Therapeutic outcomes in patients undergoing surgery after diagnosis of Cushing's disease: A single-center study

This study aimed to investigate early and late outcomes of patients who underwent neurosurgical procedures for the preoperative diagnosis of Cushing's disease (CD). Clinical, endocrine, imaging, and histologic data from 252 patients undergoing pituitary surgery at Toranomon Hospital through the end of 2012 were entered into a database and statistically analyzed. In 22 of these patients (8.7%; positive venous sampling in 15 and negative venous sampling in 7 patients), tumors were invisible on magnetic resonance imaging (MRI) and 42.9% of them achieved remission. In the remaining 230 patients, 93.5% of those with microadenomas (n=154) and 71.1% of those with macroadenomas (n=76) achieved early postoperative remission, with recurrence rates of 2.7% and 14.8%, respectively, during a 72.5-month median follow-up. In multivariate analyses, cavernous sinus invasion (CSI; odds ratio [OR], 13.0), type of surgery (OR, 4.0), and tumor size (OR, 2.7) were significant preoperative factors affecting early postoperative results, whereas peak cortisol levels ≥9.4 μg/dL in response to corticotropin-releasing hormone (CRH) and CSI were significant factors predicting recurrence. Tumor recurrence was more common in patients with non-densely granulated adenomas than in patients with densely granulated adenomas. We propose that the higher remission and lower recurrence rates in this series are due to our surgical strategies, including extracapsular tumor removal, aggressive resection of tumors with CSI, extended transsphenoidal surgery (TSS), or a combined approach for large/giant adenomas. Appropriate multimodal treatments, including radiotherapy, medication, and repeated surgery in patients with persistent or recurrent CD, could result in better overall outcomes than previously achieved.

Clinicopathological characteristics and therapeutic outcomes in thyrotropin-secreting pituitary adenomas: a single-center study of 90 cases

OBJECT

The aim of this study was to analyze clinicopathological characteristics and treatment outcomes in a large single-center clinical series of cases of thyrotropin (TSH)-secreting pituitary adenomas.

METHODS

The authors retrospectively reviewed clinical, pathological, and treatment characteristics of 90 consecutive cases of TSH-secreting pituitary adenomas treated with transsphenoidal surgery between December 1991 and May 2013. The patient group included 47 females and 43 males (median age 42 years, range 11-74 years).

RESULTS

Sixteen tumors (18%) were microadenomas and 74 (82%) were macroadenomas. Microadenomas were significantly more frequent in the more recent half of our case series (12 of 45 cases) (p = 0.0274). Cavernous sinus invasion was confirmed in 21 patients (23%). In 67 cases (74%), the tumors were firm elastic or hard in consistency. Acromegaly and hyperprolactinemia were observed, respectively, in 14 (16%) and 11 (12%) of the 90 cases. Euthyroidism was achieved in 40 (83%) of 48 patients and tumor shrinkage was found in 24 (55%) of 44 patients following preoperative somatostatin analog treatment. Conventional transsphenoidal surgery, extended transsphenoidal surgery, and a simultaneous combined supra- and infrasellar approach were performed in 85, 2, and 3 patients, respectively. Total removal with endocrinological remission was achieved in 76 (84%) of 90 patients, including all 16 (100%) patients with microadenomas, 60 (81%) of the 74 with macroadenomas, and 8 (38%) of the 21 with cavernous sinus invasion. None of these 76 patients experienced tumor recurrence during a median follow-up period of 2.8 years. Stratifying by Knosp grade, total removal with endocrinological remission was achieved in 34 of 36 patients with Knosp Grade 0 tumors, all 24 of those with Grade 1 tumors, 12 of the 14 with Grade 2 tumors, 6 of the 8 with Grade 3 tumors, and none of the 8 with Grade 4 tumors. Cavernous sinus invasion and tumor size were significant independent predictors of surgical outcome. Immunoreactivity for growth hormone, prolactin, or both hormones was present in 32, 9, and 24 patients, respectively. The Ki-67 labeling index was less than 3% in 71 (97%) of 73 tumors for which it was obtained and 3% or more in 2. Postsurgery pituitary dysfunction was found in 15 patients (17%) and delayed hyponatremia was seen in 9.

