Results of treatment of pituitary disease in multiple endocrine neoplasia, type I

OBJECTIVE

The aim of the present study was to examine the clinical and pathological features of pituitary disease in patients with multiple endocrine neoplasia, Type I (MEN I) and to assess the prognosis.

METHODS

Fifty-two patients with pituitary disease and MEN I were studied retrospectively. Medical records were reviewed, and all of the patients known to be alive were sent a questionnaire to ascertain current disease status.

RESULTS

In 12 patients, pituitary disease was the initial manifestation of MEN I. The most common lesion was prolactinoma, followed, in frequency, by acromegaly and nonsecretory adenoma. Thirty-four of the patients had surgical treatment at the Mayo Clinic, Rochester, MN, as primary treatment, 3 had radiotherapy, and 12 received no specific therapy. Twelve patients had adjunctive radiotherapy postoperatively. Of the 34 patients receiving surgical treatment, 33 had adenoma and 1 had adenoma and pituitary hyperplasia. Immunocytochemical examination demonstrated that many tumors showed reactivity for more than one pituitary hormone. On survival analysis, no excess pituitary-related mortality was found, either in the surgically treated group or in the group as a whole.

CONCLUSION

On the basis of this study, we conclude that pituitary disease is frequently the initial manifestation of MEN I; that adenomas, particularly prolactinomas, are the rule and hyperplasia is rare; that a significant proportion of tumors are plurihormonal; and that excess pituitary-related mortality is not a factor in patients with MEN I.

Hyperthyroidism caused by an ectopic TSH-secreting pituitary tumor

A woman developed what appeared to be typical Graves' disease in 1965 at the age of 45 years. After 9 years of antithyroid drug therapy, she was treated with radioiodine. Ten years later (1985) she developed postablative hypothyroidism. Despite replacement doses of thyroxine that resulted in thyroid hormone levels that were in the hyperthyroid range, TSH levels remained elevated. Initial biochemical studies, including a high alpha-subunit to TSH ratio, suggested a pituitary TSH-secreting tumor, but a CT scan of the sella turcica was normal. In 1994, while undergoing an otolaryngologic examination, the patient was found to have a nasopharyngeal mass lesion, which was ultimately shown histologically and immunohistochemically to be an ectopic pituitary tumor. Resection of the mass restored TSH and alpha-subunit levels to normal. This patient probably represents the first ectopic TSH-secreting pituitary tumor to be reported.

Molecular biological research in pituitary adenomas from the pathologists' view

Some recent findings related to pituitary adenoma pathology achieved by molecular biological methods are briefly reviewed. It is increasingly obvious that the application of the molecular pathology approach can provide a deeper insight into the causation, histogenesis, cellular derivation and differentiation as well as progression of pituitary adenomas and can help to understand better structure-function correlations.

Proliferation parameters for pituitary adenomas

In this review, the value of assessing proliferation parameters in surgically resected pituitary tumour tissue is analyzed. Histological examination of basal dura biopsies identifies invasive growth even when intraoperatively not apparent to the surgeon. Determination of DNA-polymerase activity, Ki-67 immunohistochemistry and DNA-flow-cytometry shows a clear difference in the proliferative potential of enclosed and invasive pituitary adenomas. Among the various endocrinologically differentiated groups ACTH-secreting adenomas associated with Nelson's syndrome and thyrotropinomas were the most rapidly proliferating. At present, however, our results reveal that the prognosis of an individual patient cannot be reliably predicted on the basis of such studies.

Surgical results in microadenomas

Pituitary microadenomas are small tumors whose maximal diameter is less than 1 cm. The aim of surgical removal of microadenomas should be not only the reversal of hormone hypersecretion but also the preservation of normal anterior pituitary function. Our series includes 230 patients with a microadenoma who had their first operation in our department: 45 were GH-secreting, 92 were PRL-secreting, 90 were ACTH-secreting, and 3 were TSH-secreting. Remission of disease was achieved in 81%, 77%, 91%, and 100% of GH-, PRL-, ACTH-, and TSH-secreting adenomas, respectively. There was no perioperative mortality and only 5 patients experienced a major complication. A total of 7 patients had diabetes insipidus for at least 6 months after operation. Hypopituitarism, not present in any patients before operation, developed in 3.5% of the cases. Our experience confirms that patients with microadenomas have the best chances of a successful operation. Since tumor size should gradually increase with time, we underscore the need of early diagnosis and treatment in patients with pituitary adenomas.

Management of huge pituitary adenomas

Management of huge pituitary adenoma (more than 5 cm in diameter) is one of the most important issues on the treatment of pituitary tumors. We have analyzed the therapeutic modality and the result of our cases. From 1967 to 1983, 50 patients with huge adenoma (14.1%) out of a total 354 pituitary adenomas were surgically treated. The operative mortality was 25% for radical transcranial (TC) approach (10/40), 14% (1/7) for transsphenoidal (TS) approach and 0% (0/3) for combined two stage operations. From long-term follow-up, excellent prognoses were observed in only 44% of the patients treated by radical TC operation. After 1984, we have employed partial removal by TS surgery at the first stage, followed by reoperation by TS or TC surgery with or without radiotherapy or bromocriptine in case by case. Seventeen huge pituitary adenomas out of a total 700 pituitary adenomas were operated. There was no mortality nor major complications. The two stage operation with initial TS surgery is recommended for the management of huge pituitary adenomas.

