Corticotroph cell pituitary adenoma within an ovarian teratoma. A new cause of Cushing's syndrome

A 24-year-old woman with severe Cushing's syndrome was found to have corticotroph cell pituitary adenoma arising within a benign cystic ovarian teratoma. The patient manifested sustained hypercortisolemia and lack of suppression of either adrenocorticotropin (ACTH) or cortisol production. There was no evidence of a pituitary mass or secretion of other hormones. After careful clinical evaluation, no other tumor masses were found. Resection of the ovarian tumor led to normalization of ACTH and cortisol levels. Densely granulated corticotroph tumor cells with prominent Type I microfilaments and intracytoplasmic ACTH immunoreactivity characterized the neoplasm as a pituitary corticotroph cell adenoma. This is, to our knowledge, the first case reported of a functioning pituitary adenoma arising within a benign cystic teratoma.

Diagnostic problems in breast pathology: the benefit of ultrastructural and immunocytochemical analysis

This report deals with the diagnostic importance of intracytoplasmic lumina. The separation between tubular carcinoma and sclerosing adenosis, and the ultrastructural features of variants of lobular carcinoma are discussed. The role of electron dense granules as well as other markers for neuroendocrine cells are evaluated, and finally, the difficult separation of both small-cell and spindle cell tumors is considered.

Acromegaly due to ectopic growth hormone (GH)-releasing hormone (GHRH) production: dynamic studies of GH and ectopic GHRH secretion

Dynamic studies of GH and GH-releasing hormone (GHRH) secretion were performed in a man with a GHRH-producing carcinoid tumor and acromegaly. Insulin hypoglycemia stimulated and metoclopramide inhibited both GH and GHRH acutely. Bromocriptine suppressed GH both acutely and chronically without altering circulating GHRH levels and also blunted the GH response to exogenous GHRH. TRH acutely stimulated GH, but not GHRH, secretion, and iv bolus doses of synthetic GHRH-(1-40) stimulated GH release acutely. Somatostatin infusion decreased both GH and GHRH concentrations and blunted the GH responses to TRH and GHRH-(1-40). We conclude that prolonged exposure of the pituitary gland to high concentrations of GHRH is associated with chronic GH hypersecretion and may be accompanied by a preserved acute GH response to exogenous GHRH; a paradoxical response of GH to TRH may be mediated at the pituitary level, consequent to prolonged pituitary exposure to GHRH; bromocriptine suppression of GH in acromegaly is due to a direct pituitary effect of the drug; and somatostatin inhibits both ectopic GHRH secretion as well as GH responsiveness to GHRH in vivo. Since GH secretory responses in patients with somatotroph adenomas are similar to those in this patient, augmented GHRH secretion may play a role in development of the "classic" form of acromegaly.

Immunocytochemical study of 18 tumours causing ectopic Cushing's syndrome

Eighteen cases of Cushing's syndrome caused by ectopic production of peptide hormones were investigated by histological and immunocytochemical methods and the findings correlated with clinical and biochemical observations. Immunocytochemistry showed immunoreactive adrenocorticotrophic hormone (ACTH) or peptides derived from the ACTH precursor (pro-opiomelanocortin (POMC], or both, in a total of 10 cases: five of these also contained immunoreactive-alpha-melanocyte stimulating hormone, indicating more extensive translational processing of POMC than normally occurs in healthy corticotrophs of the anterior pituitary; in two further cases peptides capable of stimulating ACTH release from the anterior pituitary were present. In the remaining six cases immunocytochemistry failed to show the presence of ACTH, other POMC derived peptides, or peptides with ACTH releasing properties. These findings correlate well with the histological and clinical observations, in that the six tumours had been clinically overt, caused rapid death, and histologically seemed to be highly malignant. In contrast, the 12 other tumours were occult to radiological examination, patients had a much improved survival rate, and histologically the tumours seemed to be less aggressive. All but one of the tumours in this series showed a degree of neuroendocrine differentiation, indicated by the presence of neuron specific enolase. These results suggest that one feature of highly malignant tumours, which cause an ectopic endocrine syndrome, is a high secretion of peptide hormones, leaving amounts that are too small to be shown by immunocytochemistry.