CONCLUSIONS

TSH-secreting adenomas, particularly those in the microadenoma stage, have increased in frequency over the past 5 years. The high surgical success rate achieved in this series is due to relatively early diagnosis and relatively small tumor size. In addition, the surgical strategies used, such as extracapsular removal of hard or solid adenomas, aggressive resction of tumors with cavernous sinus invasion, or extended transsphenoidal surgery or a simultaneous combined approach for large/giant multilobulated adenomas, also may improve remission rate with a minimal incidence of complications.

A novel C-terminal nonsense mutation, Q315X, of the aryl hydrocarbon receptor-interacting protein gene in a Japanese familial isolated pituitary adenoma family

Although the cause of familial isolated pituitary adenoma (FIPA) remains unknown in many cases, germline mutations in the aryl hydrocarbon receptor-interacting protein (AIP) gene were identified in approximately 20 % of families with FIPA. We investigated the AIP gene mutation by a standard sequencing method in 12 members of a Japanese two-generation FIPA family, which includes 3 patients with early-onset acromegaly. Multiplex ligation-dependent probe amplification analysis in a tumor sample was attempted to examine the loss of heterozygosity (LOH) in the locus. The effect of the detected mutation on cell proliferation was investigated. A germline mutation of c.943C > T (p.Q315X) generating an AIP protein with the C-terminal end deleted was found in the FIPA family. Biallelic inactivation of AIP by a combination of the germline mutation and LOH at 11q13 was confirmed in the tumor. The nonsense mutation disrupted the ability to inhibit cell proliferation. We conclude that p.Q315X mutation in the AIP gene is a pathogenic variant and the C-terminal region of AIP plays an important role in the predisposition to pituitary adenomas.

The relative trending accuracy of noninvasive continuous hemoglobin monitoring during hemodialysis in critically ill patients

The pulse CO-Oximeter (Radical-7; Masimo Corp., Irvine, CA) is a multi-wavelength spectrophotometric method for noninvasive continuous monitoring of hemoglobin (SpHb). Because evaluating the relative change in blood volume (ΔBV) is crucial to avoid hypovolemia and hypotension during hemodialysis, it would be of great clinical benefit if ΔBV could be estimated by measurement of SpHb during hemodialysis. The capability of the pulse CO-Oximeter to monitor ΔBV depends on the relative trending accuracy of SpHb. The purpose of the current study was to evaluate the relative trending accuracy of SpHb by the pulse CO-Oximeter using Crit-Line as a reference device. In 12 patients who received hemodialysis (total 22 sessions) in the intensive care unit, ΔBV was determined from SpHb. Relative changes in blood volume determined from SpHb were calculated according to the equation: ΔBV(SpHb)=[starting SpHb]/[current SpHb] - 1. The absolute values of SpHb and hematocrit measured by Crit-Line (CL-Hct) showed poor correlation. On the contrary, linear regression analysis showed good correlation between ΔBV(SpHb) and the relative change in blood volume measured by Crit-Line [ΔBV(CL-Hct)] (r=0.83; P≤0.001). Bland-Altman analysis also revealed good agreement between ΔBV(SpHb) and ΔBV(CL-Hct) (bias, -0.77%; precision, 3.41%). Polar plot analysis revealed good relative trending accuracy of SpHb with an angular bias of 4.1° and radial limits of agreement of 24.4° (upper) and -16.2° (lower). The results of the current study indicate that SpHb measurement with the pulse CO-Oximeter has good relative trending accuracy.

