Clinical and cytofunctional classification of pituitary adenomas: proposal of a new classification

Recent methodological advances in immunohistochemistry, ultrastructural techniques, hormonal assays, resolution imaging and molecular biology techniques have provided new insights into the pathology, function and cytogenesis of pituitary adenomas. Pituitary adenomas have been classified historically on the basis of tinctorial affinities, followed by the basis of ultrastructure and immunohistochemistry. The current development of technologies necessitate the new classification of pituitary adenomas which integrates these numerous parameters as well as the clinical manifestations. For this purpose, we suggest a new clinico-cytofunctional classification of pituitary adenomas, which is based on these clinical manifestations and integrates the information on biology, imaging function and ultrastructure. This classification which corresponds to current advances will not only provide pertinent clinical data but facilitate better understanding of the biology and nature of these complexed lesions.

A case of pituitary somatotroph adenoma with concomitant secretion of growth hormone, prolactin, and adrenocorticotropic hormone--an adenoma derived from primordial stem cell, studied by immunohistochemistry, in situ hybridization, and cell culture

Somatotroph adenomas often secrete prolactin (PRL) besides growth hormone (GH) and are sometimes immunostained for other anterior pituitary hormones or their subunits, such as thyroid-stimulating hormone (TSH) beta-subunit and glycoprotein hormone alpha-subunit (alpha SU). However, somatotroph adenomas showing hypersecretion of adrenocorticotropic hormone (ACTH) are extremely rare. There have been, to our knowledge, only five published reports on somatotroph adenomas accompanied by excessive ACTH secretion. Here we report a case of intracavernously invading somatotroph macro-adenoma with high serum GH, PRL, and ACTH levels. We examined the case using immunohistochemistry (IHC), in situ hybridization (ISH), and cell culture, and confirmed GH, PRL, and ACTH, as well as alpha SU, production, and the expression of Pit-1 protein by the adenoma, which is known as a transcriptional factor for GH, PRL, and TSH, not for ACTH. Therefore, the presence of unknown transcriptional factor other than Pit-1, common to GH, PRL, and ACTH, may be speculated to be expressed in this adenoma. In our previous study, we had found plurihormonal mRNA expression, especially for ACTH, the beta-subunit of follicle-stimulating hormone and luteinizing hormone in some somatotroph adenomas, using non-radio-isotopic ISH, and suggested that these adenomas might be derived from plurihormonal primordial stem cells. Our present case is significant from the viewpoint of histogenesis of pituitary adenomas, because it further supports the cell origin of somatotroph adenomas from plurihormonal primordial stem cells, and moreover it suggests the presence of unknown transcriptional factor other than Pit-1, common to GH, PRL, and ACTH.

Application of catalyzed signal amplification in immunodetection of gonadotropin subunits in clinically nonfunctioning pituitary adenomas

Pituitary adenomas that are characterized by the absence of a particular clinical syndrome and the absence of excessive hormone secretion have been classified as nonfunctioning adenomas. Recent development of immunohistochemical analysis and hormonal assay have suggested that many of these tumors have function to secret the gonadotropin subunits. A novel procedure biotin amplification in immunohistochemistry, catalyzed signal amplification (CSA) has been reported recently. In this study, the authors applied this new method to tissues from 50 cases of clinically nonfunctioning adenomas. These cases had no evidence of endocrinological signs by hormone secretion. When the CSA system was applied in normal pituitary gland, each of subunits was positive even when the antibody was diluted 1:1,000,000, which is 1,000 folds of standard indirect immunoperoxidase method. Immunohistochemical staining by indirect immunohistochemical method revealed that all 50 adenomas were negative for all the anterior hormones, including growth hormone (GH), prolactin (PRL), adrenocorticotropic hormone (ACTH), beta-subunit of luteinizing hormone (LH beta), follicle-stimulating hormone (FSH beta), thyroid stimulating hormone (TSH beta), and a-subunit of glycoprotein (alpha SU). Using avidin-biotin complex (ABC) method, two cases were positive for FSH beta and four cases were positive for alpha SU, respectively, and the immunopositivities were observed weakly in scattered cells. By CSA system, 26 cases of 50 nonfunctioning adenoma were positive for FSH beta, 16 cases were positive for LH beta, and 29 cases were positive for alpha SU, respectively. The immunoreactivities were clearly observed in cytoplasm of many adenoma cells. This amplification procedure provides a means of greatly increasing the sensitivity of the immunohistochemistry including subunits of glycoproteins that are difficult to detect by previous indirect immunoperoxidase method or ABC method. This amplification procedure provides a great increase in the sensitivity of the immunohistochemistry for the detection of gonadotropin subunits and suggest that significant proportion of the nonfunctioning adenomas are gonadotropin subunit producing adenomas.