Beta-chain human chorionic gonadotropin-producing leiomyosarcoma of the small intestine

A 22-year-old patient with primary leiomyosarcoma of the small bowel presented with symptoms including nausea and vomiting, a symptom complex similar to hyperemesis gravidarum in the pregnant female. She was found to have elevated levels of serum beta-HCG which were localized to the leiomyosarcoma cells utilizing an immunoperoxidase staining technique. Thus, this patient presents evidence that beta-HCG may be produced by sarcoma cells and, therefore, that beta-HCG may be used as a tumor marker in some sarcoma patients.

Intramedullary spinal cord germinoma producing HCG and precocious puberty in a boy

Extremely high concentrations of human chorionic gonadotropin in the cerebrospinal fluid were found in a 5-year-old boy presenting sexual precocity and leg pain. An intramedullary spinal cord tumor was revealed by myelogram and metrizamide computerized tomography, and a biopsy specimen taken at laminectomy. Histologically, the tumor showed germinoma with syncytiotrophoblastic giant cells. The tumor remitted for 5 months after irradiation of 3500 rad and chemotherapy, but recurred in spite of adding 7500 rad and more aggressive chemotherapy. No relapse has been seen for 1 year after amputation of the spinal cord at the T7 level.

Carcinoid tumor occurring in a teratoid malformation of the kidney. An immunohistochemical study

A case of a carcinoid tumor of the kidney that was intimately related to a mixed dysplastic and teratomatous lesion is reported. This lesion displayed focal transitional, mucinous, and endocrine differentiations. Immunofluorescence studies permit the identification of three immunoreactive products: somatostatin, glucagon, and serotonin. It is suggested that the carcinoid tumor arises from this peculiar lesion, which exhibits cells of endocrine lineage.

Cushing's syndrome produced by a bronchial carcinoid tumor

A case of bronchial carcinoid tumor with ectopic corticotropin production is described. Cushing's syndrome refractory to therapy, including pituitary irradiation and hypophysectomy, had been present for 12 years before the neoplasm was discovered at autopsy. The tumor was a small nodule localized in the pulmonary parenchyma and an adjacent hilar lymph node. Corticotropin, serotonin, and neuron-specific enolase were localized in the neoplasm by immunoperoxidase staining.

An atypical endocrine tumor of the lung responsive to radiation therapy and 5-fluorouracil-streptozotocin

A case is reported of a patient who presented with a peripheral left upper-lobe lung mass, a thyroid nodule, and multiple enlarged cervical and supraclavicular lymph nodes. Fine-needle aspiration cytology of the lung lesion, the thyroid nodule, and several of the lymph nodes was interpreted as small cell cancer of the lung (SCCL). The patient was treated with Cytoxan (cyclophosphamide), Adriamycin (doxorubicin), and vincristine (CAV), alternating with VP-16 + cisplatin. When progressive disease was documented after three cycles of chemotherapy, an involved cervical lymph node was biopsied. By light microscopy (LM) the tumor appeared to be a poorly differentiated adenocarcinoma, but by transmission electron microscopy (TEM) it was found to have both neuroendocrine and glandular features. Biochemical analysis of the biopsy specimen revealed immunoreactive bombesin, and on immunoperoxidase staining many tumor cells contained neuron-specific enolase. The tumor was therefore classified as an atypical endocrine tumor of the lung (AETL), a recently described morphologic variant for which no therapy has yet been established. The patient was treated with radiation therapy (RT) followed by chemotherapy including 5-fluorouracil (5-FU) (500 mg/m2 IV, d 1-5) and streptozotocin (STZ) (500 mg/m2 IV, d 1-5) every 5-6 weeks, with objective evidence of tumor regression following each modality. This report illustrates the importance of ultrastructural study in the characterization of lung cancer, and indicates the need for the further evaluation of RT and 5FU + STZ in the treatment of neuroendocrine tumors of the lung.

