Endoscopic endonasal transsphenoidal surgery in recurrent and residual pituitary adenomas: technical note

Despite a good cure rate after surgery, the recurrence rate in pituitary adenomas is globally high. The decision making in such cases can be problematic for the nature of the lesion, for the anatomic structures involved, for the different pharmacological, surgical, radiotherapeutic and radiosurgical options nowadays available. In the perspective of an improvement and refinement of the surgical procedure an endoscopic endonasal transsphenoidal approach to the pituitary was recently adopted in the Neurosurgical Department of the University of Naples. Its minimal invasiveness and its wider and direct anatomic control of the operative field has allowed a faster, greater and safer potential of tumour excision, with respect of the sphenoid, sellar and parasellar structures. The authors have examined the advantages provided by this technique in 12 patients with recurrent pituitary adenomas and in 2 craniopharyngiomas already treated via a transnasal transsphenoidal approach (TTA), where the anatomy of surgical field had been distorted by the first operation or the radiation therapy. They conclude that the endoscopic transsphenoidal re-operation might be considered the procedure of choice in case of recurrences and its easiness in such conditions could favour its larger use, before other more aggressive therapeutic solutions.

Prolactinomas in adolescents: persistent bone loss after 2 years of prolactin normalization

OBJECTIVE

To evaluate the effect of hyperprolactinaemia and its treatment with dopamine-agonists on bone mass and turnover in adolescent patients compared to adults.

PATIENTS

Forty patients with hyperprolactinaemia (20 with disease onset during adolescence and 20 during adulthood) and 40 healthy control subjects.

DESIGN

Open transverse (in patients and controls) and open longitudinal (in the patients).

MEASUREMENTS

Bone mineral density (BMD) at lumbar spine and femoral neck, serum osteocalcin (OC) and urinary cross-linked N-telopeptides of type-1 collagen (Ntx) levels were evaluated in patients and controls. In the 40 patients, bone mass and turnover were re-evaluated after 12 and 24 months of treatment with bromocriptine (BRC, dose 2.5-10 mg daily), quinagolide (CV, dose 0.075-0.3 mg daily) or cabergoline (CAB, dose 0.5-1.5 mg weekly).

RESULTS

Transverse study: BMD values were significantly lower in hyperprolactinaemic patients than in controls, both at lumbar spine (0.81 +/- 0.01 vs. 1.010 +/- 0.01 g/cm2; P < 0.001) and femoral neck (0.71 +/- 0.01 vs. 0.873 +/- 0.03 g/cm2; P < 0.001). Thirty-two patients (80%) had osteoporosis and/or osteopenia at one or both skeletal sites. A significant inverse correlation was found between T score values measured at lumbar spine and femoral neck and the estimated disease duration. BMD was significantly lower in young than adult patients both at lumbar spine (T score, -2.4 +/- 0.1 vs. -1.4 +/- 0.3, P < 0.01) and at femoral neck (T score, -2.1 +/- 0.05 vs. -1.5 +/- 0.2, P < 0.05). Similarly, serum OC levels were significantly lower (2.0 +/- 0.11 vs. 9.1 +/- 2.4 micrograms/l, P < 0. 01) while Ntx levels were significantly higher in patients than in controls (129.2 +/- 1.7 vs. 80.7 +/- 2.9 nmol Bone collagen equivalent (BCE)/mmol creatinine; P < 0.001). A significant inverse correlation was found between prolactin (PRL) levels and OC levels, lumbar and femoral T score values, as well as between disease duration and OC levels, lumbar and femoral T score values. A significant direct correlation was also found between Ntx levels and PRL levels and disease duration. Longitudinal study: Normalization of serum PRL levels was obtained in all patients after 6-12 months of treatment. A significant increase of serum OC levels together with a significant decrease of Ntx levels was observed after 12 and 24 months of treatment (P < 0.01). Urinary and serum calcium, phosphorus, creatinine, and serum alkaline phosphatase and parathyroid hormone levels did not change during the study period in all patients. After 12 months of therapy OC and Ntx concentrations were restored to normal. A slight but not significant increase of BMD values was recorded after 12 and 24 months of treatment. After 12 months of treatment the percent increment of BMD values in the whole group of patients was 1.13 +/- 0.6% at lumbar spine and 1.2 +/- 0.4% at femoral neck level, whereas after 24 months, it was 2.8 +/- 0.7% at lumbar spine and 3.5 +/- 0.7% at femoral neck level. After 12 months of treatment, the percent increment of BMD values was 0.7 +/- 0.2% and 1.6 +/- 1.1% at lumbar spine and 0.9 +/- 0.5% and 1.6 +/- 0.5% at femoral neck level in the young and adult patients, respectively, whereas after 24 months, it was 2.1 +/- 0.8% and 3.4 +/- 1.3% at lumbar spine and 2.6 +/- 0.8% and 4.4 +/- 1.0% at femoral neck level in the young and adult patients, respectively.

CONCLUSIONS

Adolescents with prolactinoma have osteopenia or osteoporosis, a finding that strengthens the need for a prompt diagnosis. Since normalization of PRL concentrations by dopamine agonist therapy is unable to restore the bone mass, other therapeutic approaches should be considered in order to prevent further long-term problems.