Expression of Pit-1 and estrogen receptor messenger RNA in prolactin-producing pituitary adenomas

The pituitary-specific transcriptional factor, Pit-1, is a member of the POU-domain family, which has a role in the development and differentiation of three pituitary cell types: somatotrophs, lactotrophs, and thyrotrophs. Recently, specific DNA-dependent interactions have been observed between Pit-1 and nuclear receptors, including: thyroid hormone receptor; retinoic acid receptor; glucocorticoid receptor; and estrogen receptor (ER). The cooperative interaction between Pit-1 and ER required for prolactin enhancer activity in rat pituitaries has been suggested. We analyzed the expression of Pit-1 messenger ribonucleic acid (mRNA) and ER mRNA in 15 human prolactin-producing adenomas using nonradioisotopic in situ hybridization. Their products were also studied by immunohistochemical analysis. Pit-1 mRNA was detected in 12 (80%) of 15 prolactin-producing adenomas. On the other hand, ER mRNA was detected in 14 (94%) of adenomas studied. mRNAs of Pit-1 and ER were detected more frequently than immunohistochemical expression of their products. By combined in situ hybridization and immunohistochemical examination, Pit-1 mRNA and ER mRNA were often colocalized with prolactin immunoreactivities. The colocalizations of Pit-1 mRNA and ER protein were observed in adenoma cells. The high incidence of the expression of ER mRNA in prolactin-producing adenomas may suggest cooperative interactions between Pit-1 and ER in functional differentiation and development of prolactin-producing adenomas.

Cyclic Cushing's disease in long-term remission with a daily low dose of bromocriptine

A 56-year-old male patient with cyclic Cushing's disease remained in a state of remission for more than one year with a relatively low dose of bromocriptine (2.5-3.75 mg/day). It has been reported that bromocriptine treatment for cyclic Cushing's disease induces only a transient remission; in the most effective cases, a relatively high dose (40 mg/day) was necessary. In the hypercortisolemic state, plasma adrenocorticotropic hormone (ACTH) and serum cortisol were not suppressed by dexamethasone and did not respond to corticotropin-releasing factor (CRF). An antehypophysectomy was not effective, even though the resected tissue contained ACTH-positive microadenomas. The present observations thus indicate the effectiveness of bromocriptine for some patients with this rare disorder.

In situ hybridization analysis of Pit-1 mRNA and hormonal production in human pituitary adenomas

The pituitary-specific transcriptional factor, Pit-1, is a member of the POU-domain family which has a role in the development and differentiation of three pituitary cell types: somatotrophs, lactotrophs, and thyrotrophs. Recent investigations have suggested the involvement of specific regulation of Pit-1 transcripts in human pituitary adenomas. In this study, we analyzed the expression of Pit-1 gene and Pit-1 product in various human pituitary adenomas using in situ hybridization (ISH) and immunohistochemistry (IHC). Northern hybridization analysis revealed 2.4- and 4.1-kb Pit-1 transcripts in normal pituitary, growth hormone (GH)-, prolactin (PRL)- and thyrotropin (TSH)-secreting adenomas. By ISH analysis, Pit-1 mRNA was detected in 42 (84%) of 50 adenomas. The highest incidence was observed in 15 GH-secreting adenomas and 8 TSH-secreting adenomas, in which Pit-1 mRNA was detected in all cases. Pit-1 mRNA expression was detected in 11 (85%) of 13 PRL-secreting adenomas. In 12 clinically non-functioning adenomas, Pit-1 mRNA was also present in 8 cases, and 5 of these were associated with immunohistochemical expression of Pit-1 product. By combined ISH and IHC, Pit-1 mRNA was often colocalized with GH, PRL or TSH beta immunoreactivities and sometimes colocalized with alpha-subunit of glycoprotein (alpha SU) immunoreactivity. The expression of Pit-1 mRNA in various cell types of human pituitary adenomas in addition to GH, TSH beta and PRL immunoreactivities suggests that Pit-1 may play a role in functional development of pituitary adenomas, including clinically non-functioning adenomas. However, some additional transcriptional factors or enhancers may be required.

