Introduction: Insulinoma is the most common functioning neuroendocrine tumor of the pancreas. Although rare, is the main cause of endogenous hyperinsulinemic hypoglycemia.The most common clinical manifestations are neurovegetative and neuroglycopenic symptoms secondary to hypoglycemia. Progressive weight gain is also an important clinical feature, due to the anabolic action of insulin and the need to feed periodically in an attempt to reduce hypoglycemia. The presence of neuroglycopenic symptoms, which sometimes may be confounded with psychiatric symptoms, may lead to delay or misdiagnosis. In our country, there are few publications about the early diagnosis and treatment of this neoplasm. Surgery still seems to be the best treatment option but, in selected case in which there are high surgical risk, the minimally invasive procedures, such as endoscopic ultrasound (EUS) guided ethanol ablation can be a good choice of treatment. We report a case of an insulinoma in a patient with extreme obesity,that was submitted to a less invasive treatment due to surgical risks. Case report: A 22-years old woman, presented progressive weight gain of 65 kg in 1 year (163kg, BMI: 59.6kg/m2). After using intragastric balloon for 6 months, she developed hypoglycemic symptoms. Prolonged fasting test (PFT), was performed and showed after 40 minutes plasma glucose: 44mg / dl (< or = 55mg/dl); C peptide: 3.2 ng / ml ( > or = 0,6ng/ml) , insulin: 47 mU / ml (> or = 3mU/ ml), anti-insulin antibody negative. EUS showed a homogeneous hypoechoic lesion in the cephalicregion of uncinate pancreas process and fine needle puncture showed cells with atypia of indeterminate significance. Magnetic Resonance Image of the abdomen showed a 1.9 cm hypervascular nodule in the cephalic portion of the pancreas, very close to cava vein. The main hypothesis was an insulinoma. Due to the patient's severe obesity and the tumor localization, a multidisciplinary team decided to do a minimally invasive procedure. EUS guided ethanol ablation with absolute ethanol and a fine needle aspiration were performed with general anesthesia without complications. On the following days of the procedure, surveillance for pancreatitis was performed. Anatomopathological showed immunohistochemistry positive for insulin and ki67% <1%. Laboratory exams of the 30th postoperative day: fasting glycemia: 89mg / dl, peptide C: 5.18ng / dl, insulin: 45.51 Uui / ml. After 6 months of the procedure, the patient remains without hypoglycemia and lost 10 kg. Conclusion: Insulinoma as described above is a rare condition, but should always be part of the differential diagnosis of obesity and hypoglycemia. Careful analysis and multidisciplinary decision-making for best behavior are key. Minimally invasive treatment is promising, with reduced surgical risks, shorter hospital stay and increased quality of life after the procedure. As seen in our case.

Introduction:TSH-secreting pituitary tumors represent about 2% of all pituitary adenomas and cause central hyperthyroidism. These tumors are characterized by high levels of free thyroid hormones in the presence of nonsuppressed serum TSH concentrations.Clinical cases: 1:A 52-year womanwith menstrual irregularity and hyperprolactinemia (127ng/mL). The pituitary´s MR showed a lesion (2.0 x1.8 x1.8cm). The diagnosis of TSHoma was made later when TSH achieved 4,78µU/mL (0.27-4.2), FT4 1.9ng/dL(0.93-1.7) and TRH stimulation test compatible. Treated with Ocreotide LAR (OCT LAR) and cabergoline, but the tumor became invasive. The surgery was indicated but the patient refused. 2:A 56-year womanwith weight loss, insomnia and hair loss. TSH 5.66µU/mL(0.5-5.3), FT4 2.4ng/mL(0.7-1.6), SHBG elevated, negativeantibodies andα-GSU in the normal range. The TRH stimulation test was compatible with TSHoma. The MR presented a tumor with 0.9x0.8x0.7cm. Treated with OCT LAR: good control of hyperthyroidism symptoms. 