Cabergoline

Cabergoline (CAB) (1-[(6-allelylergolin-8 beta-yl)carbonyl]-1-[3-(dimethylamino)propyl]-3-ethyl-urea) is an ergoline derivative with potent, selective and long-lasting inhibitory activity on prolactin (PRL) secretion acting on dopamine receptors present in pituitary lactotrophes. Receptor binding studies have demonstrated that CAB has high in vitro selectivity and affinity for the subtype D2 of the dopamine receptor. In cultures of rat anterior pituitary cells, the concentrations of CAB and bromocriptine required to inhibit PRL secretory activity by 50% (IC50) were 0.1 and 3.4 nmol/l, respectively. As compared to bromocriptine, CAB was more potent in inhibiting the binding of [3H]N-n-propylnorapomorphine and it occupied the receptor for longer. These effects were observed in all areas of the rat brain. In vivo, CAB at doses of 0.125-1 mg twice weekly caused a dose-dependent suppression of PRL secretion in women with hyperprolactinaemia. CAB was shown to be significantly more effective than bromocriptine in inducing a complete biochemical response and clinical efficacy and was better tolerated than bromocriptine in the majority of patients. Notable tumour shrinkage until tumour disappearance was observed during CAB treatment in most patients with macroprolactinoma. CAB was also shown to be effective in patients resistant or poorly responsive to bromocriptine. In view of the limited data on CAB-associated pregnancies and the long half-life of the drug, it is currently recommended that women seeking to became pregnant, once ovulatory cycles have been established, should discontinue CAB therapy 1 month before they intend to conceive. However, no data on negative effects on pregnancy or offspring have been reported. The great efficacy of CAB together with its excellent tolerability makes this drug the current treatment of choice for the majority of patients with hyperprolactinaemic disorders. Very recently, the efficacy of CAB treatment has been reported in patients with acromegaly and clinically non-functioning adenomas with controversial results. CAB was also reported to have some efficacy in patients with Nelson's syndrome and Cushing's disease although these data are available only for limited case reports.

FSH treatment improves sperm function in patients after varicocelectomy

One-hundred and eighty-three patients affected with idiopathic left varicocele, aged between 18 and 45 years, surgically treated have been studied. They were divided in 3 subsets according to sperm count: group A: <10 x 10(6)/ml, group B: 10-20 x 10(6)/ml, group C: >20 x 10(6)/ml. Six months after surgery 115 patients were treated for 3 months with pure human FSH: 75 IU i.m. every other day, while 68 patients treated with placebo served as control group. After therapy, group A showed a significant clear-cut improvement of sperm parameters: count, forward progression, swollen tails and cervical mucus penetration test (CMPT). In group B a significant improvement of sperm motility, viability, DNA integrity and CMPT was observed, while in group C only a significant improvement of CMPT was observed. In conclusion, it can be suggested that FSH treatment in patients after varicocelectomy could improve spermatogenesis, particularly in those who previously have more compromised sperm quality. On the contrary, no significant difference of sperm patterns was recorded in the control group before and after placebo.

Growth hormone and cardiac function

Impaired cardiovascular function, which may reduce life expectancy, has recently been demonstrated both in GH deficiency and excess. Moreover, experimental and clinical studies support the evidence implicating GH and/or IGF-I in the regulation of heart development. The existence of a specific acromegalic cardiomyophathy characterized by myocardial hypertrophy with interstitial fibrosis, lympho-mononuclear infiltration and areas of monocyte necrosis which often result in biventricular concentric hypertrophy has been recenty demonstrated. By contrast, patients with childhood or adulthood-onset GH deficiency (GHD) present with abnormalities of structure and function of the left ventricle. In these patients, a significant increase in the vascular intima-media thickness and an increased number of atheromatous plaques have also been reported. The abnormalities of cardiovascular system could be partially reverted by suppressing GH and IGF-I levels in acromegaly or after GH remplacement therapy in GHD patients. The evidence that GH is able to increase cardiac mass suggested its use in the -treatment of chronic heart failure of diverse etiologies. GH administration was -demonstrated to induce an improvement in hemodynamics and clinical status in some patients. Although these data should be confirmed in double-blind placebo controlled studies in larger series, the promising results open new perspectives for GH treatment in humans.

Systemic hypertension and impaired glucose tolerance are independently correlated to the severity of the acromegalic cardiomyopathy

Increased mortality from cardiovascular diseases has been reported in acromegaly. Our objective was to evaluate the impact of glucose tolerance abnormalities and/or systemic hypertension in further worsening the acromegalic cardiomyopathy. The study design was open transversal. The subjects studied were 130 consecutive naive acromegalic patients (74 women and 56 men; age, 17-80 yr). Interventricular septum (IST) and left ventricular (LV) posterior wall thickness (PWT), LV mass index (LVMi), maximal early to late diastolic flow velocity ratio (E/A), isovolumic relaxation time (IRT), and LV ejection fraction (EF) were measured by echocardiography. The results were analyzed in line with the presence of glucose tolerance abnormalities (normal in 60, impaired in 38, diabetes mellitus in 32) and the presence (in 46) or absence (in 84) of hypertension. Patients with impaired glucose tolerance and diabetes mellitus had significantly higher age (P = 0.01), and systolic (P = 0.01) and diastolic (P = 0.01) blood pressures and lower E/A (P = 0.01) and EF (P = 0.01) than those with normal glucose tolerance. Disease duration, circulating GH and insulin-like growth factor I (IGF-I) levels, IST, LVPWT, LVMi, and IRT were similar in the 3 groups. Normotensive patients had significantly lower age (P<0.001), LVPWT (P<0.001), IST (P = 0.003), LVMi (P<0.001), and IRT (P = 0.02) and significantly higher E/A (P<0.001) and EF (P<0.001) than hypertensive subjects. Disease duration, circulating GH, and IGF-I levels were similar in the 2 groups. Multiple regression analysis showed that systolic blood pressure was the strongest predictor of LVMi (P = 0.0004), followed by GH levels (P = 0.02), whereas diastolic blood pressure was the strongest predictor of LVEF reduction (P<0.0001), followed by glucose tolerance status (P = 0.02). Age was the strongest predictor of both E/A impairment (P<0.0001) and IRT (P = 0.01), followed by IGF-I levels (P = 0.02). Compared to patients with uncomplicated acromegaly, those with hypertension but without abnormalities of glucose tolerance had an increased prevalence of LV hypertrophy (75% vs. 37.2%) as well as of impaired diastolic (50% vs. 7.8%) and systolic function (18.7% vs. 3.9%), whereas patients with glucose tolerance abnormalities but without hypertension had only an increased prevalence of impaired diastolic (39.7%) and systolic function (31.7%). The subgroup of acromegalic patients suffering from hypertension and diabetes mellitus had the highest prevalence of LV hypertrophy (84.6%), diastolic filling abnormalities (69.2%), and impaired systolic function at rest (53.9%). A careful cardiac investigation should thus be performed in all acromegalic patients showing these complications.