Expression of human Pit-1 product in the human pituitary and pituitary adenomas. Immunohistochemical studies using an antibody against synthetic human Pit-1 product

OBJECTIVE

Pit-1, a member of a family of the POU-domain DNA binding factors, has been known as a pituitary-specific transcriptional factor that regulates functional differentiation toward somatotrophs, lactotrophs, and thyrotrophs in the rodent pituitary gland. The aim of this study is to elucidate the role of human Pit-1 (hPit-1) protein in the differentiation of human pituitary adenomas, using immunohistochemistry.

DESIGN

Anti-human Pit-1 polyclonal antibody against synthetic peptide was applied to perform the avidin-biotinperoxidase complex method on paraffin sections of 75 surgically obtained pituitary adenomas and 12 nontumorous human pituitaries obtained at autopsy.

RESULTS

In normal human pituitary glands, many cells were positive for hPit-1 product in the nuclei of somatotrophs, lactotrophs, and somatomammotrophs. Among 75 pituitary adenomas, hPit-1 product was expressed in 55 adenomas (73.3%). All (100%) of the growth hormone-positive and thyrotroph cell adenomas were positive for hPit-1 product. Unexpectedly, expression of hPit-1 was found in a limited number of adrenocorticotropic hormone-producing adenomas and clinically nonfunctioning adenomas, including gonadotroph cell adenomas, although localization was found only in occasional cells.

CONCLUSIONS

The invariable expression of hPit-1 protein in growth hormone-positive adenomas and thyroid-stimulating hormone-positive adenomas may suggest the role of Pit-1 protein in specific differentiation of the adenoma cells. The expression of hPit-1 in various other types of adenomas may indicate the involvement of other unidentified transcription factors or specific mediators that have roles in these differentiations. Our observation may provide some insight into the origin of cell types of some clinically nonfunctional adenomas.

Acromegaly, diabetes insipidus, and visual loss caused by metastatic growth hormone-releasing hormone-producing malignant pancreatic endocrine tumor in the pituitary gland. Case report

The case of a 52-year-old woman with acromegaly, diabetes insipidus, and visual impairment caused by a metastatic growth hormone-releasing hormone (GRH)-produced pancreatic tumor is reported. Serum growth hormone (GH) and somatomedin C levels were elevated to 14 ng/ml (normal < 5 ng/ml), and 3.20 U/ml (normal < 1.88 U/ml), respectively. Paradoxical increases were observed in GH levels after glucose tolerance and thyrotropin-releasing hormone-stimulation tests. Biopsy of a pituitary tumor observed on computerized tomography scans and magnetic resonance studies revealed a metastatic cancer. When circulating GRH levels were measured, a marked increase in plasma GRH (1145 pg/ml; normal < 4-1 pg/ml) was observed. The patient died of cachexia due to metastases. Postmortem examination revealed that a primary tumor, a malignant endocrine lesion, was present in the pancreas, with metastatic tumors in the pituitary, lung, liver, and adrenal glands. Synthesis and production of GRH by the tumor was demonstrated by Northern blotting and immunohistochemical analysis. The pituitary gland showed hyperplastic, but not adenomatous changes. The authors stress the importance of both exploration for an ectopic source of GRH and the search for a GH-producing pituitary adenoma when unusual signs and symptoms are seen in patients with acromegaly.

