for 2 days
• Plasma cortisol >5 µg / dl on 3rd day
morning ------ hypercortisolism
15

16. Determination of the Cause of Syndrome
• Serum ACTH levels
Plasma ACTH < 20 pg / ml indicates adrenal tumor
• High-dose Dexamethasone suppression test
• Overnight 8 mg test
• Obtain baseline 0800h plasma cortisol
• Oral administration of 8 mg dexamethasone at 2300h
• Obtain plasma cortisol on next morning at 0800h
(< 50% of baseline value -------- significant suppression)
• Two day test
• Oral administration of 2 mg dexamethasone every 6h for
2 days 16

17. Q 5: The most common cause of Chronic
Adrenal Insufficiency Worldwide (including
developing countries) is:
a. Autoimmune disease
b. Drugs
c. Fungal Infection
d. Malignant Metastasis
e. Tuberculosis
e.Tuberculosis
17

18. • Primary adrenal insufficiency
Addison’s disease (AD)
Inadequate production of glucocorticoids
and mineralocorticoids involving
destruction of >90% of adrenal cortex
• Secondary adrenal insufficiency:
Inadequate secretion of glucocorticoids
caused by pituitary insufficiency
Chronic Adrenal insufficiency
18

19. Causes of AD
• Idiopathic atrophy (autoimmune adrenalitis)
• Granulomatous disease
Tuberculosis(more common in our population)
Histoplasmosis
Sarcoidosis
• Infectious( Viral(AIDS),fungal, CMV)
• Neoplastic infiltration
• Haemochromatosis
• Amyloidosis
• Following bilateral adrenalectomy
19

20. Routine investigations:
Blood complete picture:
• Neutropenia
• Relative lymphocytosis
• Eosinophilia
• Mild anaemia
Serum electrolytes:
• Hyperkalaemia
• Hyponatraemia
• Hypercalcaemia
20

21. Routine investigations (contd)
• Serum urea -
• Serum creatinine
• Plasma glucose
Hypoglycemia
• Acidosis
21

22. Morning Serum Cortisol < 10 Ug/Dl
Plasma ACTH Assay > 150 Pg/Ml
Dynamic Function Tests
ACTH stimulation tests:
• Short synacthen test
• Long synacthen test
Diagnosis of AD
22

23. Short Synacthen Test
Indication: Investigation of adrenal insufficiency
Contraindication: Pituitary surgery
Principle: To evaluate the ability of adrenal cortex to
produce cortisol in response to synthetic
ACTH
Side effects: Hypersensitivity in rare cases
Preparation: No dietary restrictions
performed in morning
Requirements: Two plain tubes
250µg synacthen (1 vial)
paed dose: 36 µg/kg body weight 23

24. Short synacthen test - protocol (contd)
Procedure: 0 mins 3ml blood for cortisol
Inj synacthen 250 µg I/V or I/M
30 mins 3ml blood for cortisol
60 mins 3ml blood for cortisol
Interpretation: If post-synacthen cortisol >18 µg/dL
or
post-synacthen cortisol increases by
an increment of 8 µg/dL
Primary adrenal insufficiency is ruled out
24

25. Long Synacthen Ttest
• To differentiate between primary & secondary adrenal
insufficiency
• Prolonged stimulation of adrenal glands by synthetic ACTH
improves adrenal response
• Blood samples drawn: basal cortisol sample, then inj
synacthen 250µg I/M & Cortisol samples at 1,2,4,8 & 24 hrs
• Gradual rise in cortisol & peak at 24 hrs indicates secondary
adrenal insufficiency
• No response or initial (1hr) response which is not sustained
indicates primary adrenal insufficiency
• Gradual rise in cortisol & peak at 4-8 hrs is normal
• ACTH assay has reduced the significance of long synacthen
test
25

