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Zhang Y, Gong X, Pu J, Liu J, Ye Z, Zhu H, Lu L, Pan H, Deng K, Yao Y. Double pituitary adenomas: report of two cases and systematic review of the literature. Front Endocrinol (Lausanne) 2024; 15:1373869. [PMID: 38628582 PMCID: PMC11018951 DOI: 10.3389/fendo.2024.1373869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2024] [Accepted: 03/18/2024] [Indexed: 04/19/2024] Open
Abstract
Objective Double pituitary adenomas (DPA) are a rare clinical condition, and our knowledge of them is limited. Missing the second lesion leading to incomplete biochemical remission after surgery is an important challenge in DPA management. This study aims to analyze independent prognostic factors in DPA patients and summarize clinical experiences to prevent surgical failure. Methods Two cases of DPA patients with Cushing's disease diagnosed and surgically treated at Peking Union Medical College Hospital are reported. A literature review was performed on the online database Pubmed, and 57 DPA patients from 22 retrieved articles were included. Demographic characteristics, endocrine manifestations, diagnostic methods, tumor size, and immunohistochemical features of 59 patients were analyzed. Binary logistic regression models were used to identify independent prognostic factors affecting postoperative biochemical remission. Results Among 59 DPA patients, the mean ± SD age was 43.64 ± 14.42 years, with 61.02% being female (n = 36). The most common endocrine manifestations were Cushing's syndrome (23/59, 38.98%) and acromegaly (20/59, 33.90%). The most prevalent immunohistochemical types were ACTH-immunopositive (31/118, 26.27%) and GH-immunopositive (31/118, 26.27%) tumors. Microadenomas (<1cm) were the most frequent in terms of tumor size (62/92, 67.39%). The detection rate for double lesions on 3.0T MRI was 50.00% (14/28), which significantly higher than 1.5T MRI (P = 0.034). Univariate analysis revealed that female, Cushing's syndrome and only single lesion detected by surgical exploration were associated with significantly worse prognosis (P<0.05). Multivariate analysis identified double lesion detected by surgical exploration (OR = 0.08, P = 0.003) and contiguous type tumor (OR = 0.06, P = 0.017) as independent protective factors for DPA patients. Conclusions The double lesion detected by surgical exploration is independently associated with a better prognosis for DPA patients. Comprehensive intraoperative exploration are crucial measures to avoid missing causative lesions.
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Affiliation(s)
- Yi Zhang
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Xinyue Gong
- Eight-Year Program of Clinical Medicine, Peking Union Medical College, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, China
| | - Jun Pu
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Jifang Liu
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Zhang Ye
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Huijuan Zhu
- Department of Endocrinology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Lin Lu
- Department of Endocrinology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Hui Pan
- Department of Endocrinology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Kan Deng
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Yong Yao
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
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Kikuta H, Jinguji S, Sato T, Bakhit M, Hiruta R, Sato Y, Sekine R, Tanabe H, Okada M, Saito K, Fujii M. A Collision Tumor of Pit-1/SF-1-positive Double Pituitary Adenoma and a Craniopharyngioma Coexisting with Graves' Disease. NMC Case Rep J 2023; 10:169-175. [PMID: 37398916 PMCID: PMC10310352 DOI: 10.2176/jns-nmc.2022-0396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Accepted: 03/13/2023] [Indexed: 07/04/2023] Open
Abstract
Double or multiple pituitary adenomas expressing different types of transcription factors and collision tumors of pituitary adenomas and craniopharyngiomas are rare. In this report, we present a case of pituitary adenoma of two different cell populations, Pit-1 and SF-1, and an adenoma and craniopharyngioma collision tumor with coexisting Graves' disease. The patient had a 16-mm pituitary tumor with pituitary stalk calcification and optic chiasm compression but no visual dysfunction. Based on hormonal profile results, the tumor in the sella was considered a nonfunctioning pituitary adenoma; nevertheless, the pituitary stalk was invaded by a different lesion, which was later confirmed to be a craniopharyngioma. Using an endoscopic endonasal approach, the pituitary adenoma was removed; however, a small remnant remained medial to the right cavernous sinus. Because the pituitary stalk lesion was isolated from the pituitary adenoma, it was preserved to maintain pituitary function. Three years after the initial surgery, the patient suffered from Graves' disease and was treated with antithyroid medications. However, the intrasellar residual and pituitary stalk lesions gradually increased in size. A second surgery was performed, and the residual intrasellar and stalk lesions were completely removed. As per the initial and second histopathologies, the pituitary adenoma comprised different cell groups positive for thyroid-(TSH) and follicle-stimulating hormones, and each cell group was positive for Pit-1 and SF-1. The pituitary stalk lesion was an adamantinomatous craniopharyngioma. We believe that TSH-producing adenoma was involved in the development of Graves' disease or that treatment for Graves' disease increased TSH-producing adenoma.