Perivascular epithelioid cell tumor of the rectum: report of a case and review of the literature

We report a case of perivascular epithelioid cell tumor arising in the rectum of a 55-year-old woman. The tumor was treated by transanal endoscopic microsurgery. After 1 year follow-up, the patient is alive with no radiologic or endoscopic evidence of recurrence. Perivascular epithelioid cell tumor is a rare mesenchymal tumor characterized by co-expression of melanocytic and smooth muscle markers. This rare tumor can arise in various organs, including the falciform ligament, uterus, uterine cervix, liver, kidney, lung, breast, cardiac septum, pancreas, prostate, thigh, and gastrointestinal tract. Perivascular epithelioid cell tumor of the gastrointestinal tract is very rare, with only 23 previously reported cases. We review the literature on perivascular epithelioid cell tumors arising in the gastrointestinal tract.

276 ACTIVATION OF ROUND SPERMATID-INJECTED OOCYTES USING PHOSPHOLIPASE C ZETA IN PIGS

In several mammalian species, the generation of offspring by round spermatid injection has been reported. However, in domestic species, including pigs, no one has reported success to date. One of the reasons is that round spermatid-injected oocytes require artificial stimuli for oocyte activation, but the developmental ability of the oocytes is low in pigs, suggesting that a more optimal activation protocol is needed. During fertilization, a sperm-derived factor induces repetitive increases in intracellular calcium, known as calcium oscillations. It is now acknowledged that phospholipase C zeta (PLCζ) has an essential role in inducing calcium oscillations, not only in mammals, but also in several other vertebrates. Therefore, if PLCζ is used as a stimulus for oocyte activation, the efficiency of oocyte activation can be improved. Recently, we found that equine PLCζ (ePLCζ) has higher activity than those of other mammalian species to be studied. In the present study, we examined whether injection of ePLCζ complementary RNA (cRNA) improves the activation of round spermatid-injected oocytes in pigs. First, we examined whether ePLCζ is expressed in round spermatids. Porcine round spermatids were isolated from adult testes, and immunostaining using anti-PLCζ antibody was carried out. The PLCζ was localised at the head and tail in mature sperm, and a part of the round spermatid was also stained. Next, we evaluated the developmental ability of round spermatid-injected oocytes activated by different protocols (electrical pulses v. injection of ePLCζ cRNA). The cytoplasts were then injected with round spermatids. One hour later, the oocytes were divided into two groups. In group 1, the oocytes were activated by a direct current pulse (150 V mm–1 and 60 µs). In group 2, the oocytes were injected with ePLCζ cRNA as follows: the reagent (0.1 µg µL–1) was diluted in injection buffer [100 mM KCl and 10 mM HEPES (pH = 7.0)], loaded into glass micropipettes by aspiration, and delivered to the ooplasm by pneumatic pressure (Narishige, Tokyo, Japan). Each oocyte received 3 to 10 pL (1 to 3% of the total volume of the oocyte). After the stimulations, oocytes were cultured in PZM-5 under 38.5°C in a humidified incubator (95% air, 5% CO2). In the ePLCζ-injected group, rates of pronuclear formation (n = 22/32, 68.8%) and blastocysts (n = 2/43, 4.7%) were higher than those in the electrical pulse-treated group (n = 9/41, 22%; and n = 0/51, 0%, respectively; P < 0.05). In conclusion, our data suggest that injection of PLCζ is effective for activation of round spermatid-injected oocytes in pigs.