GH and PRL gene expression by nonradioisotopic in situ hybridization in TSH-secreting pituitary adenomas

TSH-secreting pituitary adenomas are rare. The transcriptional expression (messenger ribonucleic acids: mRNAs) of TSH beta, GH, and PRL in five patients with TSH-secreting pituitary adenoma was studied by the in situ hybridization (ISH) method in order to elucidate their multiple hormone production. These patients showed inappropriately elevated serum TSH and alpha-subunit levels as well as pituitary mass lesions. The tissues from pituitary adenomas were obtained at the time of transsphenoidal surgery and revealed immunohistochemically the expression of alpha-subunit and TSH beta in all patients. Four adenomas were immunohistochemically associated with GH or PRL localization. The presence of pituitary-specific transcriptional factor Pit-1 was demonstrated in all adenomas in the nuclei of many cells. By ISH, signals for TSH beta mRNA were present in all five cases in many adenoma cells. Expression of GH mRNA and PRL mRNA were detected not only in four adenomas in which both hormonal products were immunolocalized but also in one adenoma that was immunohistochemically negative for GH and PRL. Combined staining by ISH and immunohistochemistry revealed the expression of GH mRNA and PRL mRNA in TSH beta-immunoreactive cells. Our findings indicate that TSH-secreting adenomas are multihormone-producing and could arise from precursor or stem cells rather than from differentiated TSH-secreting cells. It is suggested that ISH combined with immunohistochemistry may provide additional detailed information concerning the multidirectional histogenesis of this rare type of adenoma.

Immunohistochemical characterization of "hyperplasia-adenoma sequence" in the pituitaries of transgenic mice expressing a human growth hormone-releasing factor gene

The morphology of hyperplastic pituitaries in seven human growth hormone-releasing factor (hGRF) transgenic mice were compared to those of two normal control mice. Under continuous stimulation by hGRF, both the total volume of the pituitary and the size of individual cells increased, and a nodular lesion, designated a "hypertrophic nodule", was identified. Immunohistochemically, the hyperplastic pituitaries consisted of various numbers of cells immunoreactive for rGH, rPRL, hACTH, rLH beta, hFSH beta, and r alpha SU, whereas the "hypertrophic nodule" was composed of rGH, rPRL, and rTSH beta positive cells, similar to the adenoma. The presence of the "hypertrophic nodule", which was intermediate in appearance between the controls and the adenomas, suggests a close relation between continuous hGRF stimulation and the development of a hyperplasia-adenoma sequence in the pituitary.

Changes in the ultrastructural distribution of prolactin and growth hormone mRNAs in pituitary cells of female rats after estrogen and bromocriptine treatment, studied using in situ hybridization with biotinylated oligonucleotide probes

The expression and distribution of prolactin (PRL) mRNA and their alterations induced by estrogen and bromocriptine were investigated using non-radioisotopic in situ hybridization (ISH) at the electron microscopic (EM) level. Our EM-ISH studies using biotinylated oligonucleotide probes showed that estrogen induced whirling changes of the rough endoplasmic reticulum (RER) of female rat PRL cells and increased transcription of PRL genes located on the polysomes of the whirling RER. The presence of mammosomatotroph cells in the rat pituitary gland was also verified in our EM-ISH studies. After bromocriptine administration, PRL cells contained many secretory granules due to the inhibition of secretion. Pre- and post-embedding EM-ISH and northern hybridization studies revealed that bromocriptine induced the distorted, vesiculated, and dilated RER, and also the suppressed PRL mRNA expression. The activity of protein kinase C (PKC), which mediates PRL gene expression, tended to be elevated by estrogen and suppressed by bromocriptine. Therefore, it is considered that the ultrastructural and quantitative changes in PRL mRNA expression evoked by estrogen and bromocriptine may be mediated by the intracellular signal transduction system, including PKC.

Lymphocytic hypophysitis: case report

We report a rare case of lymphocytic hypophysitis in a 52-year-old man who presented with a combination of hypopituitarism and diabetes insipidus. Magnetic resonance imaging with a contrast medium revealed an expanding sellar mass and thickening of the pituitary stalk with homogeneous enhancement. These findings may be useful in differentiating lymphocytic hypophysitis from pituitary adenoma. The unique clinical and radiological features of this case are discussed.