The biological implications of bronchial tumors

Seventy-six consecutively resected primary pulmonary tumors were assessed first by routine light microscopy and subsequently by electron microscopy and immunohistochemical staining techniques to precisely identify features of differentiation. In 66% of the cases, this assessment provided information that modified or revised the histologic diagnosis provided by light microscopy alone. The following conclusions were reached: (1) The term "large cell undifferentiated carcinoma" has been applied to a heterogenous group of tumors, most of which have ultrastructural and immunohistochemical features of differentiation not identifiable by routine light microscopy. (2) Forty percent of the tumors previously called "large cell undifferentiated carcinoma" have predominantly neuroendocrine differentiation and appear to have a clinical course comparable to that of small cell neuroendocrine carcinoma. (3) The majority of pulmonary carcinomas (especially those previously called "poorly differentiated" or "undifferentiated") may simultaneously demonstrate more than one pattern of differentiation when studied by electron microscopy and immunohistochemistry. (4) The frequency of neuroendocrine neoplasms of the lung, as determined by these and previous studies, is considerably greater than suspected on the basis of light microscopic studies alone. These comprise a clinical and morphologic spectrum ranging from bronchial carcinoid to small cell carcinoma, all of which have immunohistochemically demonstrable hormone production, although paraneoplastic hormonal syndromes are manifested in only a small minority of cases.

A functioning catecholamine-secreting vagal body tumor. A case report and review of the literature

There are few cases of catecholamine-secreting paragangliomas of the neck reported in the literature, most of these being of the carotid body and glomus-jugulare type. This report cites the second case of a functioning vagal body tumor secreting norepinephrine predominantly and producing labile hypertension and symptoms of pheochromocytoma. A brief update on vagal body tumors and a review of the functioning paragangliomas of the head and neck are also presented.

Carcinoma of the adrenal cortex causing primary hyperaldosteronism. A case report and review of the literature

A male patient presenting with primary hyperaldosteronism after a three-year delay, was found to have an aldosterone producing adrenocortical carcinoma. Evidence is presented that aldosterone was the only steroid produced in excess. Only six other patients with adrenocortical carcinoma and isolated primary hyperaldosteronism could be traced in the literature. The relation between histology and endocrine functions of the tumor cells is discussed.

Endocrine tumors of the duodenum. Clinical characteristics and hormone content

Nineteen patients with primary duodenal carcinoid were analysed retrospectively, and eight of the tumors were immunocytochemically examined. One tumor contained somatostatin, two tumors gastrin, two tumors both these peptides, and one tumor contained serotonin. In two tumors no peptide or amine could be demonstrated. Eight patients had ulcer symptoms and nine had gallstone disease. Only four patients had metastatic spread in spite of long delay. Five-year survival was 75% in 12 operated patients. No patient died of the tumor per se. It is concluded that a simple excision seems justified when the tumor is smaller than 2 cm, while probably more extensive surgery is needed when the tumor is larger or when there is local spread. Modern techniques of histofluorescence and immunocytochemistry facilitating a more precise classification will probably result in a better understanding as to symptomatology, prognosis, and making possible better treatment in the heterogenous group of carcinoid tumors.

Mammosomatotroph cell adenoma of the human pituitary: a morphologic entity

Nine cases of a hitherto undescribed morphologic entity, termed mammosomatotroph cell adenoma of the human pituitary, are reported. These tumors, occurring mostly in men, are invariably associated with acromegaly (or gigantism) and high-normal or slightly elevated blood prolactin levels, and it cannot be distinguished clinically from well-differentiated growth hormone cell or mixed growth hormone cell-prolactin cell adenomas. They show a slow growth rate and usually exhibit a diffuse pattern and intense cytoplasmic acidophilia by histology. The immunoperoxidase technique detects both growth hormone and prolactin within the same cells. Electron microscopy reveals monomorphous tumors with a fine structure markedly similar to that of well-differentiated, densely granulated growth hormone cell adenomas. An added feature and diagnostic marker of mammosomatotroph cell adenoma is the presence of extracellular deposits of secretory material. One tumor shows a marked abnormality of hormone packaging and storage, resulting in the cytoplasmic accumulation of pleomorphic bodies containing semicrystalline secretory material.

[Androgen-producing adrenal adenoma in an 18 year-old woman: diagnosis by gas-chromatographic steroid analysis, histology and postoperative course]

Gas-chromatographic analysis of the urinary steroids in an 18 year-old girl with primary amenorrhoea and hirsutism revealed markedly elevated excretion of androsterone, etiocholanolone, dehydroepiandrosterone, and androstendiole, both under basal conditions and after oral dexamethasone (0.5 mg q.i.d. for three days). Adrenal scintigraphy revealed the presence of a tumour of the right adrenal gland, which was subsequently removed by unilateral adrenalectomy. Histologically, the tumour showed marked anisocytosis, but since there was no evidence of capsular or angioinvasion or of mitotic activity, it was classified as an adrenocortical adenoma. Postoperatively the patient showed regression of the virilizing syndrome and normal menstrual bleeding. Urinary steroid excretion has remained normal for four years after adrenalectomy. Androgen-producing tumours must be considered as a possible cause of hirsutism in young females and should, thus, be excluded in each case. Analysis of urinary steroids by gas chromatography is a valuable tool in accomplishing this task.

