Turner's syndrome followed by acromegaly in the third decade of life: an unusual coincidence of two rare conditions

We present an unusual coincidence of acromegaly and Turner's syndrome. A girl was diagnosed with Turner's syndrome when she presented with short stature, primary amenorrhea, Hashimoto's thyroiditis, and some heart and renal anomalies. No therapy with growth hormone and only a few months treatment with estrogen-progestin was given. A typical picture of acromegaly occurred in the third decade of her life. Bone radiographs and densitometry suggested the more pronounced influence of acromegaly within the skeleton, but no features typical for acromegaly were found in the cardiovascular system. To our knowledge no case of coincidence of the above mentioned conditions has been reported to date. The influence of both of these conditions on bones and heart is discussed.

'Spindle cell oncocytoma' of the adenohypophysis: a tumor of folliculostellate cells?

We describe five primary tumors of the adenohypophysis featuring mitochondrion-rich spindle cells. The patient ages ranged from 53 to 71 years (mean 61.6 years); two were female. All presented with panhypopituitarism. Two also had visual field defect. On neuroimaging all tumors showed suprasellar extension and were indistinguishable from pituitary adenoma. None showed imaging or operative evidence of dural involvement. All were gross totally removed: four by transsphenoidal surgery and one by frontal craniotomy. Follow-up ranged from 2 to 68 months (mean 35.4 months). No recurrences were noted. The clinical workup was noncontributory in all but two patients: one (case no. 4) with an oncocytic thyroid adenoma and another (case no. 5) with squamous carcinoma of both the uterine cervix and of vocal cord. Histologically, the five tumors were composed mainly of fascicles of spindle cells with eosinophilic, granular cytoplasm. Mitoses were rare and necrosis was absent. Neoplastic cells were immunoreactive for vimentin, epithelial membrane antigen, S-100 protein, and galectin-3. Stains for pituitary hormones, synaptophysin, chromogranin, glial fibrillary acidic protein, cytokeratin CAM5.2, smooth muscle actin, CD34, and CD68 were negative. No thyroglobulin immunoreactivity was noted in the tumor of case no. 4. Ultrastructurally, the neoplastic cells contained numerous mitochondria with lamellar cristae. The neoplastic cells were linked by intermediate junctions and desmosomes. No secretory granules were noted. The histologic, immunohistochemical, and fine structural features of these tumors were unlike those of pituitary adenoma or any other primary sellar tumor. A derivation from adenohypophyseal folliculostellate cells is suggested.

Autoimmune polyglandular endocrinopathy and anterior hypophysitis in a 14 year-old girl presenting with delayed puberty

We report a 14 year-old peripubertal girl who presented at our clinic with the primary complaint of delayed puberty. She was asymptomatic except for vague complaints of fatigue. Physical examination was significant for mucosal hyperpigmentation and lack of secondary sexual characteristics. Laboratory evaluation revealed a morning cortisol concentration of <0.1 microg/dl (normal range [n.r.]: 4.3-22.4 microg/dl) and a simultaneous ACTH concentration of 2 pg/ml (n.r. 25-62 pg/ml); FSH 66.8 IU/l (n.r. for age: 1-12.8 IU/l); LH 41.1 IU/l (n.r. for age: 1-12 IU/l); E2 38 pg/ml (n.r. for age: 7-60 pg/ml). She had a flat cortisol response to an ACTH stimulation test. MRI of the pituitary gland failed to reveal a lesion. Plasma renin activity, thyroid function tests, parathyroid hormone, prolactin, IGF-I, IGFBP-3 concentrations and serum electrolytes were normal. However, her urinary sodium concentration was high. She was diagnosed with autoimmune polyglandular endocrinopathy including ovarian failure, adrenal failure and autoimmune anterior hypophysitis presenting as isolated ACTH deficiency. We emphasize that autoimmune etiology should be considered in the differential diagnosis of delayed puberty and ovarian failure and that the presence of other endocrinopathies should be searched for even in asymptomatic patients.

