Immunoreactive somatostatin in catecholamine-producing extra-adrenal paraganglioma

Advances in Adrenal and Extra-adrenal Paraganglioma: Practical Synopsis for Pathologists

Adrenal paraganglioma (or "pheochromocytoma") and extra-adrenal paraganglioma, collectively abbreviated PPGL, are rare but spectacular nonepithelial neuroendocrine neoplasms. These are the most inheritable neoplasia of all, with a metastatic potential in a varying degree. As of such, these lesions demand careful histologic, immunohistochemical, and genetic characterization to provide the clinical team with a detailed report taking into account the anticipated prognosis and risk of syndromic/inherited disease. While no histologic algorithm, immunohistochemical biomarker, or molecular aberration single-handedly can identify potentially lethal cases upfront, the combined analysis of various risk parameters may stratify PPGL patients more stringently than previously. Moreover, the novel 2022 WHO Classification of Endocrine and Neuroendocrine Tumors also brings some new concepts into play, not least the reclassification of special neuroendocrine neoplasms (cauda equina neuroendocrine tumor and composite gangliocytoma/neuroma-neuroendocrine tumor) previously thought to belong to the spectrum of PPGL. This review focuses on updated key diagnostic and prognostic concepts that will aid when facing this rather enigmatic tumor entity in clinical practice.

Obesity alters adrenergic and chemosensory signaling pathways that regulate ghrelin secretion in the human gut

Chemosensory signaling in organs such as the mouth and gut contributes to the mechanisms that control metabolism. We investigated the chemosensory pathways that regulate secretion of the hunger hormone ghrelin in response to neurotransmitters, bitter and sweet tastants at the cellular level in the human gut mucosa, and the disturbances in this regulatory pathway induced by obesity. Obesity impaired ghrelin protein production and adrenalin-induced ghrelin secretion in fundic cells, which was counterbalanced by somatostatin. Bitter agonists selective for taste receptor type 2 (TAS2Rs), TAS2R5 and TAS2R10 stimulated ghrelin secretion in fundic cells. The stimulatory effect of the broadly tuned bitter agonist, denatonium benzoate, was selectively blunted by obesity in the small intestine but not in the fundus. Luminal glucose concentrations inhibited ghrelin secretion via sodium-dependent glucose cotransporter and taste receptor type 1 member 3. Obesity altered the sensitivity of the ghrelin cell to glucose in the small intestine but not in the fundus. Sweet taste receptor activation inhibited bitter taste signaling of the ghrelin cell. In conclusion, obesity impairs the sympathetic drive that controls ghrelin release in the fundus and affects the sensitivity of the ghrelin cell to bitter and sweet stimuli in the small intestine but not in the fundus. Region-selective targeting of gut taste receptors in obesity is indicated.-Wang, Q., Liszt, K. I., Deloose, E., Canovai, E., Thijs, T., Farré, R., Ceulemans, L. J., Lannoo, M., Tack, J., Depoortere, I. Obesity alters adrenergic and chemosensory signaling pathways that regulate ghrelin secretion in the human gut.

Somatostatin-secreting Pheochromocytoma Mimicking Insulin-dependent Diabetes Mellitus

We herein present the findings of a 42-year-old woman with either adrenal pheochromocytoma or intraadrenal paraganglioma that simultaneously secreted somatostatin, thus mimicking insulin-dependent diabetes mellitus. Pheochromocytoma was clinically diagnosed based on scintigraphy, elevated catecholamine levels, and finally a histopathological analysis of resected specimens. The patient had diabetic ketosis, requiring 40 U insulin for treatment. Following laparoscopic adrenalectomy, insulin therapy was discontinued and the urinary c-peptide levels changed from 5.5-9.0 to 81.3-87.0 μg/day. Histologically, somatostatin immunoreactivity was detected and the somatostatin levels were elevated in the serum-like fluid obtained from the tumor. Clinicians should be aware of the possible occurrence of simultaneous ectopic hormone secretion in patients with pheochromocytoma.

Paragangliomas: classification, pathology, and differential diagnosis

This article discusses the paraganglion system and extra-adrenal paragangliomas. In particular, the clinicopathologic, immunohistochemical, and ultrastructural features of paragangliomas and neuroendocrine neoplasms of the larynx are presented with a discussion of the differential diagnosis.