Hyperplasia of the myenteric plexus. Its association with early infantile megacolon and neurofibromatosis

An infant with cutaneous criteria for neurofibromatosis had hyperplasia of the intestinal myenteric plexus and a clinical presentation mimicking Hirschsprung's disease. Many of his phenotypic features are also found in multiple endocrine neoplasia type IIb, a condition in which hyperplasia of the myenteric plexus is common. This case illustrates the overlapping nature of neural crest-derived conditions and the variable presentation of megacolon (ganglionic or aganglionic) in infancy.

Medullary carcinoma of the thyroid with ectopic ACTH syndrome

An autopsied patient with medullary carcinoma of the thyroid and ectopic ACTH syndrome is reported. A microadenoma of pancreatic islet coexisted in this case, which is assumed to be of D cell origin. Immunohistochemical study revealed decreased number of pituitary ACTH cells. Some of them showed Crooke's degeneration. Hormone assay study of tumor tissue and plasma disclosed abnormal ACTH, beta-MSH as well as calcitonin. Somatostatin and Substance P were also demonstrated in tissue. Histologically the tumor showed solid alveolar pattern with a minor part consisting of small cell variant and this histologic variation is discussed.

In vivo steroid studies in luteoma of pregnancy

Endocrine studies were performed in 2 cases of luteoma of pregnancy. Even though both luteomas were discovered incidentally at the time of postpartum tubal ligation and cesarean section, they were found to be functionally active, secreting several androgens. Steroid concentrations were measured in the ovarian vein blood draining the luteoma in one patient and in peripheral vein blood in both patients. Peripheral testosterone, androstenedione, and dihydrotestosterone concentrations were increased severalfold higher than the normal controls and were comparable to the concentrations reported previously in virilizing luteomas. Progesterone, 17 alpha-hydroxyprogesterone, and estradiol concentrations were increased as well. The concentrations in the ovarian vein were significantly greater than those in the peripheral vein, which indicates active secretion of these steroids by the luteoma. In spite of the high concentrations of androgens, neither the mothers nor the infants were virilized. Concentrations of androgenic steroids in the cord blood were in the normal range. Determination of steroid concentrations in the serum, taken at intervals post partum, indicated spontaneous regression of the luteomas.

In vivo endocrine studies and morphological features in a case of hilus cell tumor in mesovarium

In a 38-year-old white woman with a virilizing mesovarium hilus cell tumor and polycystic ovaries, serum levels of 13 hormones were measured under different conditions. Endocrine studies showed that testosterone was the principal secretory product of tumor cells. Androstenedione, 17-hydroxyprogesterone, and dehydroepiandrosterone sulfate were normal. Light and electron microscopic investigations of the tumor showed polygonal cells containing intracytoplasmic Reinke crystalloids. Immunoperoxidase studies demonstrated the presence of testosterone within tumor cells.

Establishment of functional human pituitary tumor cell cultures

Five primary human pituitary tumor cell cultures were initiated from adenoma fragments obtained from patients with prolactin-secreting adenomas and acromegaly. Functional cell cultures were maintained and propagated in monolayer or suspension culture for up to 9 months. Optimal cell viability and growth were achieved using Ham's F10 medium enriched with 20% fetal bovine serum, although cells from a patient with acromegaly also grew in serum-free, defined, hormone-containing medium. Bromocriptine (100 ng/ml) did not alter the growth curve of replicating cells derived from a patient with acromegaly. These cells initially secreted 5.5 micrograms human growth hormone/10(6) cells, and hormone production diminished after 6 wk. Prolactin secretion by cells derived from prolactinomas (0.5 to 1.3 micrograms/10(6) cells/24 h) was stimulated by thyrotropin-releasing hormone (10 ng/ml) in two of the cultures. Both dopamine (10 ng/ml) and nickel chloride (1 mM) suppressed PRL secretion. These studies demonstrate that responsive human pituitary tumor cell cultures can be initiated and maintained.