Current pathological classification of pituitary adenomas

A classification of pituitary adenomas basing on detailed structural and immunohistochemical studies is accepted world-wide and is mandatory for each pathologist. Monohormonal (densely or sparsely granulated GH cell adenomas, Prolactin cell adenomas, ACTH cell adenomas. FSH/LH cell adenomas, alpha-subunit-only adenomas), bihormonal (mixed GH/Prolactin cell adenomas, mammosomatotroph cell adenomas, acidophil stem cell adenomas), plurihormonal (GH/Prolactin/Glycoprotein-positive adenomas, other Glycoprotein-positive types) and hormone-negative adenomas (null cell adenomas, oncocytic adenomas) have to be differentiated.

Proliferative activity and invasiveness among pituitary adenomas and carcinomas: an analysis using the MIB-1 antibody

Although histologically benign, one-third of all pituitary tumors will be invasive of surrounding structures. In this study, the relationship between the proliferative activity in pituitary adenomas and their invasiveness was investigated. Invasion was defined as gross, operatively or radiologically apparent infiltration of dura or bone. Using the recently developed MIB-1 monoclonal antibody, which recognizes the Ki-67 cell cycle-specific nuclear antigen, the growth fractions of 37 noninvasive adenomas, 33 invasive adenomas, and 7 primary pituitary carcinomas were determined. All tumors were fully classified by histology, immunohistochemistry, and electron microscopy. The mean Ki-67 -derived growth fractions for noninvasive adenomas, invasive adenomas, and pituitary carcinomas were 1.37 +/- 0.15%, 4.66 +/- 0.57%, and 11.91 +/- 3.41%, respectively (mean +/- standard error of the mean). An analysis of variance and then individual pairwise comparisons confirmed significant differences in the mean Ki-67 labeling index between each of the three tumor groups (P < 0.01). The mean growth fraction of hormonally active pituitary adenomas (3.25 +/- 0.26%) was significantly higher than that for nonfunctioning adenomas (2.06 +/- 0.23%) (P = 0.03). Establishing a threshold labeling index of 3% served to distinguish invasive from noninvasive adenomas with 97% specificity and 73% sensitivity and was associated with positive and negative predictive values of 96 and 80%, respectively. Although invasive pituitary tumors exhibited significantly higher growth fractions than did noninvasive tumors, there were individual exceptions, indicating that in a subpopulation of invasive pituitary tumors, factors other than proliferative activity determine invasive potential.

Ectopic aldosteronoma associated to another adrenocortical adenoma in the adrenal gland of the same side

The occurrence of tumors originating from aberrant adrenocortical tissue in ectopic site is very rare. Up to now only two cases of ectopic aldosterone-producing adenoma have been described. We have observed another case of ectopic aldosteronoma, located in the retrocaval region, laterally to the body of the 12th thoracic vertebra. This ectopic tumor was associated to another adrenocortical adenoma, in the adrenal gland of the same side. The diagnostic implications of this observation are discussed.

Resection of giant invasive pituitary tumors through a transfacial approach: technical case report

Giant invasive pituitary adenomas are rare tumors that have been reported to extensively involve the cranial base, as well as other intra- and extra-cranial structures, making surgical resection by traditional approaches impossible. We report two cases, each of a giant invasive adenoma involving the entire length of the clivus and adjacent structures that was resected via a transfacial approach with excellent results. Both tumors were in middle-aged men; one was nonsecreting, and the other secreted follicle-stimulating hormone alpha-subunit. Most previously reported giant invasive adenomas have been prolactinomas. Both tumors were resected via a transfacial approach that incorporated an osteoplastic maxillotomy with palatal division and a posterior pharyngeal incision that provided exposure from the suprasellar region to C2. Both of the patients received postoperative radiation and have done very well. Their cosmetic results were excellent. The complications included postoperative meningitis in one patient and a nasal voice in the other. The transfacial approach provides excellent access for this type of extensive midline tumor requiring resection from the suprasellar region down to the foramen magnum.

[Morphological typing, evaluation of tumor dignity and prognosis and etiologic classification of adrenomedullary and adrenocortical neoplasias]

The aim of morphological tumour diagnosis is to answer clinical questions on type, biological potential, prognosis and aetiology of individual neoplasms. The limitations and perspectives of different methods used in the diagnosis of adrenal tumours, ranging from histology to molecular genetic DNA analyses, are described. When surgical specimens from adrenal neoplasms cannot be typed on the basis of histology and/or with clinica data (e.g., endocrine symptoms and history) as adrenocortical tumours, phaeochromocytomas or metastases to the adrenal, immunohistological investigations with a panel of different antibodies are necessary. After identification of the tissue derivation of an individual adrenal tumour, its biological potential must be assessed. Among adrenocortical neoplasms, adenomas and carcinomas can be distinguished by evaluation of various histological parameters (including structural features and signs of invasion) according to defined algorithms. In addition, conventional histology (by estimation of mitotic activity) allows the discrimination of tumours with especially high malignant potential from other adrenocortical carcinomas. In contrast, among adrenomedullary tumours even the combined use of histological, immunohistological and DNA cytophotometric techniques only allows the definition of risk groups (benign versus suggestive of malignancy), while reliable recognition of an individual malignant phaeochromocytoma is so far impossible. The question as to whether a particular phaeochromocytoma represents a sporadic tumour or a neoplasm inherited as one feature of a defined syndrome cannot be answered with the above methods, but only by the application of molecular genetic techniques.