The glomus tumor and its biology

This section has attempted to detail the histopathologic, biologic, pathophysiologic, and epidemiologic characteristics of jugulotympanic paragangliomas. These features do not stand devoid of clinical significance, but rather lay the foundation for the formulation of logical diagnostic and therapeutic approaches to these fascinating tumors.

Neuropeptide Y secretion from a malignant extraadrenal retroperitoneal paraganglioma

A patient with a malignant extraadrenal retroperitoneal paraganglioma had elevated levels of immunoreactive neuropeptide Y (NPY) in the peripheral blood (5988 pg/ml; normal, 123 +/- 30 pg/ml [mean +/- standard error of the mean]). A 6-month course of chemotherapy allowed surgical removal of the previously unresectable primary tumor. Postoperatively, the plasma NPY level initially fell to 1089 pg/ml; continued chemotherapy caused an additional decrease to 440 pg/ml. Four months after surgery, the plasma NPY level increased to 940 mg/ml, coincident with hepatic metastases. This case is the first report of a NPY-secreting clinically nonfunctional malignant extraadrenal paraganglioma. Determination of circulating NPY levels may be useful in the diagnosis and follow-up of patients with neuroendocrine tumors.

A paraneoplastic syndrome associated with glomus tumors of the skull base? Early observations

Independent secretion of vasoactive substances by glomus tumors of the skull base is widely recognized. Surgical removal of these tumors often results in an unexplained prolonged postoperative ileus, even in cases in which the vagus nerve is preserved. There is evidence that these tumors may secrete neuropeptides, such as cholecystokinin, in addition to catecholamines. A retrospective analysis of cases of glomus tumors of the skull base operated on at The Otology Group was carried out to correlate preoperative neuropeptide levels, vagus nerve status at surgery, and duration of postoperative ileus. High circulating levels of cholecystokinin associated with these tumors may be responsible for the unexplained phenomenon of prolonged postoperative ileus. The relevance of neuropeptides to the postoperative management of these patients is discussed. Preventive measures that may avert the potentially lethal complications of aspiration and negative nitrogen balance are described.

Histopathology, cytology and cytochemistry of pheochromocytomas and paragangliomas including chemodectomas

The results of histopathological, histochemical and ultrastructural investigations on pheochromocytomas and paragangliomas have been reported. These results allowed the functional identification of the cell types composing many of such tumours. Moreover, comparison of these data with clinico-pathologic findings outlined the advantages and limits of cytologic studies for understanding the natural history of pheochromocytomas and paragangliomas and improving our diagnostic and prognostic criteria.

Extraadrenal paragangliomas. An immunocytochemical and ultrastructural report

Although the majority of extraadrenal paragangliomas are nonfunctional, some of these tumors are associated with hormone production and clinical symptoms, notably hypertension. The authors have investigated 22 paragangliomas, five of which were diagnosed as clinically functional in a light microscopic immunocytochemical and electron microscopic study (nine cases). Histologically, all the paragangliomas exhibited similar features, with a "Zellballen" pattern of polygonal cells. All 22 cases were strongly immunoreactive to protein gene product 9.5 (PGP 9.5) antisera and moderately reactive to antineuron-specific enolase (NSE) sera. Ten cases (five functional) were focally immunoreactive to antichromogranin sera. Seven cases (four functional) were immunoreactive to neuropeptide Y and enkephalin antisera, and six (five functional) to tyrosine hydroxylase antisera. The clinically functional tumors expressed at least two of the antigens, enkephalin, neuropeptide Y, or tyrosine hydroxylase, whereas none of the 17 nonfunctional possessed more than one of these. Electron microscopic study revealed cells from all the nine cases studied to contain secretory granules. Granule sizes ranged from 100 to 280 nm and the morphologic examination of the secretory granules generally showed a dense core with a membrane-bound halo of variable size. Secretory granules were observed in the five functional cases and these were larger (220-280 nm) than those seen in the nonfunctional tumor cells (100-180 nm). Also, tumor cells from the functional cases contained numerous dilated mitochondrial profiles.