Power Doppler ultrasonographic assistance in percutaneous ethanol injection of autonomously functioning thyroid nodules

The purpose of this study was to explore the potential role of power Doppler sonography in guiding percutaneous ethanol injection of autonomously functioning thyroid nodules. Thirty-two patients with pretoxic adenoma and 15 with toxic adenoma underwent percutaneous ethanol injection under power Doppler sonographic guidance. All patients with pretoxic adenoma and 13 of 15 patients with toxic adenoma were treated successfully (normalization of circulating thyroid hormones and thyroid stimulating hormone levels and disappearance of nodular hyperactivity with complete recovery of extranodular tracer uptake at scintigraphy). Power Doppler sonography showed the progressive reduction of the intranodular blood flow until its extinction after 6 to 12 months. Nodular shrinkage was obtained in all patients (from 10.85 +/-1.04 to 2.9 +/- 0.3 ml in pretoxic adenoma and from 15.4 +/- 1.8 to 4.2 +/- 0.7 ml in toxic adenoma. Power Doppler sonographic guidance seems to improve the outcome of percutaneous ethanol injection, allowing detection of blood flow even in very small vessels, permitting the ethanol to be guided toward the main afferent vessels of the nodules, and making it possible to monitor the diffusion and the effects of ethanol on nodular vascularization.

The study of spontaneous GH secretion after 36-h fasting distinguishes between GH-deficient and normal adults

OBJECTIVE

Within an appropriate clinical context, GH deficiency (GHD) in adults can only be diagnosed biochemically by provocative testing. The evaluation of IGF-I, IGFBP-3 and even of spontaneous GH secretion do not establish the diagnosis of adult GHD. In fact, remarkable overlaps between normal and GHD adults have been reported for all these parameters. On the other hand, it is well known that even short-term fasting stimulates GH secretion in normal subjects. The aim of our study was to determine the effects of 36 h fasting on 8-h diurnal GH, insulin and glucose levels as well as on basal IGF-I, IGFBP-3, acid-labile subunit (ALS), IGFBP-1, GHBP and free fatty acid (FFA) levels.

SUBJECTS

We studied 9 GHD adults (GHD, 8 males, 1 female; age, mean +/- SEM: 37.6 +/- 2.3 years, body mass index (BMI): 24.5 +/- 1.0 kg/m2) and 20 age-matched normal subjects (NS) as controls (13 males, 7 females; age: 28.9 +/- 0.6 years, BMI: 21.6 +/- 0.4 kg/m2).

STUDY DESIGN

In all subjects we studied the effects of 36 h fasting on 8-h daytime GH, insulin and glucose levels (assay every 30 min from 0800 h to 1600 h) as well as on basal IGF-I, IGFBP-3, ALS, IGFBP-1, GHBP and FFA levels.

RESULTS

Before fasting, basal mean IGF-I, IGFBP-3 and ALS levels in GHD were lower (P < 0. 0001) than in NS. IGFBP-1, GHBP and FFA levels were similar in both groups. Before fasting mean GH concentration (mGHc) in GHD was lower (P < 0.05) than in NS (0.4 +/- 0.2 vs. 2.2 +/- 0.6 mu/l) but with a clear overlap between the 2 groups (range 0.4-0.8 vs. 0.4-6.8 mu/l). After fasting, both in GHD and NS basal IGF-I, IGFBP-3, ALS and GHBP levels did not change significantly. On the other hand, in both GHD and in NS IGFBP-1 was increased (P < 0.0001) to a similar extent, while FFA increased in NS more (P < 0.01) than in GHD. Fasting significantly increased mGHc in NS (12.0 +/- 1.2 mu/l, P < 0.0001) but not in GHD (0.6 +/- 0.2 mu/l). After fasting, no overlap was present between GHD and NS (0.4-1.6 vs. 2.4-20.8 mu/l, respectively). Mean glucose and insulin concentrations over 8 h in GHD and NS in basal conditions were similar and were reduced to the same extent in both groups.

CONCLUSIONS

Our findings demonstrate that after short-term fasting, the study of spontaneous GH secretion distinguishes between GH-deficient adults and normal subjects; this phenomenon occurs before significant changes in IGF-I and IGFBP-3 levels. These results suggest that the assessment of spontaneous GH secretion could be useful for the diagnosis of adult GH deficiency only after short-term fasting.