Analysis of the growth rate and cavernous sinus invasion of pituitary adenomas

Pituitary adenomas generally are regarded as benign tumours, but a part of them can invade the cavernous sinus and recur. We examined 43 pituitary adenomas for the following factors: tumour volume, endocrinological function, cavernous sinus invasion, and growth rates examined by using anti-proliferating cell nuclear antigen (PCNA) and MIB1 (a novel anti-Ki-67) as markers. There was significant correlation between PCNA- and MIB1-positive cell rates and PCNA- and MIB1-positive cell rates were higher in the three cases with rapid regrowth than in the other cases. Staining was stronger and more distinct for MIB1 than for anti-PCNA; thus, MIB1-positive cells were easily distinguished by their intense immunoreactivity. MIB1 may be useful for detecting those rare cases with rapid regrowth even when initially regarded as benign tumours. Adenomas with cavernous sinus invasion were significantly larger than those demonstrating no invasion. However, no significant difference was found in the frequency of PCNA- or MIB1-positive cells between adenomas with and without cavernous sinus invasion. These findings suggest that cavernous sinus invasion and growth rate are independent biological factors. Therefore, cavernous sinus invasion may be due to chemical factors produced by the tumour itself rather than as a result of rapid tumour growth.

The need for adjunctive focused radiation therapy in pituitary adenomas

In pituitary adenomas radiation therapy regardless of the technique should be limited to surgical failures. The delayed onset of beneficial effects and the high rate of pituitary insufficiency have to be weighed against the good surgical and/or medical results in the treatment of these tumours. Unfortunately surgical outcome is almost invariably correlated with invasive growth. Invasiveness is statistically significantly correlated with tumour size, as well as with high proliferation rates, which can be measured by immunohistological methods such as mAB KI-67. Owing to the good results of medical treatment, radiation therapy is usually unnecessary in prolactinomas. Patients with persistent hypersecretion of growth hormone after unsuccessful surgery may represent the ideal candidates for radiation therapy, whereas patients with persistent Cushing's disease need cure for hypercortisolism without delay. In patients with residual tumour due to non functioning adenomas, radiation therapy should only be given if the proliferation rate is high.

Primary diffuse chiasmatic germinomas: differentiation from optic chiasm gliomas

Primary germ cell tumors confined to the optic nerves and chiasm without suprasellar extension are uncommon. These tumors appear similar to chiasmatic gliomas on both computed tomography and magnetic resonance imaging, potentially resulting in treatment errors if the diagnosis is based on radiologic criteria alone. Unlike chiasmatic gliomas, suprasellar germinomas characteristically present with a clinical triad of endocrine abnormalities, diabetes insipidus, and visual complaints. We report the case of a 9-year-old boy who presented with a 5-month history of fatigue, 16-pound weight gain, polydipsia, polyuria, visual complaints, and intermittent headache. Imaging studies demonstrated findings consistent with a glioma of the chiasm with infiltration into the optic tracts. At surgery, the chiasm and optic tracts were diffusely enlarged with no other suprasellar abnormalities. Biopsy specimens were characteristic of germ cell tumor. Based on this result, the patient received a treatment regimen different from that used at our institution for chiasmatic gliomas. We feel it is imperative to biopsy chiasmatic lesions that radiologically appear to be gliomas if symptoms do not adhere to the classical clinical presentation.

[The functionally inactive endocrine pancreas tumor]

Endocrine tumors of the pancreas are extremely rare (1-3%). We present two cases with functional inactive tumors--one benign and one malignant--, which were immunohistologically secreting glucagon without having clinical symptoms. Differential diagnosis, operative strategy and therapy of endocrine tumors of the pancreas are discussed.

Novel features of tumors that secrete both growth hormone and prolactin in acromegaly

The most prominent previously reported clinical features of growth hormone (GH) and prolactin (PRL)-secreting pituitary adenomas associated with acromegaly have included the high incidence of galactorrhea in women and a generally more favorable response to dopamine agonist therapy. The authors analyzed a consecutive series of 62 acromegalic patients treated with transsphenoidal microsurgery. GH-PRL tumors were found in 30% of the patients. There was a significant difference in sex distribution between acromegalics with the GH-PRL tumor subtype and all other acromegalics. Women represented 73% of the GH-PRL immunostain subtype, as compared with the overall sex distribution of 33 women (53%) and 29 men (47%) for the entire series of acromegalic patients. Individuals with the GH-PRL subtype had significantly higher postoperative GH levels than those with the GH subtype, and significantly higher postoperative GH levels when compared with all other acromegalics with a variety of immunostain subtypes. Linear regression analysis of the pre- and postoperative GH data revealed that the increased postoperative GH levels in the GH-PRL immunostain subtype were independent of the invasiveness of the tumor and of sex of the subject. When the same linear regression technique was used, lower preoperative levels of thyroxine and thyroid-stimulating hormone were observed in the GH-PRL subtype. These data suggest inherent differences characteristic of tumors that secrete both growth hormone and prolactin.