Production and secretion of immunoreactive growth hormone-releasing factor by pheochromocytomas

The production and secretion of immunoreactive growth hormone-releasing factor (IR-GRF) by pheochromocytomas were examined immunohistochemically and immunochemically. GRF-immunoreactive (GRF-IR) cells were found, although sparsely, in 2 of 13 tumors (Cases 1 and 2), while somatostatin (SRIF)-IR cells and vasoactive intestinal peptide (VIP)-IR cells were found in nine and five tumors, respectively. Concentrations of tissue IR-GRF of 29.8 and 17.2 ng/g wet weight tissue, respectively, were found in two (Cases 1 and 2) of three tumors examined. These three tumors also contained IR-SRIF at 19.5-105.5 ng/g wet weight tissue and IR-VIP at 13.6-24.8 ng/g wet weight tissue. An increased plasma IR-GRF concentration (30.0 pg/ml) was found in a blood sample taken from the inferior vena cava near the adrenal tumor in Case 1. This is the first report that some pheochromocytomas produce GRF and secrete it into the blood circulation.

Immunoreactive somatostatin and calcitonin in pulmonary neuroendocrine tumor

A well-differentiated neuroendocrine carcinoma of the lung that secreted immunoreactive somatostatin (IR-SRIF) and IR-calcitonin (CT) in a 72-year-old women is described. The plasma concentrations of IR-SRIF (57.5 pg/ml) and IR-CT (340 pg/ml) before operation were significantly higher than the respective normal ranges. After resection of the tumor, the plasma CT level (105 pg/ml) decreased to within the normal range, and the SRIF level (32.7 pg/ml) also decreased, but was still abnormally higher, which suggested the presence of an unidentified remnant of the tumor. Abnormal accumulation of technetium 99m (99mTc) in the lumbar vertebrae was found 6 months after the operation, which indicated a metastatic tumor. The tissue concentrations of IR-SRIF and IR-CT were 103 and 94 ng/g wet weight, respectively, and SRIF-IR tumor cells and CT-IR tumor cells were demonstrated immunohistochemically. On gel-filtration chromatography of the tumor tissue, two peaks of SRIF immunoreactivity were eluted in the positions of synthetic SRIF-28 and SRIF-14, respectively. Conversion of SRIF-28 to SRIF-14 was suggested from results on changes in the two IR-SRIF components during incubation with a crude enzyme preparation extracted from the tumor tissue.

Crystals in a jugulotympanic paraganglioma

The morphologic features of a jugulotympanic paraganglioma are reported. The tumor showed the usual histology of paragangliomas. No sustentacular cells were identified. In the tumorous chief cells there were typical neurosecretory dense-core granules 60-180 nm in diameter. Granules averaging 400 nm in diameter were also observed, sometimes with a regular rhomboid core or crystallized content. Rhomboid crystals were seen in the cytoplasm in membrane-bound spaces and in telolysosomes. The crystals had a substructure consisting of alternating light and dark lines with a periodocity of 5-10 nm. Such crystals had not been reported previously in paragangliomas. The possible origin of the crystals is discussed.

Chemotherapy trials in malignant pheochromocytoma: report of two patients and review of the literature

Two patients with metastatic pheochromocytoma received chemotherapy with 5-fluorouracil, cyclophosphamide, and streptozotocin. A biochemical response occurred in one instance. A review of the literature and the results in the reported patients indicate cyclophosphamide and/or streptozotocin may have activity in this neoplasm.

Immunoreactive somatostatin and vasoactive intestinal polypeptide in adrenal pheochromocytoma. An immunochemical and ultrastructural study

An adrenal pheochromocytoma producing somatostatin (SRIF) and vasoactive intestinal polypeptide (VIP) in a 17-year-old boy is presented. High concentrations of immunoreactive (IR)-SRIF were found in plasma taken from the antecubital vein (31.0-33.0 pg/ml) and the inferior caval vein near the tumor (54.6 pg/ml), but after removal of the tumor the values became normal (11.0-15.2 pg/ml). In two portions of the resected tumor, considerable but different amounts of IR-SRIF (151.7 and 12.1 ng/g wet wt) and IR-VIP (13.0 and 5.5 ng/g wet wt) were demonstrated with size heterogeneities. Immunohistochemically, many IR-SRIF cells and a few IR-VIP cells were observed, but no cell reacting with both anti-SRIF and anti-VIP sera was found. Electronmicroscopically, many tumor cells had catecholamine-like granules (250-350 nm in diameter) while some others had VIP-like granules (110-140 nm in diameter). However, no granules resembling the SRIF granules seen in the pancreatic D cells were found. This seems to be the first report of an adrenal pheochromocytoma that produces SRIF and VIP simultaneously. It provides information on the histogenesis of hormone-producing neurogenic tumors.