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Affiliation(s)
- Haruhiko Kikuta
- Department of Neurosurgery, Fukushima Medical University, Fukushima, Fukushima, Japan
| | - Shinya Jinguji
- Department of Neurosurgery, Fukushima Medical University, Fukushima, Fukushima, Japan
| | - Taku Sato
- Department of Neurosurgery, Azuma Neurosurgery Hospital, Fukushima, Fukushima, Japan
| | - Mudathir Bakhit
- Department of Neurosurgery, Fukushima Medical University, Fukushima, Fukushima, Japan
| | - Ryo Hiruta
- Department of Neurosurgery, Fukushima Medical University, Fukushima, Fukushima, Japan
| | - Yusuke Sato
- Department of Neurosurgery, Okazaki City Hospital, Okazaki, Aichi, Japan
| | - Rei Sekine
- Department of Pathology and Pathophysiology, Fukushima Medical University, Fukushima, Fukushima, Japan
| | - Hayato Tanabe
- Department of Diabetes, Endocrinology and Metabolism, Fukushima Medical University, Fukushima, Fukushima, Japan
| | - Masayasu Okada
- Department of Neurosurgery, Niigata University Brain Research Institute, Niigata, Niigata, Japan
| | - Kiyoshi Saito
- Department of Neurosurgery, Fukushima Rosai Hospital, Iwaki, Fukushima, Japan
| | - Masazumi Fujii
- Department of Neurosurgery, Fukushima Medical University, Fukushima, Fukushima, Japan
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Torregrosa-Quesada ME, García-Martínez A, Silva-Ortega S, Martínez-López S, Cámara R, Fajardo C, Lamas C, Aranda I, Picó A. How Valuable Is the RT-qPCR of Pituitary-Specific Transcription Factors for Identifying Pituitary Neuroendocrine Tumor Subtypes According to the New WHO 2017 Criteria? Cancers (Basel) 2019; 11:cancers11121990. [PMID: 31835737 PMCID: PMC6966694 DOI: 10.3390/cancers11121990] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Revised: 11/26/2019] [Accepted: 11/28/2019] [Indexed: 11/16/2022] Open
Abstract
The classification of pituitary neuroendocrine tumors (PitNETs) subtypes continues generating interest. In 2017, the World Health Organization (WHO) proposed considering the immunohistochemical (IHC) analysis of pituitary-specific transcription factors (TF) for their typification. The present study targeted the quantification of pituitary-specific TF (TPIT, PIT-1, SF-1, GATA2, ESR1) gene expression by RT-qPCR to overcome the shortcomings of IHC and to complement it. We analyzed 251 tumors from our collection of PitNETs and performed additional IHC studies in a subset of 56 samples to analyze the concordance between gene and protein expression of the TF. The molecular and IHC studies allowed us to significantly reduce the percentage of null cell tumors in our series, most of which were reclassified as gonadotroph tumors. The concordance between the molecular and the immunohistochemical studies was good for tumors coming from the corticotroph and Pit-1 lineages but worsened for the rest of the tumors. Indeed, the RT-qPCR helped to improve the typification of plurihormonal Pit-1 and unusual tumors. Overall, our results suggest that the RT-qPCR of pituitary-specific TF and hormone genes could help pathologists, endocrinologists, and neurosurgeons to improve the management of patients with pituitary tumors.
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Affiliation(s)
| | - Araceli García-Martínez
- Research Laboratory, Hospital General Universitario de Alicante -ISABIAL, 03010 Alicante, Spain; (A.G.-M.); (S.M.-L.)
| | - Sandra Silva-Ortega
- Pathology Department, Hospital General Universitario de Alicante, 03010 Alicante, Spain; (S.S.-O.); (I.A.)
| | - Sebastián Martínez-López
- Research Laboratory, Hospital General Universitario de Alicante -ISABIAL, 03010 Alicante, Spain; (A.G.-M.); (S.M.-L.)