Complete remission of Nelson's syndrome after 1-year treatment with cabergoline

In this case report we demonstrated that treatment with the long-acting D2 receptor agonist cabergoline for 1 year induced normalization of plasma ACTH levels and disappearance of the pituitary tumor in a patient with Nelson's syndrome. A young man underwent bilateral adrenalectomy and subsequent pituitary irradiation for Cushing's disease after unsuccessful neurosurgical treatment. Thereafter, he was given cortisone acetate replacement at the dose of 62.5 mg a day. Fifteen months after pituitary irradiation, he developed Nelson's syndrome, having skin hyperpigmentation, high plasma ACTH levels (376 ng/l) and a pituitary microadenoma (5 mm) documented at magnetic resonance imaging (MRI) of the pituitary region. After 6 months of cabergoline treatment, given at the dose of 1 mg a week, plasma ACTH levels were significantly decreased (from 376 to 113 ng/l) but they were not normalized. Cabergoline dose was then increased up to 2 mg a week. Six months later plasma ACTH levels were normalized (22 ng/l) and MRI demonstrated the disappearance of the pituitary adenoma. In order to investigate on the direct effect played by cabergoline treatment on the remission of Nelson's syndrome, the treatment was withdrawn. Plasma ACTH levels significantly increased (119 ng/l) after 3 months of treatment withdrawal. At the last follow-up, during cabergoline treatment at the dose of 2 mg/week plasma ACTH levels were normalized (40.4 ng/l). This case demonstrated that cabergoline treatment is able to induce the remission of Nelson's syndrome and may be a valid therapeutic alternative in this syndrome.

Percutaneous ethanol injection under Power Doppler ultrasound assistance in the treatment of autonomously functioning thyroid nodules

Power Doppler (PD) is a recent color-Doppler Ultrasound (US)-technique, which allows to detect the presence of flow even in very small vessels, providing a sort of angiographic micromap. The aim of this study was to evaluate whether percutaneous ethanol injection (PEI) outcome might be improved by injecting the ethanol into the nodule under PD assistance. Thus, 14 patients affected with pretoxic (PTA) and 8 with toxic adenoma (TA) were submitted to this alternative tool. Before PEI, all patients were submitted to a careful endocrinological study, including an US-guided fine-needle biopsy in order to exclude the presence of malignancy. In addition, all the nodules were evaluated at PD-US and their vascular patterns were recorded on videotape and compared with those obtained after treatment. The procedure consisted of slow injection of sterile ethanol under direct PD-US control. The number of PEI sessions was 2.3+/-0.1 in PTA and 3.0+/-0.3 in TA. All patients were also evaluated 3, 6, 12 and 18 months after PEI. Successful therapy was considered when normalization of thyroid hormones and TSH was achieved together with the disappearance of nodular hyperactivity and complete recovery of extra-nodular tracer uptake at scintigraphy. PEI was tolerated very well by all patients. The most common side effect was a transient local or irradiated pain. All patients with PTA and 6 out of 8 patients with TA were successfully treated. In these cases, PD-US showed the progressive reduction of the intranodular blood flow, up to its extinction after 6-12 months, with the presence of little perilesional vascular spots. Nodular shrinkage was obtained in all patients (from 4.7+/-0.7 to 1.1+/-0.4 ml in PTA and from 21.0+/-2.8 to 6.2+/-1.6 ml in TA). In conclusion, PD assistance improves PEI procedure, since it allows to guide the ethanol injection towards the principal afferent vessels of the nodules and to monitor the diffusion and the effects of ethanol on nodular vascularization.

AlphaANP, AVP, and pituitary-thyroid axis in patients with congestive heart failure and acute respiratory failure

The pituitary-thyroid axis and neurohumoral activation indexes were simultaneously investigated in 16 in-patients hospitalized for cardiac heart failure (CHF), New York Heart Association (NYHA), class II-IV, and Killip clinical scale, class II-III, to evaluate their relationship with CHF morbidity and the relative prognostic value. At entry the patients were divided into two subgroups (A and B), according to the severity of CHF. Patients were further classified into two subgroups, according to the subsequent clinical course (C, poor outcome and D, improved clinical course). Blood samples were obtained every day for the radioimmunoassay measurement of plasma alpha-atrial natriuretic peptide (alphaANP), arginine vasopressin (AVP), and thyroid hormones, and the results were compared with those of 12 control subjects. At admission, alphaANP and 3,3',5'-triiodothyronine (rT3) values were higher, while 3,3',5-triiodothyronine (T3) to rT3 (T3/rT3) ratio was lower in subgroups A and B than in controls (p<0.001), respectively, and in C than in D (p<0.001), respectively, according to the prognosis. Conversely, no differences in other thyroid indexes, nor a significant correlation between alphaANP and either rT3 or T3/rT3 ratio were present in any of the subgroups. AVP plasma levels in subgroup A were not statistically different from those of controls, whereas they were significantly decreased in subgroups B and C (p<0.05) and D (p<0.001). In conclusion, these results indicate that in CHF the pituitary-thyroid axis is not altered, that alphaANP and T3/rT3 ratio are non-invasive and reliable predictors of severity and prognosis, while AVP might be affected by the different pathological processes leading to CHF or by the concomitant use of drugs.

Ultrasonographic evidence of joint thickening reversibility in acromegalic patients treated with lanreotide for 12 months

BACKGROUND

A major cause of morbidity and functional disability in acromegaly is represented by axial and peripheral arthropathy.

OBJECTIVE

The effect of a 12-month treatment with lanreotide (LAN) on arthropathy in 12 untreated acromegalic patients has been evaluated. Twelve healthy subjects served as controls.

STUDY DESIGN

Open prospective.

STUDY PROTOCOL

Articular cartilage thickness of shoulder, wrist and knee, as well as the size of the heel tendons, was measured by ultrasonic (USG) examination before, monthly for the first 3 months and quarterly thereafter, during treatment with 60-90 mg/month of LAN. The achievement of safe GH and IGF-I levels was considered when fasting GH was below 5 mU/l and IGF-I levels were normalized for age.