26. Q 6: As per reported natural history of Addison Disease (due to
autoimmune etiology) the first Endocrine abnormality is :
a. Decreased cortisol response to ACTH
b. Decreased morning cortisol
c. Increased CRH
d. Increased Plasma Renin Activity
e. Raised morning ACTH
d.Increased Plasma Renin Activity
26

27. Q 7: As a Consultant Chemical Pathologist in a tertiary care
hospital, you want to develop a strategy for immediate determination
of diagnosis and cause of adrenal insufficiency. Which of the
following test you would like to use at the time of patient
presentation:
a. Estimation of early morning Serum Cortisol
b. Estimation of evening Serum Cortisol
c. High dose ACTH Stimulation test with 250 µg
d. Low dose ACTH Stimulation test with 1µg
e. Simultaneous estimation of Serum Cortisol and Plasma ACTH
e. Simultaneous estimation of Serum Cortisol and Plasma ACTH
27

28. Q 8: Corticotropin-releasing hormone (CRH)
stimulation test is used in various adrenal abnormalities. All
of the following are indications of CRH stimulation test
EXCEPT:
a. As part of inferior petrosal sinus sampling for ACTH-dependent
Cushing's syndrome.
b. Discriminate between pseudo-Cushing's and Cushing's syndrome.
c. Discriminate between Primary and Secondary Adrenal Insufficiency
d. Discriminate between Secondary and Tertiary Adrenal Insufficiency
e. Discriminate between patients with an ectopic or a pituitary ACTH-
secreting tumour.
c. Discriminate between Primary and Secondary Adrenal Insufficiency
28

29. Q 9: A 72 y male industrialist is suspected of Acromegaly because of sudden
increase in his shoe size and enlargement of fingers. He is not a known case of Diabetes
Mellitus or liver disease. He was thoroughly investigated for the diagnosis of Acromegaly
and determining the cause of excess Growth Hormone (GH) if present. The results of his
investigations showed following results:
• IGF-1: 452 ng/ml (ref range: 135-449)
• OGTT with GH (by Chemiluminescence method)
o GH basal : 0.2 ng/ml
o GH level at 2 h : 0.6 ng/ml
• Pituitary MRI: Normal
What is the most probable diagnosis?
a. Equivocal results
b. Extra-pancreatic islet tumour
c. Extra-Pituitary Acromegaly
d. Normal for age
e. Pituitary Adenoma
c. Extra-Pituitary Acromegaly
29

30. For Detail Account Of GH Disorders
Please See PPT Prepared By
Dr Shagufta Yousaf
30

31. Diagnosis of Acromegaly in this pt
• IGF1 is normally decreases in elderly
• In this patient IGF 1 is markedly increased
• There is paradoxical rise of GH which is an indication of
Acromegaly
• Normal MRI of pituitary indicates extra-pituitary
acrmegaly
• GHRH Acromegaly can be the final diagnosis
31

32. Q 10: A 39 y female complains of polyuria with 24 h urinary volume more than
4.0 litre which has developed gradually over the last one year. She has been
referred to you for ‘Water Deprivation Test’ (WDT) for the diagnosis or exclusion
of Diabetes Insipidus (DI). You perform some preliminary tests which show
following results:
• Serum Sodium : 124 mmol/L (132-142)
• Urine osmolality: 118 mOsmol/Kg
Now how will you proceed with this patient? Please select the best option:
a. Central DI requiring WDT for confirmation
b. DI and Psychogenic polydipsia excluded not requiring WDT.
c. Nephrogenic DI requiring WDT for confirmation
d. No clue of any disorder requiring WDT
e. Psychogenic polydipsia requiring WDT for confirmation.
e. Psychogenic polydipsia requiring WDT for confirmation.
32

33. For Detail Account Of Diabetes
Insipidus Please See PPT Prepared By
Dr Shagufta Yousaf
33

34. Q 11: All the following are characteristics of an Ideal
Tumour Marker EXCEPT:
a. Can be used for evaluating prognosis
b. Can be used for prediction of therapeutic response
c. Elevated at early stage of the disease
d. High levels at the time of diagnosis
e. Levels decrease without any treatment
e. Levels decrease without any treatment
34