A clinical and histopathological study of factors affecting MRI signal intensities of pituitary adenomas

Our aim was to elucidate the factors which determine the MRI signal intensities of pituitary adenomas. We examined 51 patients with surgically-confirmed pituitary adenomas. Using a spin-echo pulse sequence (SE 500/15), coronal and sagittal images (3 mm slices) were obtained. Signal intensities on T1-weighted images were measured in the parenchyma of the adenoma and in normal grey matter. The relative intensity of the adenoma was assessed by calculating the ratio of its signal intensity to that of the normal grey matter of the same patient. Paraffin-embedded sections were used for haematoxylin and eosin staining. The number of cells in a prescribed area was counted, and the mean of five such counts was taken as the cell density. Immunohistochemically stained sections using antibodies for various pituitary hormones were similarly examined; the ratio of the total number of hormone-positive cells to the overall total number of adenoma cells was calculated. Four independent variables were used in the analysis: the age of the patient, the maximum diameter of the adenoma, the cell density and the proportion of hormone-positive cells in the adenoma and, with the signal intensity ratio as the dependent variable, a multiple regression analysis was performed. This revealed that the the greatest influence upon the signal intensities on T1-weighted images was the proportion of hormone positive cells.

Magnetic resonance imaging measurements of pituitary stalk compression and deviation in patients with nonprolactin-secreting intrasellar and parasellar tumors: lack of correlation with serum prolactin levels

Prolactin (PRL) Levels are frequently elevated in patients with non-PRL-secreting adenomas or other intrasellar and parasellar diseases ("pseudoprolactinomas"). This phenomenon is believed to result from a loss of dopaminergic inhibition on pituitary lactotrophs and is known as the "stalk-section effect." Using magnetic resonance imaging scans and a high-magnification sella technique, we measured a number of parameters indicative of the disruption of normal sellar structures. The investigator was blind to the patient's diagnosis and PRL level while collecting the data. Parameters measured were the tumor size, the angular deviation of the pituitary stalk, and the degree of compression of the pituitary stalk. Measurements were obtained from 44 patients with pathologically confirmed tumors that had no immunohistochemical reactivity to PRL. PRL levels were often higher than expected. Four patients (9%) had a PRL level of more than 150 ng/ml, and three patients (7%) had a PRL level of 200 ng/ml or more. One patient with a plasmacytoma eroding the sella floor had a PRL level as high as 504 ng/ml. There was no significant correlation of PRL level and the degree of pituitary stalk compression, stalk deviation, or tumor size. PRL levels were found to be markedly elevated in some patients with a tumor causing little distortion of the pituitary stalk. Conversely, PRL levels were often normal despite evidence of massive distortion of the stalk. Therefore, magnetic resonance imaging evidence of pituitary stalk distortion cannot be used to determine the diagnosis of prolactinoma versus pseudoprolactinoma in most cases.(ABSTRACT TRUNCATED AT 250 WORDS)

Diseases of the pituitary

This article reviews current understanding of the pathology and pathogenesis of pituitary diseases. It emphasizes the importance of morphologic analysis in the diagnostic sphere. The investigation of structure-function correlations in pituitary adenomas combined with a greater understanding of the molecular basis of disease will lead to new discoveries and elucidate the factors underlying pituitary tumorigenesis.

[Lung cancer with extra pulmonary symptoms as the chief manifestation. A clinical analysis of 47 cases]

In patients with cancer of the lung, extrapulmonary symptoms can be found before or after the tumor is discovered. In this paper, 47 cases of lung cancer presenting extrapulmonary symptoms as their major clinical manifestation are reported. The symptoms might arise from the central nervous system, bones and joints, esophagus, intestine, etc. Some of the symptoms were due to compression or invasion of the cancer to the adjacent organs. Paraneoplastic syndromes, such as ectopic endocrine syndrome and carcinoid syndrome, were also encountered. Keeping these extrapulmonary manifestations in mind, patients suspicious of having lung cancer should be carefully examined and closely followed up until a correct diagnosis is made.