RESULTS

Before treatment, thickening of shoulder, wrist and knee cartilages, and of heel tendons, was found in all patients compared with controls (P < 0.01). During the first 3 months of LAN treatment, a significant decrease in circulating GH (from 86.8 +/- 19.8 to 25.6 +/- 9.8 mU/l) and IGF-I levels (from 624 +/- 47.8 to 412.2 +/- 44.5 microg/l) was observed. Overall, a slight decrease was noted in all the articular sites examined, but it reached statistical significance only at the right shoulder (P < 0. 001). However, a notable improvement of joint pain and active and passive articular mobility were recorded in all patients, as well as of weakness, soft tissue swelling, hyperhydrosis and headache. After 6 months of LAN treatment, a further significant decrease was observed at the level of the right shoulder (P < 0.01) and the right knee (P < 0.01). Eight patients achieved safe GH and IGF-I levels. After 12 months of LAN treatment, a significant decrease was observed at the level of all the articular sites examined (P < 0.01), as well as at the level of both heel tendons (P < 0.01). Safe GH and IGF-I levels were achieved in all but one of the patients who, similarly, had a significant decrease in shoulder, wrist and both heel tendon thicknesses. The thickness reduction of right shoulder cartilage, a non-weight-bearing joint, was significantly greater than that observed at the level of the right and left knee cartilages and heel tendons (37.4 +/- 4.4% vs. 18 +/- 6.1%, 19.3 +/- 4.4%, 16.5 +/- 4.2%, and 13.7 +/- 5.5%, respectively, P < 0.01). No difference was found in thickness decrease of all sites examined between the eight patients achieving safe GH levels after 3-6 months, and the remaining four patients, or between patients with estimated disease duration below (n = 6) or above 10 years (n = 6).

CONCLUSIONS

Improvement in articular and periarticular soft tissue hypertrophy of the shoulder and wrist, two non-weight-bearing joints, but also of the knees, two weight-bearing joints, and heel tendons, was obtained by suppressing GH and IGF-I levels for 12 months with LAN treatment, although complete reversal of joint thickening was not achieved. Since no difference in the response to treatment, in terms of joint size decrease, was found between patients with short or long disease duration, treatment longer than 12 months may be needed to reverse the acromegalic arthropathy completely.

Impaired cardiac performance in elderly patients with growth hormone deficiency

Several evidences indicate that GH and/or insulin-like growth factor I (IGF-I) are involved in the regulation of cardiovascular function. In patients with childhood and adulthood-onset GH deficiency (GHD), the impairment of cardiac performance is manifest primarily as a reduction in the left ventricular (LV) mass (LVM), inadequacy of LV ejection fraction both at rest and at peak exercise, and abnormalities of LV diastolic filling. No study has been reported to date in elderly GHD patients that investigated cardiac function. In particular, it is unknown whether cardiac function is modified in accordance with patients' age as a physiological response to aging, as in normal subjects the rate and extent of LV filling are reduced with age. This study was designed to evaluate heart morphology and function, by echocardiography and equilibrium radionuclide angiography, respectively, in rigorously selected elderly patients with GHD but without evidence of other complications able to affect cardiac performance. Eleven patients with hypopituitarism (6 men and 5 women, aged 60-72 yr) and 11 sex- age- and body mass index-matched healthy subjects entered this study. None of the patients and controls presented with or had previously suffered from other concomitant diseases, such as diabetes mellitus, coronary artery diseases, long-standing hypertension, and hyperthyroidism, which could affect cardiac function. All patients had been previously operated on via the transsphenoidal and/or transcranic route for nonfunctioning pituitary adenoma, meningioma, or craniopharyngioma, and 6 of them had been irradiated. Eight patients had FSH/LH insufficiency, 5 had TSH insufficiency, and 6 had ACTH insufficiency, appropriately replaced. All subjects were tested with the combined arginine plus GHRH test showing a GH response below 9 microg/L. No significant difference was found in plasma IGF-I levels (49.2 +/- 8.5 vs. 71.8 +/- 7.5 microg/L) between patients and controls. However, IGF-I levels were lower than the normal range in 8 patients and 3 controls. Interventricular septum thickness (9.1 +/- 0.2 vs. 9.1 +/- 0.2 mm), LV posterior wall thickness (9.1 +/- 0.2 vs. 9.0 +/- 0.2 mm), and LVM after correction for body surface area (97.6 +/- 1.8 vs. 99.9 +/- 1.5 g/m2) were similar in patients and controls. Similarly, the LV ejection fraction at rest was similar in patients and controls (57.1 +/- 2% vs. 63.2 +/- 2.5%; P = NS), and it was normal (> or = 50%) in all controls and in 10 of 11 patients. By contrast, the LV ejection fraction at peak exercise was markedly depressed in elderly GHD patients compared to age-matched controls (51 +/- 2.5% vs. 73.3 +/- 3%; P < 0.001). A normal response (> or = 5% increase compared to basal value) of LV ejection fraction at peak exercise was found in 8 controls (72.7%) and in 2 of 11 patients (18.2%). No difference was found in the peak rate of LV filling, whether peak filling rate was normalized to end-diastolic volume (2.5 +/- 0.2 vs. 2.6 +/- 0.2 end-diastolic volume/s) or stroke volume (4.3 +/- 0.3 vs. 4.0 +/- 0.3 stroke volume/s), between patients and controls. Finally, exercise duration was significantly shorter in elderly GHD patients than in age-matched controls (7.2 +/- 2.1 vs. 9.1 +/- 0.2 min; P < 0.01). In the patient group, the GH peak after arginine plus GHRH test was significantly correlated with the LV ejection fraction at rest (r = 0.822; P < 0.01), whereas IGF-I was significantly correlated with the peak rate of LV filling whether the peak filling rate was normalized to end-diastolic volume (r = -0.863; P < 0.001) or stroke volume (r = -0.616; P < 0.05) or expressed as the ratio of peak filling rate to peak ejection fraction rate (r = -0.736; P < 0.01). Disease duration was significantly correlated with heart rate at peak exercise (r = 0.614; P < 0.05) and with systolic and diastolic blood pressures both at rest (r = 0.745; P < 0.01 and r = 0.650; P < 0.05) and at peak exercise (r = 0.684; P < 0.05 and r =