35. Q 12: A 52 y male who is a known patient of Cirrhosis of liver as a
sequale of Hepatitic C. His Alpha Fetoprotein (AFP) has been
monitored regualrly and usually remains below 200 ng/ml. A recent
report, howevr, shows AFP 545 ng/ml and on repeating the test a
simialr values was obtained. What is the most probable cause of rise
of AFP in this patient:
a. Carcinoma of Colon
b. Carcinoma of the pancrease
c. Extension in Cirrhosis
d. Hepatocellular Carcinoma
e. Testicular germ cell tumour
d. Hepatocellular Carcinoma
. 35

36. Q 13: CA-125 is a time-honoured marker of Carcinoma Ovaries.
There are efforts to imporve its efficiency ad diagnostic marker for
Stage 1 Ovarian Carcinomas.
All of the following are situations when CA-125 can be used as a
better marker for the diagnosis of Ovarian Carcinoma EXCEPT:
a. In combination with AFP
b. In combination with Carcinoembryonic Antigen
c. In combination with Human Epididymis Protein
d. Serial monitoring of CA 125
e. Use in post-menopausal women
a.In combination with AFP
36

37. Q 14: For the monitoring of Carcinoma Breast several
biochemical or circulating tumour markers have been found useful.
Which of the following tumour markers have been approved by FDA
for the detection of recurrent Breast Carcinoma:
a. CA-15-3
b. CA-27.29
c. CA-549
d. Extracellular domain of HER2 (HER 2 ECD)
e. Mucinlike Carcinoma Associated Antigen (MCA)
b.CA-27.29
. 37

38. Q 15: Research in Oncogene has led to discovery of certain gene which can
predict certain cancers with reasonable accuracy. A subset of these Oncogene
have been found quite commonly in otherwise healthy women raising the moral
and ethical issues of prophylactic surgery.
Which of the following oncogenes is a suppressor gene used for inherited
prediction of Breast Cancer in a family with the patients of these cancers:
a. APC mutation
b. BRCA mutation
c. Her-2/neu gene
d. N-ras mutation
e. VHL Mutation
b.BRCA mutation
. 38

39. For Detail Account of Tumour Markers
Please See PPT Prepared By
Drs Anwar Magsi and Fawad Sana
39

40. SAQs
40

41. Q:16: Diagnosis of Growth Hormone Deficiency in short stature children is one of the most
common Endocrine challenges a Chemical Pathologist has to face. As a Consultant
Chemical Pathologist you have been instructed by your University Administration to
establish an “Auxology Clinic” i.e. Growth Clinic in the hospital in collaboration with
Consultant Paediatricians. Please address following issues in this regard:
a. Please make a list of essential equipment and charts etc. required for clinical
examination of the children referred to this ‘Growth Clinic’ from Primary Care
Services.
b. A major problem in diagnosis of Growth Study is selection of children who have
high pre-test likelihood ratio i.e. they have higher chance of testing positive for
Growth Hormone Deficiency (GHD). Such screening is essential for a cost
effective and efficient “Auxology Clinic”.
Please make a FIVE line criteria for selecting children to undergo GHD studies.
c. Name the specific tests which are carried out for the diagnosis of GHD without any
stimulation.
d. Name the provocative tests which can be used for the confirmation of GHD.
. 41

42. Suggested Answer to Q.16a
Please make a list of essential equipment and charts etc.
required for clinical examination of the children referred
to this ‘Growth Clinic’ from Primary Care Services.
(Plz see next slide)
42

43. Equipment and Charts for Growth Clinic
• Weighing machine
• Vertical stadiometer for children ˃2 years of age
• Neonanometer for children ˂2years of age
• Glucometer with strips
• Refrigerator ( to keep insulin at optimal temperature)
• WHO growth charts for length for age for girls and boys
for less than 2 years age
• CDC growth charts for height for age for girls and boys for
more than 2 years age
43