3: A 55-year man with headachesand visual field loss. TSH 2.47µU/mL(0.5-5.3), FT4 2.3ng/mL(0.7-1.6) and negative antibodies. The pituitary MR presented a tumor with 1.1x1.0x1.0cm and compression of the optic chiasm. The diagnosis was confirmed with the TRH stimulation and high level of α-GSU. The patient had an arrhythmia and the surgery was cancelled. He has been treated successfully with OCT LAR. 4: A 45-year-old asymptomatic woman with routine tests: TSH 5.11 μUI/mL(0.27-5.0), FT4 1.97ng/dL(0.75-1.10) and negative antibodies. The diagnosis was confirmed by α-GSU, TRH stimulation andpituitary lesion with 2.1x1.9x1.8cm. She has been treated with OCTand presented normalization of hormones, α-GSU and tumorreduction. 5:A 62-year-old woman with tremors, TSH 13.9 µUI/mL (0.45-4,5), FT4 2.2 ng/mL (0.6-1.3) and positive anti-TPO. The α-GSU was normal for postmenopausal woman, but had a high α-GSU/TSH molar ratio. The pituitary´s MR showed a lesion with 5 mm. The treatment with OCT LAR was indicated. 6:A 59-year-old woman withhyperthyroidism clinic and liver cirrhosis. TSH 6.29µUI/L (0.27-4.2), FT4 3.2ng/dL(0.93-1.7),α-GSU 2251ng/L (340-4000) and a 0.9 cm pituitary lesion. There was no tumor control with OCT LAR. Transesphenoidal surgery couldn'tbe considered because of coagulation disorders. Antithyroid drugs was contraindicated due to its hepatotoxicity. Then weperformed a radiosurgery but the patient lead to death after intestinalhemorrhage. 7:A 51-year-old man complaining of palpitations, irritability and tiredness. Laboratory tests showed an increase in FT4L: 2.3ng/dL (0.9-1.7) with inappropriately normal TSH: 1.77 μUI/L (0.27-4.2) and presence of pituitary microadenoma.Conclusion: In the presence of inappropriate normal or increased TSH levels and high FT4 levels the TSH- secreting pituitary adenoma should be considered even though is a rare disease.

Introduction: Retroperitoneal tumors are rare and account for less than 0.1% of all malignant tumors. Although we find more often benign tumors, malignant variants account for 85% of tumors. Once retroperitoneum has a heterogeneous content, there are innumerable non-endocrinological differential diagnoses for these lesions, such as sarcomas (among them the liposarcoma, the leiomyosarcoma and the fibrosarcoma), lymphoma, lipomas, leiomyomas, fibromas and teratomas. Cystic lymphangioma and hibernoma may still be remembered and sought after. Among the endocrinological differential diagnoses, we mainly have: pheochromocytomas, paragangliomas and adrenal carcinomas. The 2 cases described below are examples of non-endocrine differential diagnosis of retroperitoneal lesion. Clinical Case 1: C.L.S.P, 45 years old, female, with low back pain for 1 year, with no weight changing at the analised period. She had no signs or symptoms of hyperandrogenism, hypercortisolism or hypertension, but noticed a palpable mass in the abdomen. Physical examination: palpable mass on the right flank and mesogastrium, well delimited. MRI: Heterogeneous mass, measuring 10x5.6x4 cm, hypervascularized, with cystic foci and lobulated contours, into abdominal cavity, to the right of the midline, determining compression of the below infrarenal vena cava and displacing some intestinal loops above. Laboratory tests: plasma metanephrines, urinary cortisol and cortisol, cortisol after 1mg of dexamethasone, salivary cortisol and ACTH, without changes. DHEAS, 11-deoxycortisol, androstenedione and testosterone, also without changes. Anatomopathological: Peritoneal sarcoma. Clinical Case 2: L.C.F., 42 years old, female, diabetic and hypertensive for about 20 years. She started lumbar pain, on the left, with 6 months of evolution, associated with a loss of 12 kg in the period. She had no signs or symptoms of hyperandrogenism and hypercortisolism. Physical examination with no changes. MRI: Expansive lesion occupying the left adrenal locus, with well defined margins, heterogeneous characteristics, delimiting areas of necrosis / liquefaction, as well as area suggestive of blood content, measuring 15.7x11.1x10.6 cm. Laboratory tests: plasma metanephrines, aldosterone, salivary cortisol, cortisol after 1mg of dexamethasone, urinary cortisol, ACTH, Cortisone, 21-deoxycortisol, DHEAS, Compound S, androstenedione, 17-OHP and estradiol without alterations. Anatomopathological: KIDNEY LEIOMYOSARCOMA. Immunohistochemistry: AE1 / AE3 negative, diffuse AML positive, diffuse caldemon positive, desmin negative and S100 negative. Conclusion: Thus, these differential diagnosis of retroperitoneal lesions should also be suspected by the endocrinologist.