Role of somatostatin analogue-based therapy in unresponsive malignant thymomas

Thymomas are rare neoplasms that are usually associated with parathymic syndromes, pure red cell aplasia, myasthenia gravis, hypogammaglobulinaemia and other mainly immunological disorders. Therefore, the management of thymoma patients is often complex and presents many diagnostic and therapeutic issues. Controversies concerning the definition of the histological subtypes and the role played by thymoma-associated syndromes are of primary importance in determining the oncological approach. Although low-stage thymomas have a high percentage of recovery, thymomas which are locally advanced, metastatic or previously treated with standard therapeutic options have no well-defined and effective treatment approaches. The data previously described by us on somatostatin receptor scintigraphy showing high uptake of indium-labelled octreotide by thymic masses and the successful treatment of a patient with thymoma and pure red cell aplasia with octreotide and prednisone has provided us the rationale for using such treatment in patients with advanced thymoma.

Functional imaging of thymic disorders

Human thymomas are rare tumours which usually develop in the chest. The diagnosis via guided biopsy, the evaluation of the extent of the tumour and its boundaries with adjacent organs, the choice of the appropriate therapeutic option, and the assessment of response to treatment are usually made with computed tomography (CT) alone or in combination with magnetic resonance imaging (MRI). More recently, radiopharmaceuticals and nuclear medicine procedures have been used increasingly in the imaging and functional characterization of benign and malignant thymic disorders. Two groups of radiopharmaceuticals have been used. The first includes several oncotropic tracers, such as 201Tl-chloride, 99mTc-sestamibi and 18F-fluorodeoxyglucose, which are significantly concentrated in thymic tumours. Their uptake correlates with tumour grades and cellularity. The second class includes two radioligands: [(111)In-DTPA-D-Phe1]-octreotide (DTPA, diethylenetriamine penta-acetic acid) and [(111)In-DTPA-Arg1]-substance P, which bind to specific receptors. [(111)In-DTPA-Arg1]-substance P binds to its receptors that are largely expressed in the thymus of patients with autoimmune diseases. [(111)In-DTPA-D-Phe1]-octreotide recognizes the somatostatin receptor subtype 2. In patients with active disease investigated in our institution [(111)In-DTPA-D-Phe1]-octreotide has been shown to concentrate in the majority of thymoma deposits. Conversely, it is not concentrated in adult patients with benign lymphofollicular thymic hyperplasia. This finding has had a significant impact on the management of patients with myasthenia gravis as it differentiates early-stage thymoma from benign hyperplasia, unlike CT and MRI, which often fail to distinguish between the two. In addition to its role in diagnostic imaging, somatostatin receptor scintigraphy also enables us to select patients with advanced or metastatic thymoma unresponsive to conventional therapies, who might benefit from a somatostatin analogue-based treatment, serving thus as a link between diagnosis and therapy. In this article, we discuss and analyse the results of functional imaging with different radiopharmaceuticals, primarily those that we have obtained with [(111)In-DTPA-D-Phe1]-octreotide.

A longitudinal study of vasopressin cell antibodies, posterior pituitary function, and magnetic resonance imaging evaluations in subclinical autoimmune central diabetes insipidus

Cytoplasmic autoantibodies to vasopressin-cells (AVPcAb) have been detected not only in patients with overt central diabetes insipidus (CDI), but also in patients with endocrine autoimmune diseases without CDI. This suggests that complete CDI can be preceded by a preclinical stage. Among 878 patients with endocrine autoimmune diseases without CDI, 9 patients found to be AVPcAb positive and 139 AVPcAb-negative controls were enrolled in this open prospective study. They were evaluated for AVPcAb and posterior pituitary function at least yearly for about 4 yr (range, 37-48 months); during this span, magnetic resonance imaging (MRI) of posterior pituitary and stalk was performed only in the AVPcAb-positive patients. Five of the 9 AVPcAb-positive patients had normal posterior pituitary function at study entry. They were AVPcAb positive throughout the follow-up period. At later stages of the study, 3 of them developed partial CDI, and 1 developed complete CDI. The remaining 4 patients showed impaired response to the water deprivation test at study entry and were diagnosed as having partial CDI. Two of them agreed to receive desmopressin replacement for 1 yr. After this treatment, the patients became negative for AVPcAb and displayed normal posterior pituitary function until the end of the follow-up. Conversely, the 2 untreated patients with partial CDI remained AVPcAb positive. One of them developed overt CDI. None of the controls became AVPcAb positive or developed CDI. The normal hyperintense MRI signal of the posterior pituitary, present at study entry, persisted subsequently in all 9 AVPcAb-positive patients, including those developing overt CDI, only disappearing in the late phase of complete CDI. In asymptomatic subjects, the monitoring of AVPcAb, but not MRI, seems to be useful to predict a progression toward partial/overt CDI. Early desmopressin therapy in patients with partial CDI could interrupt or delay the autoimmune damage and the progression toward clinically overt CDI.

Prevalence of coeliac disease in patients with thyroid autoimmunity

The occurrence of autoimmune thyroid disorders among patients with coeliac disease (CD) is well documented, but the exact prevalence of CD among patients with autoimmune thyroid diseases (ATD) is as yet unclear. We screened 150 newly diagnosed patients with ATD by serum endomysial antibody detection (EmA). In 5 subjects (3.3%) EmA positivity was found; all underwent jejunal biopsy. On gluten-free diet an excellent clinical and histological response was recorded with an improvement of hypothyroidism and reduction of the thyroxine dosage. Our data suggest a significant high prevalence (3.3%) of CD in patients with ATD, in particular with Hashimoto's thyroiditis.