65 THE EFFECTS OF CUMULUS CELLS ON DEVELOPMENTAL RATES OF VITRIFIED MOUSE OOCYTES IN C57BL/6J STRAIN

Unfertilized oocytes are one of the most desired germ-cell stages for cryopreservation because these cryopreserved oocytes can be used for assisted reproductive technologies, including IVF and intracytoplasmic sperm injection. However, in general, the fertility and developmental ability of cryopreserved oocytes are still low. We have recently reported that, in the presence of surrounding cumulus cells, matured mouse oocytes vitrified using calcium-free media and ethylene glycol retain their developmental competence (Kohaya et al. 2011 J. Reprod. Dev. 57, 675–680). Since the previous study was carried out using ICR mice (closed colony), we examined whether our protocol can be applied for C57BL/6J mice (inbred strain), which are commonly used for production of transgenic and knockout mice. The effect of cumulus cells on the ability of C57BL/6J mouse oocytes to be fertilized and develop in vitro was examined. Cumulus oocyte complexes (COC) derived from female mice with super ovulation were collected by flushing. Cumulus cells were removed for a portion of the oocytes (DO) using hyarulonidase. Oocytes from both treatment groups (COC and DO) were then vitrified according to the protocol we previously reported (Kohaya et al. 2011). After warming, vitrified COC and DO were used for IVF. All percentage data were subjected to arcsine transformation before statistical analysis. Data were analyzed by one-way ANOVA and Tukey’s test. Significance was considered at P < 0.05. The pronuclear formation rate of vitrified DO after IVF (20/58, 33.3%) was reduced compared with vitrified COC (55/90, 62.1%). Vitrified COC showed significantly (P < 0.05) higher developmental ability to develop into the 2-cell (50/90, 57.0%) and blastocyst stages (42/90, 45.9%) compared with vitrified DO [24.8% (16/58) and 18.4% (11/58), respectively]. The vitrified COC developed to term at a high success rate (51/90, 56.7%) being equivalent to the rate obtained with IVF using fresh COC (52/90, 57.8%). Taken together, the current results clearly demonstrate that, in the presence of surrounding cumulus cells, matured mouse oocytes vitrified using calcium-free media and ethylene glycol retain their developmental competence. These findings will contribute to improve oocytes vitrification in not only experimental animals but also in clinical application in human infertility.

[Case of laryngopharyngeal edema after a spinal tumor resection in prone position with extensive neck flexion]

A 63-year-old woman developed laryngopharyngeal edema after a cervical spinal tumor resection in prone position. The tracheal tube was removed after 11 hours of general anesthesia and nasal airway was inserted because stridor was audible. Blisters were found on the skin of the anterior neck of the patient. Examinations at 3 h after the extubation suggested upper airway stenosis including stridor, increased work of breathing, oxygenation impairment, and hypercapnia. The trachea of the patient was intubated and the examination of the upper airway by inserting a fiberoptic bronchoscope through the patient's mouth revealed laryngopharyngeal edema. It was considered that the disturbance of venous and/or lymphatic flow of anterior neck due to extensive neck anteflexion during the surgery in prone position had induced the laryngopharyngeal edema; however, we could not verify the cause of the edema. The edema persisted for weeks. We conclude that we should avoid extensive neck anteflexion during surgery in prone position and it is recommended to observe the upper airway for a few hours after extubation because there could be airway obstruction due to delayed and/ or progressive laryngopharyngeal edema.