44. Equipment and Charts for Growth Clinic (Cont)
• Height velocity chart for boys and girls
• Calculators to calculate midparental height in boys and girls
• Calculator for calculating CDC height for age percentiles in boys
and girls
• Charts to estimate bone age
• Syringes (insulin, 5 cc, 10cc, iv canulas)
• 25% dextrose, 5% dextrose saline, distilled water
• Sample collection tubes for serum (growth hormone) and plasma
glucose
• Other emergency drugs in a tray like antiemetic, solucortef, etc.
44

45. Suggested Answer to Q.16b
A major problem in diagnosis of Growth Study is
selection of children who have high pre-test likelihood
ratio i.e. they have higher chance of testing positive for
Growth Hormone Deficiency (GHD). Such screening is
essential for a cost effective and efficient “Auxology
Clinic”.
Please make a FIVE line criteria for selecting
children to undergo GHD studies
(Plz see next slide)
45

46. Selection of Patients for GH Studies
• Height progressively decline to lower percentile
usually < 3rd percentile
• Weight increasing with chronological age
• Reduced Growth velocity
• Delayed bone age
• Other systemic cause of short stature / constitutional
delay are ruled out e.g. Hypothyroidism, Coeliac
Disease etc.
46

47. Suggested Answer to Q.16c
Name the specific tests which are carried out for
the diagnosis of GHD without any stimulation.
• IGF 1
• IGF BP3
47

48. Suggested Answer to Q.16d
Name the provocative tests which can be used for the
confirmation of GHD.
• Exercise Stimulation Test
• L-Dopa Stimulation Test
• Arginine Test
• Insulin Stimulation Test
48

49. Q:17: Use of Prostate Specific Antigen as a marker for screening of
Prostatic Cancer has been one of the most controversial topics in cancer
management. The levels of Serum PSA from 4.0 to 10 ng/ml present a
diagnostic dilemma. Many strategies have been proposed to improve the
diagnostic accuracy of PSA for prostatic carcinoma, though there is no
consensus about acceptance of these PSA modifications.
Please name the strategies proposed for improvement of diagnostic
performance of PSA. Write brief description of THREE of these
strategies (not more than two lines for each).
(Plz see next slide)
49

50. Strategies proposed to improve the diagnostic
performance of PSA
For PSA between 4 -10.0 ng/mL.
• PSA velocity (change in PSA over time),
• PSA density (PSA per unit volume of prostate),
• Free PSA
• Complexed PSA
• Age specific reference ranges
• Race specific reference ranges
50

51. Age specific reference ranges:
PSA level increase with age.
• 40 to 49 years — 0 to 2.5 ng/mL
• 50 to 59 years — 0 to 3.5 ng/mL
• 60 to 69 years — 0 to 4.5 ng/mL
• 70 to 79 years — 0 to 6.5 ng/mL
By lowering the upper limit of reference interval, more cancer
will be detected in younger men for whom a potential cure by
radical prostatectomy is most beneficial.
51

52. PSA Velocity
• The rate of PSA increase as a function of time.PSA increases
more rapidly in men with prostatic cancer than in healthy men.
• After establishing a base line concentration of PSA in each
patient, the rate of increase of PSA is than calculated.
• The increase of PSA in health, BPH, and prostatic cancer
appears to be different with a highest rate (>0.75µg/L/yr)
observed in patient with prostatic cancer.
• The specificity improves to 90%for BPH and sensitivity is 72%
for prostatic cancer.
52

53. Prostatic Density :
• Divide PSA concentration by the prostatic volume as
determined by transrectal ultrasonography.
• Patient with PSA between 4 a 10µg/L, a negative
digital rectal examination result, and elevated PSA
density have increased risk of prostate cancer.
• Adjusting the PSA density cutoff value for total PSA
level might improve the test sensitivity.
53

54. Thank You and Best Of Luck
54