Primary gastric choriocarcinoma: immunohistochemistry, postmortem documentation, and hormonal effects in a postmenopausal female

A rare tumor, primary choriocarcinoma of the stomach, occurred in a post menopausal female. The diagnosis was confirmed by autopsy and by immunohistochemical demonstration of HCG in trophoblastic tumor cells. Theories concerning development of this neoplasm are briefly discussed. In addition, this postmenopausal case uniquely permitted examination of the hormonal effects of the tumor on target tissues without the clouding issue of normal menstrual hormones. It appears that the observed estrogen- and progesterone-related tissue responses were not mediated through the ovary; instead, direct tumor production of these hormones is implicated.

Ectopic hormone production by endocrine tumors: localization of hormones at the cellular level by immunocytochemistry

Clinical and laboratory data, histologic, electron microscopic and immunocytochemical findings of the tumors of eight patients suffering from Cushing's syndrome and of one patient with hypercalcemia are described. The unlabeled antibody enzyme method was used for the detection of insulin, glucagon, somatostatin, pancreatic polypeptide, corticotropin, beta-lipotropin, calcitonin, parathyroid hormone, and gastrin. Ectopic Cushing's syndrome was caused by pancreatic endocrine tumors, medullary thyroid carcinoma, a bronchial, a gastric and a thymic carcinoid, and a carcinoid of the mediastinum. Hypercalcemia in one patient was related to a pancreatic endocrine tumor. After surgery the clinical symptoms disappeared in two patients, but persisted or relapsed in five patients. ACTH-immunoreactivity could be demonstrated in six of eight tumors; calcitonin-immunoreactivity was found in the tumor of the patient suffering from hypercalcemia. ACTH-immunoreactivity could be localized to secretory granules by immunoelectron microscopy, and the presence of ACTH and beta-LPH in the same tumor cells could be shown in one pancreatic tumor. A combination of production of orthotopic and ectopic hormones was found in one, and secretion of two ectopic hormones was detected in another pancreatic endocrine tumor.

Medullary carcinoma of the thyroid in the multiple endocrine neoplasia IIA syndrome

Clinical, biochemical, and morphologic parameters in 72 patients with familial medullary thyroid carcinoma (MTC) associated with multiple endocrine neoplasia IIA (MEN IIA) were reviewed. Sixty-nine patients had undergone total thyroid resection. In 27 patients (Group I) the thyroid tumors were smaller than 0.7 cm in diameter; five of these patients had C-cell hyperplasia alone. In 19 patients (Group II) tumors ranged from 0.7 to 1.5 cm, and in 26 patients (Group III) they were larger than 1.5 cm. The mean ages at surgery were 19.6 years (Group I), 33.7 years (Group II), and 32.2 years (Group III). Regional lymph node metastases occurred less often in patients of Group I, 4/20 (20%) and Group II, 4/13 (30%) than in those of Group III, 14/17 (82%) [p = 0.0001]. Elevated postoperative plasma calcitonin levels, indicative of residual MTC, were observed less frequently in patients in Group I, 6/27 (22%) and Group II, 6/15 (50%) than in Group III, 11/15 (73%) [p = 0.005]. All of the patients in Group I and Group II are alive (mean follow-up of 3.5 years and 6.0 years following surgery), whereas 6/26 (23%) Group III patients have died of metastatic MTC, three within 2 years of initial diagnosis. Histologic features varied with tumor diameter. All tumors from patients in Group III contained amyloid, while the majority of those from patients in Group I had an infiltrative configuration and 9/22 tumors lacked amyloid. Among neoplasms from patients in Group III, mitotic figures correlated with distant metastases or death from tumor. Only 1/16 patients who died from MTC had a distinctive tumor morphology, namely a prominent component of small cell anaplastic carcinoma. Early detection of minimal MTC in MEN IIA family members offers the best chance of curing patients with this potentially fatal lesion.

Endodermal sinus tumor of the ovary with virilization. Light- and electron-microscopic study

A case of endodermal sinus tumor of the ovary associated with hirsutism and increased testosterone production is described. Electron-microscopic examination revealed accumulation of basement membrane-like material and other ultrastructural features consistent with endodermal sinus tumor. Groups of polyhedral cells associated with the tumor were found to contain abundant lipid material. These luteinized stromal cells were evidently responsible for the endocrine manifestations.