Genes expressed in the mouse pituitary corticotrope AtT-20/D-16v tumor cell line

The pituitary corticotrope AtT-20 stable cell line has been used as a model system to study peptide secretion, glucocorticoid regulation, and several other processes. In order to better understand this model cell line, a phage cDNA library was generated from AtT-20/D-16v cell mRNA and cDNA sequences were obtained for 317 clones representing 203 known genes and 48 novel cDNAs. The sequencing results revealed the prevalence of the mouse leukemia virus in this cell line and also identified a number of putatively secreted molecules that were not previously recognized as being secreted from AtT-20/D-16v cells or pituitary corticotropes. Nine completely novel cDNAs and 39 cDNAs homologous to known ESTs were also identified. A listing of other genes known to be expressed in AtT-20/D-16v cells is also provided.

Dynamic MR imaging of neurohypophyseal germ cell tumors for differential diagnosis of infundibular diseases

PURPOSE

To investigate the MR dynamic patterns of neurohypophyseal germ cell tumors (GCTs) for differential diagnosis of infundibular diseases affecting young people.

MATERIAL AND METHODS

Eleven patients with neurohypophyseal GCTs underwent dynamic MR studies with Tl-weighted spin-echo (SE) or turbo SE techniques. Other infundibular lesions, including adenohypophysitis (n=3), Langerhans' cell histiocytosis (LCH, n=2), and 1 hemangioblastoma from von Hippel-Lindau disease, were also evaluated. Serial images were obtained every 15 s (turbo SE) or 30 s (SE technique) for 240 s after rapid injection of contrast medium. The dynamic patterns were analyzed quantitatively with the contrast medium enhancement ratio.

RESULTS

On dynamic MR images, GCTs typically showed a gradual enhancement increase with a peak between 105 s and 180 s, while two showed a relatively rapid increase. LCH and hemangioblastoma showed a dynamic pattern similar to GCTs, while adenohypophysitis demonstrated a sharp rise and a steeper wash-out with an obvious peak before 90 s.

CONCLUSION

Typical dynamic pattern of GCTs was the gradual enhancement increase without wash-out. Dynamic MR imaging can distinguish GCTs from adenohypophysitis, but is not useful for differentiation from LCH.

Limited effects of placental and pituitary growth hormone on cytokine expression in vitro

The hypothesis that growth hormone (GH) can affect immune responses in man has been evaluated by monitoring cytokine expression in cultures from peripheral blood mononuclear cells, by enzyme-linked immunosorbent assay (ELISA) and ribonuclease protection assay, and in tonsillar cells by ELISA. In addition to pituitary GH (GH-N), the placental form (GH-V), differing from pituitary GH by 13 amino acids has also been tested. Only few effects reached statistical significance and were in no case greater than 15%. Pituitary GH slightly reduced IL-5 production and stimulated IFN-gamma production. The latter effect was also observed with prolactin and could thus be induced through the prolactin receptor. It is proposed that GH has no strong effects on the parameters investigated, possibly as a result of redundancy in the cytokine network. Alternatively, effects on leukocytes are mediated by other tissues such as the liver or are clear only in response to stronger challenges.

Molecular analysis of LHX3 and PROP-1 in pituitary hormone deficiency patients with posterior pituitary ectopia

The cause of posterior pituitary ectopia associated with anterior pituitary hormone deficiencies is unknown. We describe children with combined pituitary hormone deficiency (CPHD) or isolated GH deficiency. In all cases, magnetic resonance imaging examination revealed abnormal pituitary gland development featuring ectopic posterior lobe location and frequently hypoplastic anterior lobes. Embryonic development of the pituitary requires the coordinated expression of specific transcription factors. Mutations of the PIT-1 and PROP-1 transcription factors are responsible for CPHD in some patients with normally positioned posterior pituitaries. In mice, the Lhx3 LIM homeodomain transcription factor is required for both structural development and cellular differentiation of the pituitary gland. Thus, we hypothesized that mutations in one or both of the two human LHX3 isoforms are responsible for posterior pituitary ectopia associated with anterior pituitary hypopituitarism. Comprehensive molecular analysis of the LHX3 isoforms was performed to test this hypothesis. No loss of function mutations in the LHX3 gene were detected. In addition, analysis of PROP-1 did not reveal mutations that might cause this phenotype. These studies suggest that the abnormal processes leading to the development of CPHD or GH deficiency associated with posterior pituitary ectopia are not a result of aberrant LHX3 or PROP- 1 function, but may be caused by defects at other gene loci.