155 ESTABLISHMENT OF AN IN VITRO FERTILIZATION PROTOCOL USING CRYOPRESERVED EPIDIDYMAL AND EJACULATED RAT SPERMATOZOA

In rats, successful IVF with cryopreserved rat sperm has never been reported. The objective of the present study was to establish and improve the IVF protocol using epididymal and ejaculated rat spermatozoa after cryopreservation. At first, we examined whether cryopreserved ejaculated spermatozoa would be useful for IVF in Wistar rats. Capacitation-associated tyrosine phosphorylation was accelerated in frozen-thawed ejaculated sperm in a time-dependent manner. These frozen-thawed spermatozoa were co-cultured with cumulus–oocyte complexes in modified R1ECM for 10 h. The putative zygotes were transferred to R1ECM and then cultured up to 144 h. Although the rates of insemination and 2 pronucleus (2PN) formation were low (26.5 and 23.0%, respectively), most of 2PN oocytes were developed to the 2-cell stage (91.0%). A total of 44 embryos at the 2-cell stage derived from frozen-thawed ejaculated sperm were transferred to 5 recipient females and 21 pups (47.7%) were delivered. Next, we used frozen-thawed epididymal spermatozoa for IVF in Wistar rats. After thawing, intracellular cyclic adenosine monophosphate (cAMP), free cholesterol levels and capacitation-associated protein tyrosine phosphorylation levels of the sperm were assayed. Intracellular cAMP and free cholesterol levels in frozen-thawed epididymal sperm were maintained at a low level, suppressing capacitation-associated tyrosine phosphorylation. Treatment with a phosphodiesterase inhibitor, 3-isobutyl-1-methyl-xanthin (IBMX) dramatically increased cAMP and capacitation-associated tyrosine phosphorylation levels in frozen-thawed epididymal sperm. When the IBMX-treated frozen-thawed sperm was used for IVF, the proportions of 2PN and the development to blastocysts were significantly higher (approximately 40 and 20%, respectively) than those of frozen-thawed epididymal sperm treated without IBMX (approximately 10 and 3%, respectively). These embryos were developed to term at a high success rate (49%) equivalent to the rate obtained with IVF using fresh sperm (58%). Moreover, we tried to apply our IVF system to inbred rat strains [Fischer 344 (F344) and Brown-Norway (BN)]. We examined whether the IVF protocol was available for F344 and BN rats. Fresh and frozen-thawed sperm collected from cauda epididymides in F344 and BN were used for detection of capacitation-associated tyrosine phosphorylation. In fresh F344 sperm, capacitation-associated tyrosine phosphorylation was induced in a time-dependent manner. Although tyrosine phosphorylation was inhibited in frozen-thawed F344 sperm, it was dramatically accelerated by IBMX treatment as well as frozen-thawed Wistar sperm. However, tyrosine phosphorylation in fresh and frozen-thawed BN sperm was suppressed and the phosphorylation in frozen-thawed sperm was not improved by IBMX. Taken together, we developed an IVF protocol using cryopreserved rat sperm and our data suggest that the IVF system can be applied not only to Wistar rats but also to the F344 strain. This research was also partially supported by a research project grant awarded by the Azabu University Research Services Division.

Diagnostic usefulness of 3 tesla MRI of the brain for cushing disease in a child

It is sometimes difficult to confirm the location of a microadenoma in Cushing disease. Recently, we experienced an 11-yr-old female case of Cushing disease with hyperprolactinemia. She was referred to our hospital because of decrease of height velocity with body weight gain. On admission, she had typical symptoms of Cushing syndrome. Although no pituitary microadenomas were detected on 1.5 Tesla MRI of the brain, endocrinological examinations including IPS and CS sampling were consistent with Cushing disease with hyperprolactinemia. Oral administration of methyrapone instead of neurosurgery was started after discharge, but subsequent 3 Tesla MRI of the brain clearly demonstrated a 3-mm less-enhanced lesion in the left side of the pituitary gland. Finally, transsphenoidal surgery was performed, and a 3.5-mm left-sided microadenoma was resected. Compared with 1.5 Tesla MRI, 3 Tesla MRI offers the advantage of a higher signal to noise ratio (SNR), which provides higher resolution and proper image quality. Therefore, 3 Tesla MRI is a very useful tool to localize microadenomas in Cushing disease in children as well as in adults. It will be the first choice of radiological examinations in suspected cases of Cushing disease.

Surgical management and outcomes in patients with Cushing disease with negative pituitary magnetic resonance imaging

OBJECTIVE

To analyze our experience with transsphenoidal surgery (TSS) in patients with Cushing disease (CD) with no visible adenoma on magnetic resonance imaging (MRI).

METHODS

Between January 1988 and October 2010, 183 patients with CD underwent TSS at Toranomon Hospital. We retrospectively analyzed data in 18 patients without visible adenomas on MRI and compared them with 106 patients with microadenomas.

RESULTS

Of 106 patients with MRI-visible microadenomas, postoperative remission was achieved in 104 patients (98.1%) and recurrence of CD was observed in 4 patients (3.8%) during a mean follow-up of 5.2 years. Of the 18 patients with negative MRI, postoperative remission was achieved in 0 of the 3 patients with negative inferior petrosal sinus sampling (IPSS), in 50% of those with positive IPSS (7 of 14 patients), and in 1 patient with inconclusive IPSS. No disease recurrence has been observed during a mean follow-up of 3.3 years in the 8 patients with remission, and no tumor has emerged on MRI in 10 patients with failed surgery during a mean follow-up of 4.2 years. No major perioperative complications, including hypopituitarism, occurred in this series.