Calcified pituitary prolactinoma

A case of calcification in a pituitary prolactinoma is presented. Calcification was radiologically evident for 10 years and was histologically confirmed after surgery. Immunochemical staining showed prolactin only, and the calcified mass was surrounded by granulated lactotrophs without a boundary zone of tissue necrosis.

Atypical endocrine tumors of the lung

Seven malignant peripheral lung tumors that were diagnosed using light microscopy as large-cell carcinomas or as epidermoid or adenocarcinomas were studied by light and electron microscopic histochemistry. All tumors contained numerous dense-core granules. The cells were joined by desmosomes and contained well-developed tonofilament bundles. Serotonin was demonstrated in six of seven tumors and argyrophilic granules were demonstrated in five of six tumors tested. Four tumors produced mucus. All tumors extended to the visceral pleura and two invaded the chest wall. The existence of lung tumors that contain serotonin and bear argyrophilic putative endocrine granules, but that do not have a light-microscopic histology characteristic of either carcinoid or oat-cell carcinomas, is confirmed. The presumptive endocrine nature of such tumors usually passes unrecognized because they lack criteria to allow diagnosis by routine methods.

Multiple endocrine neoplasia, type IIb. Report of a case

Multiple endocrine neoplasia, type IIb, is a rare syndrome characterized by mucosal neuromas, medullary thyroid carcinoma (MTC), pheochromocytoma and somatic abnormalities. A case of a 10-year-old girl with multiple mucosal neuromas and bilateral MTC is reported. The presumptive diagnosis of MTC was made on the basis of abnormal basal values of calcitonin and increased calcitonin secretion after pentagastrin injection. The manifestations of the syndrome are summarized, and the importance of repeated evaluation of thyroidal C-cell and adrenal medullary function in patients with the characteristic aspect of the syndrome is emphasized.

ACTH-secreting medullary carcinoma of the thyroid: monitoring of clinical course with calcitonin and cortisol assays and immunohistochemical studies

The clinical course of a patient with Cushing's syndrome secondary to metastatic medullary carcinoma of the thyroid was documented with serial calcitonin and cortisol assays and tumor immunohistochemistry studies. Cortisol levels were originally markedly elevated but returned to normal after total thyroidectomy. These levels rose again when the patient developed liver metastases but normalized during chemotherapy, never to rise again despite the appearance of cervical lymph node metastasis. Calcitonin levels remained elevated throughout the course. The original tumor was composed of two cell lines: one containing both calcitonin and ACTH and another containing only calcitonin-reacting cells. However, the cervical metastasis showed a marked decrease in both cell lines with fever than 1% of cells reacting to ACTH, and only 25% to calcitonin. The almost total disappearance of ACTH-reacting cells may have been therapeutically induced or may represent a consequence of tumor progression.

Neuroendocrine carcinomas of the esophagus

Of a total of 928 primary esophageal cancers, 16 cases of "undifferentiated" esophageal carcinoma were isolated. The topographic and age distributions as well as the clinical presentation and evolution of these tumors were basically similar to those of the usual esophageal squamous carcinoma. By light microscopy, the tumors were comprised exclusively or predominantly of small, round-to-fusiform cells. The cytoplasm appeared scanty and the nuclei were comparatively large and hyperchromatic. Mitotic activity was prominent. Four of the sixteen neoplasms showed occasional foci of squamous differentiation. Argyrophilic cells were seen in all cases, although their number and distribution were variable. Occasional mucosubstance droplets were present in 2 cases. Argentaffin and amyloid stains were negative in all tumors. Ultrastructural studies revealed variable numbers of granules consisting of a dense core, a pale halo, and a single, delimiting membrane; these measured between 80 and 220 nm in diameter. Four of the sixteen cases displayed conspicuous tonofilament bundles and rare keratohyalin granules. The predominant ultrastructural common denominator of these tumors was the presence of characteristic neurosecretory-type granules; thus, their classification as neuroendocrine carcinomas would appear justified. Nevertheless, the abundant tonofilaments and the rare keratohyalin granules and mucosubstance droplets seen in several cases indicate that some of these epithelial cancers possess and express variable capabilities toward multidirectional differentiation.