Pituitary insufficiency after penetrating injury to the sella turcica

We report a 28-year-old male patient with a pituitary insufficiency after a simple fracture of the sella turcica. He was injured by a long nail that punctured the lower jaw. No fracture other than that of the sella turcica was detected. An endocrinological examination revealed both anterior and pituitary dysfunction and diabetes insipidus that continued for about two months.

Long-term outcome of endocrine function in patients with neurohypophyseal germinomas

Since neurohypophyseal germinomas occur at the pituitary and hypothalamic axis in children and adolescents, the endocrinopathy is one of the common and critical QOL determinants. We carried out a retrospective study on the outcome of endocrine function in patients with neurohypophyseal germinoma, in order to improve or preserve pituitary function after treatment. Sixteen patients (7 men and 9 women), aged 6 to 26 years were admitted and followed up for 95.3 (14-197) months. DI was noted in 12 patients in pretreatment and 16 in posttreatment regardless of tumor size. We carried out the replacement of GH in all 8 patients, presenting the symptoms under 15 years of age. Gonadal or gonadotropic, thyroid and adrenal hormones were replaced in 9, 12 and 15 patients, respectively. Patients with large tumor compressing chiasm or hypothalamus needed hormonal replacement such as gonadal or gonadotropic and thyroid hormones more frequently (<0.01) than those with small one. In addition, two patients with a small tumor at the pituitary stalk and the 3rd ventricle floor showed the improvement of secretion pattern in gonadotropins and ACTH after chemotherapy, although they later needed radiation therapy to control the tumor. Based on our study and review of literature, the endocrinological studies before and after treatment demonstrated that pituitary dysfunction present before treatment persisted or worsened even after tumor remission, except for patients with small and localized ones. The poor endocrine results is considered to be largely radiation-related. Chemotherapy alone seems to be insufficient to obtain complete response (CR). To avoid radiation related pituitary injury, combination of 24 Gy or less dosage of radiation and appropriate chemotherapy is essential. The earlier diagnosis by repeatedly using neuroimaging and serum and CSF tumor markers and earlier initiation of treatment, before irreversible pituitary-hypothalamic damage occurs, contributes to improvement of the outcome of pituitary functions in patients with neurohypophyseal germinomas.

Ectopic pituitary with pregnancy changes in a benign cystic teratoma of the ovary

We report on the rare finding of pituitary tissue, including both adenohypophysis and neurohypophsis, in a mature cystic teratoma of the ovary removed from a 26 year old female at the time of cesarean section. Immunocytochemistry of the ectopic anterior pituitary component showed pregnancy-related changes that have previously only been described in pituitaries obtained at autopsy.

The synaptophysin-synaptobrevin complex is developmentally upregulated in cultivated neurons but is absent in neuroendocrine cells