Expression of plurihormonal mRNAs in somatotrophic adenomas detected using a nonisotopic in situ hybridization method: comparison with lactotrophic adenomas

We used a nonisotopic in situ hybridization (ISH) method to investigate the expression of pituitary hormone, including glycoprotein hormone mRNAs in 17 somatotrophic and four lactotrophic adenomas. Our ISH studies of lactotrophic adenomas showed that their hormonal gene expression was confined to prolactin, whereas those of somatotrophic adenomas showed that some of them expressed plurihormonal genes. In some somatotrophic adenomas that were immunohistochemically negative for pituitary hormones, positive reactions, mainly for adrenocorticotropic hormone (ACTH), follicle-stimulating hormone beta subunit (FSH beta), and luteinizing hormone beta subunit (LH beta) mRNAs, were observed in our ISH studies. These results suggest that some somatotrophic adenomas may originate from plurihormonal primordial stem cells, which we have presumed serve as precursors for various hormone-expressing cells. It is unclear why some somatotrophic adenomas derived from plurihormonal primordial stem cells manifest clinically only as the acromegalic hyperfunction syndrome or gigantism. Additional translational factors or some other somatic mutations may play important roles in the clinical manifestations of such adenomas. In conclusion, some somatotrophic adenomas appear to be derived from plurihormonal primordial stem cells, whereas lactotrophic adenomas are well differentiated tumors that originate from lactotrophic cells, which represent the final stage of acidophilic cell line differentiation.

Clinical and immunohistochemical studies on TSH-secreting pituitary adenoma: its multihormonality and expression of Pit-1

Eight patients with thyrotropin (TSH)-secreting pituitary adenoma are described. Serum TSH levels were inappropriately elevated in spite of elevated thyroid hormones. The serum-free glycoprotein alpha-subunit level was elevated in all the patients. The alpha-subunit to TSH molar ratio, a "tumor marker" for TSH-secreting adenoma, ranged from 1.06 to 6.16. All patients had macroadenoma and underwent transsphenoidal surgery. Light-microscopic indirect immunoperoxidase method applied on formalin-fixed paraffin-embedded specimens revealed alpha-subunit and TSH beta immunoreactivity in all adenomas. The proportion of TSH beta-positive cells ranged from 20% to 75% of adenoma cells. Six adenomas (75%) were associated with growth hormone (GH) and/or prolactine (PRL) immunoreactivity. By the double staining method, TSH beta and the alpha-subunit were frequently colocalized in the same cells, but some cells were found to contain either alpha-subunit or TSH beta. We also analyzed the localization of a pituitary-specific transcriptional factor, Pit-1, which has been suggested to play a role in functional differentiation toward growth hormone, prolactine, and TSH. All cases were positive for Pit-1 product using antibody against human Pit-1 synthesized peptide. Pit-1 product was localized in the nuclei of many adenoma cells and was frequently identified in cells that were positive for both TSH beta and growth hormone or prolactine. From our investigations, the role of Pit-1 in multidirectional differentiation during the development of TSH-secreting adenoma was suggested.

Gigantism in sibling unrelated to multiple endocrine neoplasia: case report

The cases of gigantism sisters with somatotroph adenomas unrelated to multiple endocrine neoplasia (MEN) Type 1 are reported. The sisters grew rapidly since they were 5 or 6 years old and were diagnosed to have gigantism with pituitary adenoma by computed tomographic scan and magnetic resonance imaging. A serum endocrinological examination showed the elevated growth hormone values. After thyroxine-releasing hormone stimulation, growth hormone values exhibited a paradoxical rise. They were supposed to be unrelated to MEN Type 1, because analysis of the 11th chromosomes and the other endocrine functions were normal. They were operated on by the transphenoidal method. Immunohistochemical staining of both tumor specimens confirmed somatotroph adenomas. Pituitary adenoma associated with MEN Type 1 is a well-recognized entity. However, the sporadic occurrence of pituitary adenoma unrelated to MEN Type 1, especially in siblings, is extremely rare. Fifteen cases of pituitary adenomas in siblings were described in the literature. As for gigantism, only two brothers were reported. Our case of gigantism sisters is the second sporadic case. In our review of the isolated cases of pituitary adenoma in siblings described in the literature, 12 (70%) of 17 cases including ours are acromegaly or gigantism. This incidence is much higher than that of MEN Type 1 patients with pituitary adenomas. The cause of the familial occurrence of pituitary adenomas is still unclear, although autosomal recessive inheritance has been suggested. It has been stated that point mutations in codon 201 or 227 of the Gs alpha gene located in chromosome 20 were found in about 35 to 40% of somatotroph adenomas.(ABSTRACT TRUNCATED AT 250 WORDS)

Incidental pituitary lesions in 1,000 unselected autopsy specimens

PURPOSE

To elucidate the frequency of false-positive results in imaging diagnoses of a functioning pituitary microadenoma, the authors studied various kinds of incidental lesions greater than 2 mm in diameter from a larger series of pituitary glands.