| | - Rosa Cámara
- Endocrinology Department, Hospital Universitario Politécnico La Fe, 46026 Valencia, Spain;
| | - Carmen Fajardo
- Endocrinology Department, Hospital Universitario La Ribera, Alzira, 46600 Valencia, Spain;
| | - Cristina Lamas
- Endocrinology Department, Complejo Universitario de Albacete, 02006 Albacete, Spain;
| | - Ignacio Aranda
- Pathology Department, Hospital General Universitario de Alicante, 03010 Alicante, Spain; (S.S.-O.); (I.A.)
| | - Antonio Picó
- Endocrinology Department, Hospital General Universitario de Alicante -ISABIAL, Miguel Hernández University, 03010 Alicante, Spain
- Correspondence: ; Tel.: +34-659467594
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Ogando-Rivas E, Alalade AF, Boatey J, Schwartz TH. Double pituitary adenomas are most commonly associated with GH- and ACTH-secreting tumors: systematic review of the literature. Pituitary 2017; 20:702-708. [PMID: 28766078 DOI: 10.1007/s11102-017-0826-6] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Double adenomas in the pituitary gland are a rare occurrence. The ability to cure a hormone-producing adenoma with surgery is dependent on the ability to identify and completely remove the correct adenoma. The relative frequency of each subtype of hormone-secreting adenomas confirmed with magnetic resonance image (MRI), surgery and immunohistochemistry is not defined. METHODS Following PRISMA guidelines, we performed a systematic review of PubMed Central, Google Scholar, Scopus Database, Cochrane database and Science Research, using the key-words: "double pituitary adenomas", "multiple pituitary adenomas" and only papers where multiple or truly separate double pituitary adenomas were identified pre-surgically by MRI and/or confirmed by pathology/immunohistochemistry staining were included. RESULTS We reviewed papers from 1975 to 2016 and found 17 cases with two pituitary adenomas and 1 with three pituitary adenomas. The ages ranged from 22 to 67 years old, and there were twelve females and five males. Immunohistochemical staining showed that the most common double pituitary adenomas were growth hormone (GH)- followed by adrenocorticotropic (ACTH)-secreting. CONCLUSION Double pituitary adenomas are rare but most commonly found with GH- or ACTH-producing tumors. It is critical to remove all identified possible adenomas to achieve biochemical cure and clinicians should have heightened sensitivity in patients with acromegaly or Cushing's Disease.
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Affiliation(s)
- Elizabeth Ogando-Rivas
- Department of Neurosurgery, New York Presbyterian Hospital, Weill Cornell Medical College, Box 99, 525 East 68th St., New York, NY, 10065, USA
| | - Andrew F Alalade
- Department of Neurosurgery, New York Presbyterian Hospital, Weill Cornell Medical College, Box 99, 525 East 68th St., New York, NY, 10065, USA
| | - Jerome Boatey
- Department of Neurosurgery, New York Presbyterian Hospital, Weill Cornell Medical College, Box 99, 525 East 68th St., New York, NY, 10065, USA
| | - Theodore H Schwartz
- Department of Neurosurgery, New York Presbyterian Hospital, Weill Cornell Medical College, Box 99, 525 East 68th St., New York, NY, 10065, USA.
- Department of Otolaryngology, New York Presbyterian Hospital, Weill Cornell Medical College, Box 99, 525 East 68th St., New York, NY, 10065, USA.
- Department of Neuroscience, New York Presbyterian Hospital, Weill Cornell Medical College, Box 99, 525 East 68th St., New York, NY, 10065, USA.