Pituitary adenomas with invasion of the cavernous sinus space: a magnetic resonance imaging classification compared with surgical findings

We present 25 pituitary adenomas that were confirmed surgically to have invaded the cavernous sinus space. The surgical results are compared with the preoperative magnetic resonance imaging findings. For comparable radiological criteria, we classified parasellar growth into five grades. This proposed classification is based on coronal sections of unenhanced and gadolinium diethylene-triamine-pentaacetic acid enhanced magnetic resonance imaging scans, with the readily detectable internal carotid artery serving as the radiological landmark. The anatomical, radiological, and surgical conditions of each grade are considered. Grades 0, 1, 2, and 3 are distinguished from each other by a medial tangent, the intercarotid line--through the cross-sectional centers--and a lateral tangent on the intra- and supracavernous internal carotid arteries. Grade 0 represents the normal condition, and Grade 4 corresponds to the total encasement of the intracavernous carotid artery. According to this classification, surgically proven invasion of the cavernous sinus space was present in all Grade 4 and Grade 3 cases and in all but one of the Grade 2 cases; no invasion was present in Grade 0 and Grade 1 cases. Therefore, the critical area where invasion of the cavernous sinus space becomes very likely and can be proven surgically is located between the intercarotid line and the lateral tangent, which is represented by our Grade 2. We also measured tumor growth rates, using the monoclonal antibody KI-67, which shows a statistically higher proliferation rate (P < 0.001) in adenomas with surgically observed invasion into the cavernous sinus space, as compared with noninvasive adenomas.

ACTH and TSH producing ectopic suprasellar pituitary adenoma of the hypothalamic region: case report

A 34-year-old woman with a long-term history of amenorrhoea, headache and visual disturbances was operated for a hypothalamic tumor which could be completely removed. Postoperatively the patient developed a transient SIADH-syndrome and deep vein thrombosis; otherwise the clinical course was uneventful. There has been no sign of tumor recurrence at a follow-up period of fifteen months. Histological examination of the tumor revealed an ectopic pituitary adenoma with production of ACTH and TSH shown by immunohistochemistry.

[An active endocrine glomus tumor (paraganglioma) as a cause of tinnitus and hypertension]

A glomus jugulare tumor arises from the glomus bodies located in the adventitia of the dome of the jugular bulb. A glomus tumor has the same microscopic appearance as a carotid body tumor. The present report includes the extraordinary clinical and morphological features of a catecholamine-secreting glomus tumor (paraganglioma) in a 41-year-old woman. The patient presented with uncontrollable hypertension und pulsatile tinnitus. The diagnostic and therapeutic management is reported, including MIBG scintigraphy, computed tomography, magnetic resonance imaging, embolization, angiography, selective venous sampling studies and control of hypertension. After cardiovascular stabilization and tumor embolization, the tumor was removed surgically, with subsequent resolution of hypertension. While light microscopical analysis showed a classical glomus tumor, ultrastructural analysis revealed particular details of the tumor cells.

Pituitary adenomas: serum hormone levels and immunohistochemical staining for ACTH, GH and prolactin

In 37 pituitary adenomas obtained by surgery the immunohistochemical staining for ACTH, GH and prolactin and the tumor size were related to the basal serum hormone levels. 5 adenomas were associated with Cushing syndrome, 9 with acromegaly, 17 with hyperprolactinemia and 6 were preoperatively diagnosed as inactive. A rather close correlation between immunoreactivity of tumor tissue and basal serum hormone levels was found for GH and prolactin whereas these two parameters were not significantly correlated in the corticotrophic adenomas examined. Furthermore there was no obvious correlation between serum hormone levels and tumor size. Several non immunoreactive adenomas showed slight hyperprolactinemia; all of them were macroadenomas with extended sellar lesions. This fact may be explained by disturbances in the hypothalamic-hypophyseal regulation of serum prolactin.

Histologic, flow cytometric, and genetic criteria in endocrine surgery

Differential diagnosis of endocrine neoplasms as benign or malignant is frequently extremely difficult. Similarly, assessing prognosis in cases of malignancy is problematic. Traditionally, histologic criteria, including grade of the tumor, architectural features, and cytologic appearance, have been used to predict biologic behavior. In addition, clinical scoring systems may be useful in assigning prognosis in individual cases. Examination of the DNA profile of individual cells by flow cytometry may correlate with the aggressiveness of the tumor. Recent developments in molecular genetics have yielded genetic markers that may be useful in diagnosis and prognosis as well as illuminating the pathogenesis of endocrine neoplasia. This review summarizes the status of traditional and newer methods of pathologic interpretation of endocrine neoplasms. In general, the most accurate assessment of these tumors is derived from consideration of a collage of the clinical and pathologic criteria discussed herein.

The effects of Gamma Knife surgery of pituitary adenomas on tumor growth and endocrinopathies

Fifteen patients were treated in the Gamma Knife Unit and followed for 18 months or longer. Four patients had Cushing's disease, 4 had acromegaly, 3 had Nelson's syndrome and 3 had prolactinomas. One patient had no endocrinopathy. One of the patients with acromegaly and 2 of those with prolactinomas had been operated prior to Gamma Knife treatment. Radiological tumor localization was not an insuperable problem in this series. The effect of Gamma Knife treatment on the anterior pituitary neoplasia, as such, was consistently successful. All the tumors which received 10 Gy or more to the edge showed either a reduction in volume or at least cessation of growth. On the other hand, the effect of the treatment was less consistent in respect to the endocrinopathies. These results are discussed in respect of dose and tumor size. It is suggested that the role of the Gamma Knife in the treatment of pituitary adenomas requires further clarification, based on prospective studies.