Regulated secretion requires the formation of a fusion complex consisting of synaptobrevin, syntaxin and SNAP 25. One of these key proteins, synaptobrevin, also complexes with the vesicle protein synaptophysin. The fusion complex and the synaptophysin-synaptobrevin complex are mutually exclusive. Using a combination of immunoprecipitation and crosslinking experiments we report here that the synaptophysin-synaptobrevin interaction in mouse whole brain and defined brain areas is upregulated during neuronal development as previously reported for rat brain. Furthermore the synaptophysin-synaptobrevin complex is also upregulated within 10-12 days of cultivation in mouse hippocampal neurons in primary culture. Besides being constituents of small synaptic vesicles in neurons synaptophysin and synaptobrevin also occur on small synaptic vesicle analogues of neuroendocrine cells. However, the synaptophysin-synaptobrevin complex was not found in neuroendocrine cell lines and more importantly it was also absent in the adrenal gland, the adenohypophysis and the neurohypophysis although the individual proteins could be clearly detected. In the rat pheochromocytoma cell line PC 12 complex formation between synaptophysin and synaptobrevin could be initiated by adult rat brain cytosol. In conclusion, the synaptophysin-synaptobrevin complex is upregulated in neurons in primary culture but is absent in the neuroendocrine cell lines and tissues tested. The complex may provide a reserve pool of synaptobrevin during periods of high synaptic activity. Such a reserve pool probably is less important for more slowly secreting neuroendocrine cells and neurons. The synaptophysin on small synaptic vesicle analogues in these cells appears to resemble the synaptophysin of embryonic synaptic vesicles since complex formation can be induced by adult brain cytosol.

Somatic MEN1 gene mutation does not contribute significantly to sporadic pituitary tumorigenesis

Pituitary adenomas are a common manifestation of multiple endocrine neoplasia type 1 (MEN1) but most of them occur sporadically. There are only a few well defined genetic abnormalities known to occur in these sporadic tumours. The MEN1 gene located on 11q13 has recently been cloned and allelic deletion and mutation analysis studies have implicated the MEN1 gene in a significant fraction of the sporadic counterparts of typical MEN1 neoplasms (parathyroid tumours, insulinomas and gastrinomas). To determine if MEN1 gene inactivation is also involved in the development of sporadic pituitary adenomas, allelic deletions of chromosome 11q13 and MEN1 gene mutations and polymorphisms were assessed in 35 sporadic tumours of the anterior pituitary (9 prolactin-secreting, 8 GH-secreting, 3 TSH-secreting, 2 TSH/GH-secreting, 4 Cushing, 9 silent). Thirty-one tumours were found to be heterozygous for at least one MEN1 intragenic polymorphism (25 cases) or for a flanking gene polymorphism (6 cases). The remaining tumours were not informative. No mutations were found in any tumour except in one prolactinoma which was homozygous or hemizygous for a mutation (1-117 C-->T) in a region close to the promoter. Unfortunately, blood or normal tissue was not available in this case. Our data show that somatic MEN1 mutations do not contribute significantly to tumorigenesis of sporadic pituitary adenomas and suggest that mutation of other genes are likely to contribute to the pathogenesis of these tumours.

17Beta-hydroxysteroid dehydrogenase type 1, 2, 3, and 4 expression and enzyme activity in human anterior pituitary adenomas

17Beta-hydroxysteroid dehydrogenase (17betaHSD) isoforms reversibly catalyze the final step in the formation of estradiol (E2) from estrone (E1) and the formation of testosterone from androstenedione. We have investigated 17betaHSD type 1, 2, 3, and 4 gene expression and 17betaHSD estrogenic activity in human anterior pituitary adenomas. 17BetaHSD messenger ribonucleic acid (mRNA) expression was studied by RT-PCR in 42 pituitary tumors and 3 normal pituitaries, 17betaHSD activity was studied in 11 tumors and 17betaHSD type 1 was immunolocalized in vitro in 6 tumors. 17BetaHSD type 1 gene expression was detected in 34 of 42 adenomas in all tumor subtypes; 17betaHSD type 2 mRNA was detected in 18 of 42 adenomas, but not in prolactinomas; 17betaHSD type 3 mRNA was detected in 12 of 42 adenomas, but not in corticotropinomas; 17betaHSD type 4 was expressed in 20 of 42 adenomas by all adenoma subtypes. Reversible 17betaHSD activity was found in 9 of 11 adenomas, and 17betaHSD type 1 immunopositivity was cytoplasmically distributed in all 6 adenomas in vitro. All 4 17betaHSD isoforms are variably expressed in human anterior pituitary adenomas, which also show 17betaHSD enzyme activity, suggesting that 17betaHSD may play an important role in regulating the local cellular levels of estradiol.