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Wen G, Tang C, Zhong C, Li J, Cong Z, Zhou Y, Liu K, Zhang Y, Tohti M, Ma C. One-and-a-half nostril endoscopic transsphenoidal approach for pituitary adenomas-a technical report. J Otolaryngol Head Neck Surg 2016; 45:60. [PMID: 27846864 PMCID: PMC5111234 DOI: 10.1186/s40463-016-0174-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2016] [Accepted: 11/02/2016] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Binostril endoscopic transsphenoidal approach (BETA) provides sufficient manipulation space and wide endoscopic vision, although it increases the trauma of nose. Mononostril endoscopic transsphenoidal approach (META) has minimal trauma of nose, at the expense of space within the operation. We describe a one-and-a-half nostril endoscopic transsphenoidal approach (OETA) that combines the advantages of BETA and META. METHODS We introduced OETA for pituitary adenomas with a detailed technical description. A retrospective analysis was also performed on 57 consecutive patients who underwent one-and-a-half nostril endoscopic transsphenoidal surgery between March 2014 and June 2015 at Jinling hospital. RESULTS The gross total resection rate was 79%. The gross complete resection rate of Knosp grade 3 tumors were 63.6, and 27.3% in grade 4 tumors. Postoperative hormone remission was achieved in 14 out of 18 (77.8%) patients with secreting adenomas. Postoperative abnormal visual function improvement was achieved in 23 out of 32 patients (73%) with preoperative visual dysfunction. The overall intra-operative CSF leak was 17.5%, with the postoperative CSF leak decreased to 3.5% after the sellar reconstruction with the unilateral "rescue" nasoseptal flap procedure. The main sinonasal complaints 2 weeks after surgery were: loss of sense of smell (28%), decrease in sense of taste (4%), trouble breathing during the day (18%), thick nasal discharge (36%), post nasal discharge (8%), dried nasal material (6%), and headache (6%). Three months after surgery, there were no reports of decrease of taste, post nasal discharge, or dried nasal material. Other complaints were decreased significantly. Six months after surgery, the main complaints of sinonasal quality of life were negligible, and overall health status was near complete recovery to preoperative status. CONCLUSIONS The one-and-a-half nostril endoscopic transsphenoidal approach for pituitary adenomas is a simple and reliable technique. It provides not only a sufficient surgical corridor for a 2-surgeon/4 or 3-hands technique, but also ensures minimal invasion of the nasal canal.
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Affiliation(s)
- Guodao Wen
- Department of Neurosurgery, Jinling Hospital, School of Medicine, Nanjing University, 305 East Zhongshan Road, Nanjing, 210002, Jiangsu Province, People's Republic of China
| | - Chao Tang
- Department of Neurosurgery, Jinling Hospital, School of Medicine, Nanjing University, 305 East Zhongshan Road, Nanjing, 210002, Jiangsu Province, People's Republic of China
| | - Chunyu Zhong
- School of Medicine, Nanjing medical University, 104 Hanzhong Road, Nanjing, 210002, People's Republic of China
| | - Junyang Li
- Department of Neurosurgery, Jinling Hospital, School of Medicine, Nanjing University, 305 East Zhongshan Road, Nanjing, 210002, Jiangsu Province, People's Republic of China
| | - Zixiang Cong
- Department of Neurosurgery, Jinling Hospital, School of Medicine, Nanjing University, 305 East Zhongshan Road, Nanjing, 210002, Jiangsu Province, People's Republic of China
| | - Yuan Zhou
- Department of Neurosurgery, Jinling Hospital, School of Medicine, Nanjing University, 305 East Zhongshan Road, Nanjing, 210002, Jiangsu Province, People's Republic of China
| | - Kaidong Liu
- Department of Neurosurgery, Jinling Hospital, School of Medicine, Nanjing University, 305 East Zhongshan Road, Nanjing, 210002, Jiangsu Province, People's Republic of China
| | - Yong Zhang
- Department of ear-nose-throat, Jinling Hospital, School of Medicine, Nanjing University, 305 East Zhongshan Road, Nanjing, 210002, People's Republic of China
| | - Mamatemin Tohti
- Department of Neurosurgery, The People's Hospital of Xinjiang Uygur Autonomous Region, 91 Tianchi Road, Urumqi, 830001, People's Republic of China
| | - Chiyuan Ma
- Department of Neurosurgery, Jinling Hospital, School of Medicine, Nanjing University, 305 East Zhongshan Road, Nanjing, 210002, Jiangsu Province, People's Republic of China.
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Roberts S, Borges MT, Lillehei KO, Kleinschmidt-DeMasters BK. Double separate versus contiguous pituitary adenomas: MRI features and endocrinological follow up. Pituitary 2016; 19:472-81. [PMID: 27209585 DOI: 10.1007/s11102-016-0727-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
PURPOSE Double pituitary adenomas are defined as two adenomas within a gland. These have distinct light microscopic and immunohistochemical features and may be clearly-separate or contiguous. Most reports have focused on the various hormonal combinations in double tumors rather than on any potential increased risk for residual mass or endocrinopathy. METHODS Departmental files were searched to identify all double adenomas from 1/1/2000 to 3/1/2016, with review of magnetic resonance imaging (MRI) to determine if the dual nature of the lesions could be discerned retrospectively after histologic diagnosis of double adenoma. All cases were immunostained for standard anterior pituitary hormones. RESULTS Eight cases were identified: 2 follicle-stimulating hormone (FSH)/alpha subunit (ASU) + prolactinoma (PRL); 1 PRL + corticotroph (ACTH); 1 hormone-negative + PRL; 1 ACTH + ASU/growth hormone (GH)/PRL; 1 GH/PR + PRL; 1 FSH/ASU, + ACTH; 1 GH + luteinizing hormone (LH). One patient had clearly-separate lesions identified preoperatively and required two surgical procedures for gross total resection. A second patient had 2 lesions recognized at surgery and afterwards on retrospective neuroimaging. The remaining 6 patients had double adenomas discovered at the time of histologic examination that were not resolvable at surgery or on retrospective neuroimaging. Four patients, 2 with clearly-separate and 2 with contiguous double adenomas, had persistent MRI abnormalities, and one had continued endocrine abnormalities. CONCLUSIONS Double contiguous pituitary adenomas are difficult to anticipate preoperatively or to resolve intraoperatively. Although double contiguous adenomas are much more common than double separate lesions, both have a risk for subtotal resection and, thus, residual mass and/or endocrinopathy may ensue.