Ectopic acromegaly

Ectopic acromegaly is a rare syndrome (less than 1% of acromegalic patients) caused by ectopic growth hormone-releasing hormone (GHRH) or growth hormone (GH)-producing tumors. Its recognition is clinically important because acromegaly may be a symptom of an aggressive tumor, and different therapeutic approaches are required. Most cases are caused by either extra- or intracranial GHRH-producing tumors, whereas in rare instances the underlying disease is an ectopic GH-secreting tumor. The routine evaluation of circulating GHRH in all acromegalic patients may allow its early recognition, because plasma levels greater than 0.3 ng/mL are virtually diagnostic of a GHRH-producing tumor (frequently a bronchial or pancreatic carcinoid), whereas suppressed levels may suggest an ectopic GH-producing tumor. In addition to classic imaging techniques, whole body scintiscan with labeled octreotide may help in the localization of ectopic tumors. Surgical removal of the ectopic tumor is the therapy of choice, but it is not always feasible because patients often present with widespread metastases. Patients with GHRH-induced acromegaly benefit from the administration of the long-acting somatostatin analog, octreotide, which reduces GH, IGF-I, and GHRH, and may shrink the ectopic tumor, its metastases, and the secondary pituitary enlargement.

Neurosurgical experience with tumours of the pineal region at Clinica Puerta de Hierro

The clinicopathological experience with 50 cases of pineal region tumours at Clinica Puerta de Hierro is presented. In this series, 88% of the patients were evaluated by CT-scan. Pineal region tumours make up approximately 0.7% of the intracranial expansive processes in the Spanish population. The largest group of lesions appearing in this localization is that of the germinomas (38%), followed by nontumoural lesions (20%) and tumours generally considered to be of the vicinity, such as meningiomas, gliomas and metastases (18%), tumours of the pineal parenchyma (14%), and non-germinoma germinal tumours (10%). In our series, in addition to an intracranial hypertension syndrome, an ophthalmological and, to a minor degree, an endocrinological syndrome predominate in germ-cell tumours, with a cerebellar syndrome appearing in gliomas of the pineal region. All the patients in the series diagnosed as having a germinoma and treated by irradiation are alive, and free of disease, after follow-up ranging from 2 to 20 years (mean: 8 years). The experience obtained with the present series supports the opinion that, in radiosensitive tumours, surgical resection adds no therapeutic benefit to treatment with radiotherapy alone. We suggest that when dealing with a tumour of the pineal region, CT-scan and clinical assessment now permit an initial selection of patients susceptible to surgery as a first therapeutic option, indicating those patients who, because they are considered to have either a "probable germinoma" or a "tumour of uncertain diagnosis", should undergo stereotaxic biopsy or trial radiotherapy and, only when this has proved a failure, should be subjected to open surgery.

Gamma knife surgery for sellar and suprasellar tumors

Recent advances in neuroimaging, coupled with stereotactic delivery of ionizing radiation, permit precise, single-treatment irradiation of various intracranial tumors. This article describes the authors' experience with the 201-source 60Co gamma knife. Initial results indicate a potential therapeutic role for radiosurgery in controlling tumor growth and hormone hypersecretion in most patients. The authors believe that radiosurgery should be considered for small pituitary adenomas when prior microsurgery has failed to control tumor growth. Radiosurgery is a primary treatment alternative for patients who are elderly, medically infirm, or refuse microsurgical removal. Further follow-up is necessary to evaluate the long-term tumor control rate, hormonal effects, and tolerance of surrounding critical structures to stereotactic radiosurgery.

Cystic endocrine tumor of the pancreas

A large cystic tumor in the pancreatic body was found incidentally in an 85-yr-old male. A distal pancreatectomy was performed after a diagnosis of cystadenocarcinoma. Microscopic examination of the resected specimen revealed a pancreatic cystic endocrine tumor; however, this tumor produced no symptoms. Immunohistochemical studies of the tumor cells showed positivity for gastrin, neuron-specific enolase, chromogranin A, and synaptophysin, and two cell types of neurosecretory granules were recognized in electron-microscopic studies. Although endocrine tumors of the pancreas are usually solid and cystic change occurs only rarely, such tumors should be considered in the differential diagnosis of patients who have a cystic lesion in the pancreas.

Percutaneous aspiration for hormone levels in the diagnosis of functioning endocrine tumors

Percutaneous aspiration to measure hormone levels in suspected functioning endocrine adenomas has been performed in 23 suspected cases of parathyroid adenomas, 7 cases of ACTH-producing thoracic carcinoid tumors, and 1 case of gastrinoma. When tumors secrete hormone or peptide markers, the biochemical assay can replace cytology to identify the lesion with greater specificity and at less expense.

Proliferation in pituitary adenomas: measurement by MAb KI 67

The monoclonal antibody MAb KI 67 reacts with a nuclear antigen throughout the entire cell cycle and allows easy evaluation of proliferating tumour cells on routinely prepared smear and frozen sections. 120 pituitary adenomas were investigated by use of the monoclonal antibody KI 67 in a two-step avidin-biotin-peroxidase complex (ABC) technique. The KI 67 labelling index (LI) ranged in all adenomas from 0.2 to 4.6%. In 90 cases of transphenoidally operated adenomas the dura of the sella floor was investigated histologically. Adenomas with histologically proven dural infiltration showed a statistically significant higher KI 67 LI (p less than 0.001) compared to non-invasive adenomas.