MATERIALS AND METHODS

One thousand pituitary glands were studied in a nonselected autopsy series. Most causes of death were acute diseases or accidents. Each gland was fixed in 10% formalin and was then cut horizontally into three or four pieces, which were prepared for usual light microscopy.

RESULTS

Of 178 glands found to have incidental lesions, 61 (34%) lesions were larger than 2 mm. Included were adenomas and hyperplasias (n = 20), Rathke cysts (n = 37), infarctions (n = 2), and hemorrhages (n = 2). Seventeen (74%) of 23 laterally localized lesions were adenomas, and 33 (87%) of 38 medially situated lesions were Rathke cleft cysts. These lesions were found in 5.8%-8.3% of subjects in every generation aged 30 years or older.

CONCLUSION

Incidental lesions should be considered a cause of false-positive findings (6.1%) when an imaging diagnosis is made of a functioning pituitary microadenoma.

Prepubescent pituitary null cell macroadenoma with silent macroscopic apoplexy: case report

Secreting pituitary adenomas have marked prevalence in pediatric adenomas. We described a case of an 11-year-old boy with pituitary null cell macroadenoma with silent macroscopic pituitary apoplexy. The patient was admitted with bitemporal hemianopsia and a gradual deterioration of visual acuity. An endocrinological study revealed a low concentration of testosterone and in the plasma a decreased response of luteinizing hormone and follicle-stimulating hormone to luteinizing hormone-releasing hormone. This patient may be the first case of prepubescent null cell macroadenoma confirmed with immunohistochemical study in addition to the findings of classical histopathology.

[A case of diffuse idiopathic skeletal hyperostosis (DISH) causing dysphagia]

A case of diffuse idiopathic skeletal hyperostosis causing dysphasia was reported. A 62 year-old man was admitted to our hospital complaining of nuchal pain and dysphagia. Roentgenograms of the cervical spine demonstrated a "flowing" ossification anterior to three contiguous vertebral bodies, C 4-6. Esophagraphic examination demonstrated esophageal compression caused by the enormous ossification. Roentgenograms of the thoracic and lumbar spine revealed an anterior bony bridge and prediscal ossicles at multiple levels of the vertebral column. These radiographic features were characteristic of DISH. The authors discussed the symptomatology, differential diagnosis and treatment of DISH mainly involving the cervical region, and emphasized the importance of being able to recognize this unfamiliar disorder in the neurosurgical clinic.

[Immunohistochemical and clinicoendocrinological studies of gonadotropin producing pituitary adenomas]

In order to study the secretion of gonadotropins in clinically non-functioning pituitary adenomas, 83 cases were investigated by immunohistochemistry. Expression of one or more of gonadotropin subunits (alpha-subunit, follicle-stimulating hormone (FSH) beta, luteinizing hormone (LH) beta) was found in 38 (45.8%) of all adenomas studied. alpha subunit and FSH beta were positive in 28 (33.7%) and 27 (32.5%) cases respectively, whereas LH beta was detected in seven (8.4%) adenomas. The presence of both alpha subunit and FSH beta was found in 17 cases, while alpha subunit was singly positive in 11 cases and FSH beta, in 10 cases. LH beta was not detected alone, but was always accompanied by alpha subunit or FSH beta. By the double staining method, alpha subunit and FSH beta were not always colocalized in the same cells. Some cells were found to contain both alpha subunit and FSH beta, but others contained either alpha subunit or FSH beta. Clinical characteristics of gonadotropin positive adenomas (38 cases) were studied in comparison with null cell adenomas (37 cases), which were negative for all anterior pituitary hormones. The former (male 27, female 11) ranged in age from 21-74 years old (mean, 46.5 yr.), and the latter (male 16, female 21) from 28-68 yr (mean, 49.5 yr.). Gonadotropin positive adenomas tended to occur in middle-aged men. All 38 adenomas were macroadenomas, and 29 patients complained of visual failure. Clinical symptoms accompanied by hypersecretion of FSH was infrequent. Hypogonadism (amenorrhea, galactorrhea, loss of libido) were observed in 8 (9.6%) cases.(ABSTRACT TRUNCATED AT 250 WORDS)