Ki-67 labelling index and invasiveness among anterior pituitary adenomas: analysis of 103 cases using the MIB-1 monoclonal antibody

AIMS

To investigate the relation between proliferative activity of anterior pituitary adenomas, quantified by the Ki-67 labelling index, and their invasive behaviour.

METHODS

Expression of Ki-67 was evaluated in 103 anterior pituitary adenomas consecutively operated on in a 36 month period and correlated with surgical evidence of invasiveness.

RESULTS

Non-invasive (n = 65) and invasive (n = 38) adenomas were identified from surgically verified infiltration of sellar floor dura and bone. The wall of the cavernous sinus was infiltrated in 16 cases. Forty one adenomas were non-functioning and 62 functioning (24 prolactin, 21 growth hormone, 10 ACTH, seven mixed). The overall mean (SD) Ki-67 labelling index was 2.64 (3.69) per cent (median 1.5). The mean index was 3.08 (4.59) per cent in functioning and 1.97 (1.78) per cent in non-functioning tumours; 5.47 (9.52) per cent in ACTH adenomas and 2.33 (2.42) per cent in others (p = 0.01); 3.71 (5.17) per cent in invasive and 2.01 (2.45) per cent in non-invasive adenomas (p = 0.027); and 5.58 (7.24) per cent in cavernous sinus infiltrating v 2.10 (2.39) per cent in cavernous sinus non-infiltrating adenomas (p = 0.0005). To identify a value of labelling index beyond which adenomas should be considered invasive and another beyond which cavernous sinus infiltration should be suspected, normality Q-Q plots were obtained: a threshold labelling index of 3.5% for invasive adenomas and of 5% for cavernous sinus infiltrating adenomas was defined, with statistically significant differences (p = 0.02 and p = 0.004, respectively).

CONCLUSIONS

The Ki-67 labelling index can be considered a useful marker in determining the invasive behaviour of anterior pituitary adenomas.

Biochemical, biophysical, and pharmacological characterization of bacterially expressed human agouti-related protein

The agouti-related protein gene (Agrp) is a novel gene implicated in the control of feeding behavior. The hypothalamic expression of Agrp is regulated by leptin, and overexpression of Agrp in transgenic animals results in obesity and diabetes. By analogy with the known actions of agouti, these data suggest a role for the Agrp gene product in the regulation of melanocortin receptors expressed in the central nervous system. The availability of recombinant, highly purified protein is required to fully address this potential interaction. A nearly full-length form of AGRP (MKd5-AGRP) was expressed in the cytosolic or soluble fraction of Escherichia coli and appeared as large intermolecular disulfide-bonded aggregates. Following oxidation, refolding, and purification, this protein was soluble, and eluted as a single symmetric peak on RP-HPLC. Circular dichroism studies indicated that the purified protein contains primarily random coil and beta-sheet secondary structure. Sedimentation velocity studies at neutral pH demonstrated that MKd5-AGRP is monomeric at low micromolar concentrations. Mobility shifts observed using SDS-PAGE under reducing and nonreducing conditions for bacterially expressed and mammalian expressed AGRP were identical, an indication of a similar disulfide structure. The purification to homogeneity of a second, truncated form of AGRP (Md65-AGRP) which was expressed in the insoluble or inclusion body fraction is also described. Both forms act as competitive antagonists of alpha-melanocyte stimulating hormone (alpha-MSH) at melanocortin-3 (MC-3) and melanocortin-4 receptors (MC-4). The demonstration that AGRP is an endogenous antagonist with respect to these receptors is a unique mechanism within the central nervous system, and has important implications in the control of feeding.