Dysregulation of adrenal 11 beta-hydroxylase activity in hypertensive subjects: usefulness of the ACTH 1-17 stimulation test

BACKGROUND AND AIM

The aim of this study was to determine the validity of our previous hypothesis of adrenal 11 beta-hydroxylase (11-OH) dysregulation in "essential" low-renin hypertension.

METHODS AND RESULTS

A comparison was made between 30 hypertensive patients and 30 age-matched controls (NC) in basal conditions and after ACTH stimulation (ACTH 1-17) test. The 11-deoxycortisol (S) and deoxycorticosterone (DOC) integrated areas under the curve (AUCs) of stimulus were significantly higher in the hypertensives (p < 0.001) and pointed to adrenal 11-OH dysregulation.

CONCLUSIONS

The ACTH 1-17 test detects impairment of 11-OH activity of probable genetic origin. The relative mineralocorticoid excess thus provoked could be an additional cause of "essential" low-renin hypertension.

Persistence of increased cardiovascular risk in patients with Cushing's disease after five years of successful cure

Patients with Cushing's disease (CD) mainly die because of cardiovascular accidents. The aim of this study was to evaluate whether patients with CD still have increased cardiovascular risk and suffer from premature atherosclerosis once cured. Fifteen patients cured from CD for a long term period (5 yr), 30 sex-and age-matched controls, and 30 body mass index (BMI)-matched controls were included in this study. BMI; waist to hip ratio (WHR); systolic (SBP) and diastolic (DBP) blood pressures; serum total, low density lipoprotein (LDL), and high density lipoprotein (HDL) cholesterol; serum triglycerides, fibrinogen, and lipoprotein(a) levels; prothrombin time; activated partial thromboplastine time; and basal and glucose load-stimulated insulin and glucose levels were measured in patients and controls. By echo-Doppler ultrasonography, the intima media thickness (IMT), systolic and diastolic media-media distances, blood systolic (SPV) and diastolic (DPV) peak velocity, systolic (SLD) and diastolic (DLD) lumen diameter, and distensibility coefficient (DC) were measured at both common carotid arteries where the presence, size, and location of atherosclerotic plaques were also evaluated. Compared with a sex- and age-matched control population, CD patients had BMI (P < 0.001), WHR (P < 0.001), SBP (P < 0.005), DBP (P < 0.05), fasting glucose (P < 0.001) and insulin (P < 0.05), glucose load-stimulated glucose and insulin levels (P < 0.05), total cholesterol (P < 0.05), LDL cholesterol (P < 0.01), fibrinogen (P < 0.01), and lipoprotein(a) (P < 0.05) levels higher and HDL cholesterol levels (P < 0.05) lower than controls. At ultrasonography, in the patients, IMT (P < 0.05), SPV (P < 0.05) and DPV (P < 0.001) were significantly increased whereas SLD (P < 0.001), DLD (P < 0.001), and DC (P < 0.05) were significantly decreased compared to controls. In addition, CD patients had higher WHR (P < 0.05), DBP (P < 0.05), glucose load-stimulated glucose and insulin levels (P < 0.05), and fibrinogen levels (P < 0.01) and lower HDL cholesterol (P < 0.05) levels than BMI-matched controls. At ultrasonography, increased common carotid arteries IMT (P < 0.05) and DPV (P < 0.05) and decreased DLD (P < 0.05) and DC (P < 0.05) were measured in patients compared to those in BMI-matched controls. Atherosclerotic plaques were found in 26.7% of patients, in none of the sex- and age-matched controls, and in 3.3% of the BMI-matched controls. In CD patients, a significant correlation was found between both WHR and fasting serum insulin levels and DBP (r = 0.52 and r = 0.55; P < 0.05), triglycerides levels (r = 0.56 and r = 0.77; P < 0.05), and IMT (r = 0.64 and r = 0.56; P < 0.05). Right (r = -0.70; P < 0.005) and left (r = -0.65; P < 0.01) DC were inversely correlated to the duration of CD in the patient group. At the multiple regression analysis, WHR was the best predictor of fasting insulin levels (beta = 0.77; P < 0.05), and vice versa, fasting insulin level was the best predictor of WHR (beta = 1.20; P < 0.05). In conclusion, patients cured from CD for a long term period have a high prevalence of atherosclerosis and maintain increased several cardiovascular risk factors of the active disease, probably due to a residual abdominal obesity and/or insulin resistance syndrome.

Inhibition of T cell apoptosis by IFN-beta rapidly reverses nuclear translocation of protein kinase C-delta

Type I interferons rescue activated human T cells from cytokine deprivation-induced apoptosis. Our data now show that IFN-beta also rapidly inhibits apoptotic signals induced through the Fas receptor (CD95) in human T cells. To identify upstream signaling elements that could be targets of IFN-beta, we have studied protein kinase C (PKC). PKC-delta is actively involved in the regulation of apoptosis and immunofluorescence staining revealed that early in apoptosis PKC-delta accumulated in the nucleus. Addition of IFN-beta to T cells already deprived of survival factors or treated with anti-Fas antibody caused a rapid retranslocation of PKC-delta away from the nucleus. Furthermore, the generation of a constitutively active catalytic fragment by cleavage of PKC-delta by caspase 3 occurred only after translocation of full-length PKC-delta to the nucleus. IFN-beta also inhibited caspase 3 and the proteolytic activation of PKC-delta. We conclude from these studies that nuclear translocation of PKC-delta is an early event in T cell apoptosis and that IFN-beta rapidly reverses this process.