CONCLUSIONS

When the pituitary origin of adrenocorticotropic hormone secretion is established by IPSS in patients with normal MRI findings, we recommend TSS as the first-line treatment for CD, although chance of surgical cure (50% in this series) is lower than that of MRI-visible microadenomas. In contrast, other therapeutic options must be considered in patients with negative MRI and IPSS findings.

Characterization of metabolic phenotypes of mice lacking GPR61, an orphan G-protein coupled receptor

AIMS

GPR61 is an orphan G protein-coupled receptor whose function remains unknown. The purpose of the present study is to elucidate the importance of GPR61 in metabolism by characterization of GPR61-deficient mice.

MAIN METHODS

Male GPR61-deficient mice were characterized regarding various metabolic parameters, including food intake, body weight, oxygen consumption, body temperature, locomotor activity, and in a pair feeding study. Hypothalamic gene expression was analyzed using real-time quantitative RT-PCR.

KEY FINDINGS

GPR61-deficient mice exhibited marked hyperphagia and heavier body weight than wild-type mice. Hyperphagia of GPR61-deficient mice was observed before the differences in body weight became apparent between the genotypes. When body weight difference did become apparent between genotypes, increases in visceral fat pad weight, liver weight, liver triglyceride (TG) content, plasma leptin, and plasma insulin were observed in GPR61-deficient mice, suggesting that GPR61 deficiency caused obesity associated with hyperphagia. Oxygen consumption, body temperature, and locomotor activity were not significantly different between GPR61-deficient and wild-type mice. Pair-fed GPR61-deficient mice had a greater fat mass than wild-type mice despite comparable body weight in both genotypes. The mRNA levels of proopiomelanocortin (POMC) and brain-derived neurotropic factor (BDNF) in the hypothalamus of GPR61-deficient mice were significantly lower than those of wild-type mice.

SIGNIFICANCE

GPR61-deficient mice exhibited obesity associated with hyperphagia. These findings suggest that GPR61 is involved in the regulation of food intake and body weight, and may be of importance when considering GPR61 as a therapeutic target for obesity or eating disorders.

Surgical outcome in 90 patients with craniopharyngioma: an evaluation of transsphenoidal surgery

OBJECTIVE

To analyze surgical outcomes in 90 patients with craniopharyngioma treated by standard transsphenoidal surgery (TSS) or extended transsphenoidal surgery (eTSS).

METHODS

From 1990-2008, 90 patients (64 adults and 26 children) underwent TSS for craniopharyngioma (34 subdiaphragmatic and 56 supradiaphragmatic). TSS was performed as the initial surgery in 62 patients and as the second procedure in 28 patients.

RESULTS

Total tumor removal was achieved in 70 (77.8%) patients, subtotal removal was achieved in 17 (18.9%), and partial removal was achieved in 3 (3.3%). Total removal was more often accomplished in initial surgery (56 of 62 [90.3%]) than second surgery (14 of 28 [50.0%]). Postoperative deterioration of anterior pituitary hormones developed in 31 of 47 (66.0%) patients with preoperative normal function or partial anterior pituitary loss. New-onset postoperative diabetes insipidus (DI) developed in 35 of 67 (52.2%) patients. Of 61 patients with preoperative visual loss, 55 (90.2%) noted some degree of visual improvement after surgery. The early postoperative mortality rate was 2.2% (2 of 90 patients). Cerebrospinal fluid (CSF) leakage occurred in 11 patients (12.2%), and 5 patients required surgical repair of the leak. Tumor recurrence was observed in seven (7.8%) patients during a mean follow-up period of 4.6 years.

CONCLUSIONS

Most craniopharyngiomas including the supradiaphragmatic type can be removed safely by TSS with a good outcome, although endocrine function frequently worsens after surgery. Dural fascia graft is a very effective technique to prevent CSF leaks, especially after eTSS.