Inhibition of lipoprotein lipase activity following injection of pituitary extracts into rabbits

Rabbits given a single subcutaneous injection of an alkaline extract of hog, bovine, or human anterior pituitary glands developed marked hyperlipemia within 12 to 24 hours. The injections in some instances were followed by sickening and death of the animal, though no anatomical changes responsible for these consequences could be determined. No such sequelae were observed in animals given much larger injections of comparable extracts made from other tissues. An inhibitor to lipoprotein lipase appeared regularly in the serum of the injected animals in association with the hyperlipemia. The injection of heparin into such animals failed to result in the elaboration of clearing factor, and serum from these animals inhibited in vitro the hydrolysis of lipid emulsions by active lipoprotein lipase obtained from normal rabbits or human beings. The inhibitor was produced only in vitro by the pituitary extracts. It did not antagonize the anticoagulant action of heparin, and is probably a lipoprotein.

Identification of the adrenocorticotrophin-producing cells in the rat hypophysis by autoradiography

The relative rates of protein (hormone) synthesis and secretion by the various cell types in the anterior hypophysis of the rat have been studied by means of autoradiography. Normal and adrenalectomized male rats were injected with tritiated glycine and their hypophyses removed and fixed at 20, 40, and 90 minutes and 15 hours after injection. Autoradiograms of the hypophysial sections were prepared and autoradiographic grains were counted in the film overlying the cytoplasm of individual cells. With the aid of this method, a unique cell type was identified in the hypophyses of adrenalectomized rats. This cell is morphologically distinct from "gonadectomy cells," "thyroidectomy cells," and from previously described normal cell types, and is therefore designated as the "adrenalectomy cell." Among the 7 cell types differentiated in this study, the "adrenalectomy cell" had the highest tritium content and, in addition, at the time intervals studied this cell had the fastest rate of appearance and disappearance of protein tritium. This autoradiographic evidence of rapid protein (or polypeptide) turnover following adrenalectomy indicates that the "adrenalectomy cell" is the site of adrenocorticotrophin production in the adrenalectomized rat. Further autoradiographic and cytological evidence is presented which suggests that the "adrenalectomy cells" may be derived from chromophobes, and that a portion of the "large chromophobes" as defined in this study may be the site of adrenocorticotrophin production in the normal rat.

Isolation and biochemical study of secretory granules from rat pituitary glands

Secretory granules from anterior pituitary glands of young adult male castrate rats were isolated by differential centrifugation, microfiltration, and discontinuous density gradient centrifugation. The granules were obtained as pellets, sectioned, and studied with the electron microscope. A major part of the gonadotropin and a substantial amount of the TSH were associated with the isolated granules. Negligible amounts of growth hormone and prolactin were present as contaminants. Succinic dehydrogenase, glucose-6-phosphatase, acid protease, and acid and alkaline phosphatases were not found in the granules. Alkaline protease was the only enzyme found to be associated with the granules, and it is suggested, in the light of these results, that the alkaline protease may be involved in the release of the hormones.

The intracellular localization of hormonal activity in transplantable thyrotropin-secreting pituitary tumors in mice

Mouse pituitary tumors secreting almost exclusively thyroid stimulating hormone have been characterized electron microscopically. Tumors of known thyrotropin content were separated into nuclear, mitochondrial, microsomal, and soluble fractions by differential centrifugation. The hormonal activity of these fractions was correlated with that of the total homogenates and with their nitrogen and phosphorus content. Essentially all the thyrotropin of the homogenate was recovered in a particulate fraction sedimenting between 20,000 and 40,000 g. This fraction contained the RNA granules and membranous components typical of microsomal pellets, but also showed the presence of small dense bodies surrounded by smooth membranes. These bodies were also visible within the endoplasmic reticulum of intact cells, and it is postulated that these bodies may represent the sites of intracellular elaboration and/or storage of TSH. Thyrotropin is tightly associated with microsomal particles but can be brought into solution by treatment with alkaline media, deoxycholate, and certain organic solvents.