[Leydig's cell tumor with endocrine syndrome: presentation of a case and review of the literature]

We present a case of Leydig's cell tumour in a young adult, with endocrinal manifestation. The relative rarity of these neoplasias. The opposition of their clinical manifestations, virilizing in the child and feminizing in the adult. Its always benign evolution in infancy and its occasional malignity in the adult (20%) are commented on and reviewed.

The gastroenteropancreatic endocrine system and related tumors

Up to 16 types of endocrine cells have been characterized morphologically (and most of them also functionally) in the gastroenteropancreatic area. Four main groups of pancreatic endocrine tumors (with several subtypes) have been identified: islet cell, ectopic, nonfunctioning, and poorly differentiated tumors. A detailed classification system that combines cytologic and clinicopathologic patterns has been developed for the study of 132 pancreatic tumors. Among a large series (more than 120 cases) of endocrine tumors arising in the gastrointestinal tract, serotonin-producing argentaffin carcinoids have been separated from hindgut trabecular carcinoids, producing glucagon- and pancreatic polypeptide-related peptides, paragangliomas, somatostatin cell tumors, gastrinomas, and argyrophil ECL cell carcinoids. The clinicopathologic profile of the various pancreatic and gastrointestinal tumor entities has been delineated and involvement in the multiple endocrine neoplasia syndrome has been analyzed in detail.

[A case of adenocarcinoma of the nasal cavity associated with syndrome of inappropriate secretion of antidiuretic hormone(SIADH)]

An inappropriate antidiuretic hormone secretion (SIADH) has been recognized as the cause of hypotonic hyponatremia, and the occurrence of this syndrome, accompanied by an ADH-producing adenocarcinoma in the nasal cavity, is reported. In February, 1987, a 50-year-old male, showing sights of delirium, disorientation, and irritability was admitted to the hospital. The patient was observed to be healthy, except for a neck lymphnode metastasis that was present up to the time of his hospitalization. The hyponatremia was incidentally found, although dehydration or intravascular volume depletion were not noted. These neuropsychiatric symptoms were considered to be associated with hyponatremia due to SIADH. He had had a partial maxillectomy, a neck dissection, and irradiation to the nose and nasal cavity 32 months earlier, and then underwent a surgical resection of the neck metastasis; he had a total of 10 other operations before the onset of the symptoms. Upon initial inspection, since neither an intracranial invasion nor a brain metastasis was found, we diagnosed that his symptoms were due to an autonomic disturbance caused by surgical and mental "stress". When he died of cardiac failure due to a mediastinal invasion 8 months after the onset of SIADH, tumor tissues was extirpated in an autopsy and was then cultured. In this manner, it was proved that the tumor cells had been producing ADH. This procedure clarified that the syndrome had resulted from an ADH-producing tumor of the nasal cavity.

Ectopic ACTH and adrenal myelolipoma

We describe a case of adrenal myelolipoma that occurred in a 66-year-old male with an ACTH producing oat cell lung carcinoma. To our knowledge, this is the first case in which myelolipoma has occurred in association with ectopic ACTH-induced Cushing's syndrome. The literature is reviewed and the pathogenesis of myelolipoma is discussed.

[The functional pathology of hypophyseal adenomas]

This review summarizes some aspects of pituitary adenoma pathology. A new embracing pituitary adenoma classification has been developed which correlates morphologic findings with endocrine activity. It is based on hormone content, histologic, immunohistochemical and ultrastructural features, cellular composition and cytogenesis, and separates pituitary adenomas into 7 distinct entities.

Human renal carcinoma expresses two messages encoding a parathyroid hormone-like peptide: evidence for the alternative splicing of a single-copy gene

A peptide secreted by tumors associated with the clinical syndrome of humoral hypercalcemia of malignancy was recently purified from human renal carcinoma cell line 786-0. The N-terminal amino acid sequence of this peptide has considerable similarity with those of parathyroid hormone (PTH) and of peptides isolated from human breast and lung carcinoma (cell line BEN). In this study we obtained the nucleotide sequence of a 1595-base cDNA complementary to mRNA encoding the PTH-like peptide produced by 786-0 cells. The cDNA contains an open reading frame encoding a leader sequence of 36 amino acids and a 139-residue peptide, in which 8 of the first 13 residues are identical to the N terminus of PTH. Through the first 828 bases the sequence of this cDNA is identical with one recently isolated from a BEN cell cDNA library; however, beginning with base 829 the sequences diverge, shortening the open reading frame by 2 amino acids. Differential RNA blot analysis revealed that 786-0 cells express two major PTH-like peptide mRNAs with different 3' untranslated sequences, one of which hybridizes with the presently described sequence and the other one with that reported for the BEN cell PTH-like peptide cDNA. Primer-extension analysis of 786-0 poly(A)+ RNA together with Southern blot analysis of human DNA confirmed the presence of a single-copy gene coding for multiple mRNAs through alternate splicing. In addition, the 3' untranslated sequence of the cDNA described here has significant similarity to the c-myc protooncogene.