Comparison of six months therapy with octreotide versus lanreotide in acromegalic patients: a retrospective study

OBJECTIVE

We analysed the effects of 6-months' treatment with octreotide s.c. and lanreotide-SR on circulating GH and IGF-I levels in acromegaly.

DESIGN

Open retrospective study.

PATIENTS

Thirty-eight patients with active acromegaly (plasma IGF-I levels greater than 2 standard deviations for age-matched controls and increased serum GH levels not suppressible by oral glucose load) were studied. All patients received s.c. octreotide at a dose of 150-600 microg/day for six months as first therapy and subsequently, lanreotide i.m., 30-60 mg either at 14 or 10 day intervals, for 6 months. A 3 months' washout was applied before starting lanreotide treatment.

MEASUREMENTS

Mean serum GH levels (from three samples), IGF-I, and clinical examination were performed before and 30, 60, 90 and 180 days after octreotide and lanreotide treatments. Safety tests, HbA1c and, thyroid function were evaluated every three months.

RESULTS

Circulating GH and IGF-I levels were significantly reduced (P < 0.001) after one, three and six months of both octreotide and lanreotide treatment. The absolute values were lower and the percent decrease in serum GH levels obtained after octreotide treatment was significantly greater, at all scheduled assessments, than after lanreotide (P < 0.01). Serum IGF-I levels during octreotide were significantly lower only after the first month of therapy (P < 0.01).

CONCLUSIONS

Our study shows that octreotide s.c. is able to induce an earlier reduction in IGF-I levels and a more marked reduction in GH levels than lanreotide. However, after six months of therapy the number of patients with safe GH levels and normal IGF-I age-matched levels, was similar with both drugs. Therefore we suggest that octreotide treatment be preferentially used in the short-term presurgical treatment, while lanreotide can be used in chronic therapy when better compliance is necessary.

Lack of T cell proliferation without induction of nonresponsiveness after antigen presentation by endothelial cells

BACKGROUND

After priming or reactivation in lymph nodes, T cells recirculate to sites of inflammation, and enter tissues by migrating across activated endothelium. Given that activated endothelial and tissue parenchymal cells express both class I and class II MHC molecules, it is probable that transmigrating T cells encounter cognate antigen on endothelial cells, and on tissue parenchymal cells once they have entered the tissue.

METHODS

In this study the consequences of antigen presentation by endothelial and epithelial cells to human CD4+ T cell clones were analyzed and compared by a two-step culture system.

RESULTS

T cell clones that required B7-mediated costimulation to be activated were found not to be able to proliferate to antigen presented by either endothelial or epithelial cells, unless trans-costimulation was provided by the addition of B7-transfected cells in the cultures. Furthermore, antigen presentation by epithelial cells induced nonresponsiveness in the T cell clones. In contrast, after cognate recognition on endothelial cells, the ability of the T cell clones to proliferate to a subsequent rechallenge with antigen presented on a specialized APC was unaffected.

CONCLUSIONS

These data suggest that endothelial cells have unique properties as antigen-presenting cells, in that they do not influence the subsequent reactivity of cognate T cells.

Effect of a short-term treatment with alendronate on bone density and bone markers in patients with central diabetes insipidus

The aim of this open prospective randomized study was to evaluate the effect of a 6-month treatment with alendronate on the bone mineral density (BMD) at lumbar spine in patients with central diabetes insipidus. Eighteen patients with central diabetes insipidus and 18 sex- and age-matched healthy subjects entered this study. At study entry, all subjects underwent BMD assessment at the lumbar spine and measurement of serum osteocalcin (OC) and cross-linked N-telopeptides of type I collagen (Ntx). Thereafter, 9 of the 18 patients were randomized to receive treatment with alendronate at a dose of 10 mg, orally, once daily for 6 months (group 1), whereas the remaining 9 patients did not receive any treatment affecting bone status during this period (group 2). After 6 months, bone metabolism and bone density study were repeated in all patients. At baseline, lumbar BMD values (0.86+/-0.03 vs. 1.01+/-0.02 g/cm2; P<0.001) and serum OC levels (4.7+/-0.3 vs. 7.9+/-0.2 microg/L; P<0.001) were significantly lower, whereas urinary Ntx levels were significantly higher [72.0+/-1.9 vs. 64.6+/-1.7 nmol bone collagen equivalents (BCE)/nmol creatinine (Cr); P<0.01] in patients than in controls. After randomization, no difference in lumbar BMD, serum OC, or urinary Ntx was found between patients of group 1 and group 2. At the 6 month follow-up, no difference in serum OC levels was found compared to baseline evaluation in patients of both group 1 and group 2. By contrast, a significant decrease in urinary Ntx levels was found in patients of group 1 (70.3+/-3.0 vs. 75.4+/-2.1 nmol BCE/nmol Cr; P<0.05), but not in patients of group 2 (68.8+/-3.3 vs. 68.5+/-3.0 nmol BCE/nmol Cr; P = NS). A significant increase in lumbar BMD values was found in patients of group 1 (0.88+/-0.04 vs. 0.83+/-0.04 g/cm2; P<0.05), whereas a significant decrease in lumbar BMD values was found in patients of group 2 (0.86+/-0.05 vs. 0.89+/-0.05 g/cm2; P<0.05). Lumbar BMD increased 7.0+/-1.5% in patients of group 1 and decreased 4.2+/-1.8% in patients of group 2 (P<0.001). In conclusion, this study demonstrated that a 6-month treatment with alendronate in patients with central diabetes insipidus was effective in significantly improving BMD at the lumbar spine, which was significantly worsened in untreated patients. Therefore, alendronate treatment could be used in patients with central diabetes insipidus with documented osteopenia or osteoporosis.