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Affiliation(s)
- Sammie Roberts
- Department of Pathology, Anschutz Medical Campus, University of Colorado at Denver, 12605 E. 16th Avenue, Aurora, CO, 80045, USA
| | - Manuel Thomas Borges
- Department of Neuroradiology, Anschutz Medical Campus, University of Colorado at Denver, 12605 E. 16th Avenue, Aurora, CO, 80045, USA
| | - Kevin O Lillehei
- Department of Neurosurgery, Anschutz Medical Campus, University of Colorado at Denver, 12605 E. 16th Avenue, Aurora, CO, 80045, USA
| | - B K Kleinschmidt-DeMasters
- Department of Pathology, Anschutz Medical Campus, University of Colorado at Denver, 12605 E. 16th Avenue, Aurora, CO, 80045, USA.
- Department of Neurosurgery, Anschutz Medical Campus, University of Colorado at Denver, 12605 E. 16th Avenue, Aurora, CO, 80045, USA.
- Department of Neurology, Anschutz Medical Campus, University of Colorado at Denver, 12605 E. 16th Avenue, Aurora, CO, 80045, USA.
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Budan RM, Georgescu CE. Multiple Pituitary Adenomas: A Systematic Review. Front Endocrinol (Lausanne) 2016; 7:1. [PMID: 26869991 PMCID: PMC4740733 DOI: 10.3389/fendo.2016.00001] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2015] [Accepted: 01/08/2016] [Indexed: 12/20/2022] Open
Abstract
PubMed, Scopus, and Web of Science Core Collection databases were systematically searched for studies reporting synchronous double or multiple pituitary adenomas (MPA), a rare clinical condition, with a vague pathogenesis. Multiple adenomas of the pituitary gland are referred to as morphologically and/or immunocytochemically distinct tumors that are frequently small-sized and hormonally non-functional, to account for the low detection rate. There is no general agreement on how to classify MPA, various criteria, such as tumor contiguity, immunoreactivity, and clonality analysis are being used. Among the component tumors, prolactin (PRL)-immunopositive adenomas are highly prevalent, albeit mute in the majority of cases. The most frequent clinical presentation of MPA is Cushing's syndrome, given the fact that in more than 50% of reported cases at least one lesion stains for adrenocorticotrophic hormone (ACTH). Plurihormonal hyperactivity may be diagnosed in a patient with MPA when more than one tumor is clinically active (e.g., ACTH and PRL) or in cases with at least one composite tumor (e.g., GH and PRL), to complicate the clinical scenario. Specific challenges associated with MPA include high surgical failure rates, enforcing second-look surgery in certain cases, and difficult preoperative neuroradiological imaging evaluation, with an overall sensitivity of only 25% for magnetic resonance imaging to detect distinct multiple tumors. Alternatively, minor pituitary imaging abnormalities may raise suspicion, as these are not uncommon. Postoperative immunohistochemistry is mandatory and in conjunction to electron microscopy scanning and testing for transcription factors (i.e., Pit-1, T-pit, and SF-1) accurately define and classify the distinct cytodifferentiation of MPA.
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Affiliation(s)
- Renata M. Budan
- Department of Endocrinology, “Iuliu Hatieganu” University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Carmen E. Georgescu
- Department of Endocrinology, “Iuliu Hatieganu” University of Medicine and Pharmacy, Cluj-Napoca, Romania
- Endocrinology Clinic, Cluj County Emergency Clinical Hospital, Cluj-Napoca, Romania
- *Correspondence: Carmen E. Georgescu,
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