Pancreatic endocrine tumors

In this review the current state of our understanding of endocrine tumors of the pancreas is considered. It is based on the experience with a series of 365 tumors. The first part of the article focuses on origin and classification, markers, frequency, criteria of malignancy as well as general structural features of the pancreatic endocrine tumors. In the second half of the article the functioning tumors, i.e. tumors that cause hormonal syndromes, and the nonfunctioning tumors as well as the endocrine tumors associated with multiple endocrine neoplasia type 1 are dealt with in detail. Special emphasis is put on the immunocytochemical profile and the biological features of the respective tumors.

Ectopic growth hormone-releasing hormone (GHRH) syndrome in a case with multiple endocrine neoplasia type I

A 36-yr-old man with multiple endocrine neoplasia (MEN) type I had an ectopic growth hormone-releasing hormone (GHRH) syndrome due to a GHRH-secreting pancreatic tumor. The immunoreactive (IR)-GHRH concentration in his plasma ranged from 161 to 400 pg/ml (299 +/- 61 pg/ml, mean +/- SD; normal, 10.4 +/- 4.1 pg/ml), and a significant correlation was found between his plasma IR-GHRH and GH (r = 0.622, p less than 0.02). After removal of the pancreatic tumor, the high plasma GH concentration returned to nearly the normal range (42.2 +/- 31.3 to 9.6 +/- 3.8 ng/ml). These changes paralleled the normalization of his plasma IR-GHRH (16.1 +/- 3.8 pg/ml) and some of his symptoms related to acromegaly improved. However, plasma GH (7.7 +/- 1.3 ng/ml) and IGF-I (591 +/- 22 ng/ml) concentrations were high at 12 months after surgery, suggesting adenomatous changes in the pituitary somatotrophs. Before surgery, exogenous GHRH induced a marked increase in plasma GH, and somatostatin and its agonist (SMS201-995) completely suppressed GH secretion, but not IR-GHRH release. No pulsatile secretion of either IR-GHRH or GH was observed during sleep. An apparent increase in the plasma GH concentration was observed in response to administration of TRH, glucose, arginine or insulin, while plasma IR-GHRH did not show any fluctuation. However, these responses of plasma GH were reduced or no longer observed one month and one year after surgery. These results indicate that 1) a moderate increase in circulating GHRH due to ectopic secretion from a pancreatic tumor stimulated GH secretion resulting in acromegaly, and evoked GH responses to various provocative tests indistinguishable from those in patients with classical acromegaly, and 2) the ectopic secretion of GHRH may play an etiological role in the pituitary lesion of this patient with MEN type I.

[Localization of adrenal tumors]

The application of newly developed methods to localization of adrenal tumours has improved diagnostic accuracy, yet the challenge still exists. The sensitivity of ultrasound is too low for imaging small adrenal tumours, thus reducing sonography to a screening method. Computed tomography is a fast and sensitive localizing method, even for small tumours, with a low radiation exposure. Endocrine-active tumours with high hormone-secreting activity or displaying a tendency to additional extra-adrenal presentation will generally be best localized by scintigraphic imaging. Sonography and computed tomography as non-invasive methods and invasive puncture of the tumour or of the cyst with consequent cytological examination of the obtained material are most important procedures in the diagnosis of endocrine-inactive adrenal masses.

Prostatic carcinoma with endocrine features. A report of a neoplasm containing multiple immunoreactive hormonal substances

A case of prostatic carcinoma with the cellular patterns of an adenocarcinoma and carcinoid tumor is reported. The tumor contained ultrastructural dense core neuroendocrine granules, and immunoperoxidase staining revealed prostatic acid phosphatase, prostatic-specific antigen, chromogranin, neuron-specific enolase, serotonin, adrenocorticotrophic hormone (ACTH), somatostatin, parathormone, calcitonin, bombesin, and glucagon but no insulin. The patient had exhibited hypercalcemia that may have been related to hormone production by the tumor. The literature on the endocrine aspect of the prostate and its tumor is reviewed.

Testicular failure in patients with extragonadal germ cell tumors

Eight patients with mediastinal or retroperitoneal germ cell tumors who had undergone testicular biopsy or orchiectomy were retrospectively analyzed for primary testicular abnormalities, subfertility, and abnormal sex hormone levels. Testicular tissue was abnormal in all patients, revealing peritubular fibrosis (six), decreased spermatogenesis (eight), interstitial edema (five), Sertoli cells only (one), and Leydig cell hyperplasia (two). Detailed hormone analysis in five patients revealed elevations of luteinizing hormone in four, decreased serum testosterone in two, elevations of estradiol in two, and elevation of human chorionic gonadotropin in one patient. A history of infertility was documented 2 months to 13 years before presentation in four patients and suspected in another. Extragonadal germ cell tumors, like their testicular counterparts are associated with primary germ cell defects, some of which seem to be independent of gonadotropin production by the tumor. In addition, the rather high incidence of antecedent infertility suggests that either a congenital or acquired primary germ cell defect contributes to defective spermatogenesis and the development of cancer in incompletely migrated germ cells.