Leydig-like cells in the adrenals of a woman with ectopic ACTH syndrome

A 36 year old woman with hypercorticism and markedly elevated blood ACTH levels underwent pituitary ablation because of suspected hypophysial Cushing's disease. Since no adenoma was detected in the anterior lobe and the hypercorticism persisted, a bilateral adrenalectomy was performed. Four months later lymph node and mediastinal metastases of an anaplastic small cell carcinoma, with the presence of argyrophil granulation, as well as immunoreactive 19-39ACTH, beta-LPH and alpha-endorphin, were found. The primary site of ectopic ACTH production was not revealed. A light and electron microscopic study of the adrenals, in addition to cortical hyperplasia, disclosed numerous small cells associated with nonmyelinated sympathetic nerve fibers and containing cytoplasmic inclusions indistinguishable from Reinke crystals. The Leydig-like cell-nonmyelinated nerve complexes, noted in both the adrenal cortex and medulla, showed perivascular localization, and their morphologic features were similar to those of hilus cells of the ovaries or extraglandular Leydig cells of the testis. The underlying mechanism accounting for the development of Leydig-like cells remained obscure; cytodifferentiation from pluripotent mesenchymal cells, possibly mediated by secretory products of sympathetic nerve fibers, may provide an explanation for their formation.

Coexistence of bilateral pheochromocytoma and pancreatic islet cell tumor: report of a case and review of the literature

A 14-year-old Japanese male with a previously undescribed combination of bilateral pheochromocytoma and an islet cell tumor of the pancreas is presented. The combination of endocrine neoplasms in this patient overlaps multiple endocrine neoplasia (MEN) Type 1 and Type 2. A total of 14 reported cases of MEN overlapping Type 1 and Type 2 is reviewed. Of the 14, 7 patients with acromegaly developed a paraganglioma(s), 2 patients with Sipple syndrome had a pituitary adenoma, and in the other 5 patients, an intestinal carcinoid or a pancreatic islet-cell tumor occurred in association with either a thyroid medullary carcinoma or a paraganglioma(s). We believe that the occurrence of MEN overlapping Type 1 and Type 2 is more than a fortuitous association, and can be explained on the basis of the neuroectodermal origin.

Pathogenesis of prolactin-secreting pituitary adenomas

42 women with amenorrhoea and hyperprolactinaemia had trans-sphenoidal surgery and resection of histologically verified pituitary adenomas. 74% of these patients developed amenorrhoea and/or galactorrhoea in immediate association with the use or discontinuation of oral contraceptives or post partum. There was enough adenomatous tissue for immunocytochemical studies in 35 specimens and specific localisation of prolactin was possible in 31. There is evidence that about 10% of the population have small pituitary tumours, and the majority of these tumours, though asymptomatic, are potentially prolactin-secreting. It is suggested that oestrogens, which are known to modulate prolactin secretion in normal human beings and in animals, can induce the growth and expression of otherwise silent pituitary lesions and that this should be considered a risk of oral-contraceptive use.

Ectopic ACTH syndrome: clinicopathological correlations

Ten out of 164 cases of bronchogenic carcinoma showed pathological evidence at necropsy of the ectopic ACTH syndrome. All occurred in association with oat-cell carcinoma, constituting 19% of that group. The pathological features consisted of adrenocortical hyperplasia confined to the zona fasciculata and Crooke's hyaline change in the pituitary. Immunoperoxidase stainable ACTH was detected in the pituitary but not in the carcinoma tissue, a surprising finding, which may be due to the different nature of ACTH present in tumour tissue. The ectopic ACTH syndrome was diagnosed ante mortem in only four out of 10 patients on the basis of hypokalaemia and metabolic alkalosis. The lack of clinical pointers in all but terminal cases is discussed as well as possible measures for earlier diagnosis.

[Classification and pathogenesis of pituitary adenomas in humans and animal experiments]

Pituitary adenomas should be classified by the grade of differentiation in undifferentiated (acidophil or mucoid cell type) and in highly differentiated types. Corresponding to their structural identify, the latter are separated into GH cell-, prolactin cell-, TSH cell-, or ACTH cell-adenomas. Chromophobe adenomas which are nearly ungranulated tumors, were divided into small cell- and large cell-adenomas and into oncocytic adenomas. Undifferentiated acidophil and GH cell-adenomas mostly induce an acromegaly. Undifferentiated mucoid and ACTH cell-tumors result exclusively in a hyperfunction of ACTH. The morphological correlate of a hyperprolactinemia is variable. Chromophobe adenomas of small cell type and oncocytic adenomas are on the whole endocrinologically inactive. Studies of the paraadenomatous adenohypophysis let us assume that prolactin cell- and ACTH cell-adenomas develop from hyperplasias of the specific cells. In animal experiments, pituitary adenomas can be classified into highly differentiated (prolactin cell-, TSH cell-, or ACTH cell-adenomas) and also into undifferentiated adenomas. The highly differentiated ones develop hyperplasiogenic and are monohormonally active. They are on the whole structurally identical with the human adenomas. The undifferentiated ones are the consequence of a process of dedifferentiation. They show in part a plurihormonal activity.

Fine structure of adrenal cortex in ectopic ACTH syndrome

A 49-year-old man with pancreatic adenocarcinoma, suggestive of islet cell origin, showed clinical and biochemical features of ectopic ACTH syndrome and underwent bilateral adrenalectomy. Light microscopy revealed adrenocortical compact cell hyperplasia and lipid depletion. The zona glomerulosa was detected in small foci and fasciculata cells extended up to the capsule. Electron microscopy disclosed enlargement of adrenocortical cells, massive SER accumulation, RER increase, lipid depletion, prominence of the Golgi apparatus and development of complex interdigitations between closely apposed cell membranes. These changes were attributed to the stimulative effect of ACTH discharged from the non-pituitary tumor. Mitochondria exhibited enlargement, pleomorphism and cavitation. Most of the adrenocortical cells contained mitochondria with vesicular cristae--a characteristic feature of fasciculata cells. In a few cells, under the capsule, some mitochondria possessed lamellar cristae. Gradual transformation to the vesicular type was, however, apparent indicating that mitochondria are not rigidly constant structures.

Embryonal carcinoma of the ovary: a clinicopathologic entity distinct from endodermal sinus tumor resembling embryonal carcinoma of the adult testis

The clinical and pathologic features of 15 examples of a hitherto undescribed germ cell tumor of the ovary are delineated. This tumor resembles the embryonal carcinoma of the adult testis and may be distinguished from the endodermal sinus tumor on the basis of its histologic and immunohistochemical characteristics. An indirect immunoperoxidase method for the localization of human chorionic gonadotropin (HCG) and alpha-fetoprotein (AFP) was done on formalin-fixed paraffin-embedded tissue from 10 neoplasms; HCG was present in all 10 neoplasms, and AFP was found in seven. HCG was indentified only in cells resembling syncytiotrophoblast, whereas AFP was present only in mononuclear embryonal cells, indicating that the two protein antigens were localized in different cell types. Abnormal hormonal manifestations, consisting of precocious puberty, irregular bleeding, amenorrhea, or hirsutism, were present in nine (60%) of the patients. The actuarial survival for the entire group was 39%; for those with stage I tumors, 50%. We are proposing the term "embryonal carcinoma" for this neoplasm in order to distinuish it from the more common endodermal sinus tumor of the ovary and to emphasize the histologic similarity to embryonal carcinoma of the adult testis.

Ultrastructure of hemangiopericytoma associated with paraneoplastic hypoglycemia

A recurred and metastasized hemangiopericytoma of menigeal origin caused a terminal hypoglycemia syndrome in a 40 year old man. The disease had been observed over a period of 10 years. The total weight of the tumour metastases was 1800 g. Electron microscopical examination of the tumour cells revealed, in particular, a markedly developed ergastoplasm, prominent Golgi complexes surrounded by many microvesicles, round to ovoid electron dense bodies and fine fibrillar structures. Furthermore, large deposits of basement membrane-resembling material were found in the pericapillary and intercellular spaces. On the basis of the structural characteristics which indicate distinct synthesizing capacity of the cells, an excessive glucose consumption by the tumour is suggested to be an important factor in the pathogenesis of tumour hypoglycemia. The question whether the ultrastructure of the tumour also exhibits secretory processes, which may be related to the release of a presumed inhibitor of hepatic gluconeogenesis and/or glycogenolysis, remains open. Typical granules as in polypeptide hormon secreting cells were not observed. The possibility that the demonstrated electron dense membrane limited bodies represent atypical secretory granules is discussed.