Classification of pituitary adenomas

The open sella technique for surgical treatment of pituitary macroadenomas: Safety and efficacy in a large clinical series

PURPOSE

To analyse the efficacy and safety of the transsphenoidal microsurgical approach with open sella technique (OST) for the treatment of pituitary adenoma (PA) with suprasellar extension.

METHODS

We retrospectively reviewed 2305 consecutive patients with PA who underwent their first surgery through the transsphenoidal microsurgical approach at our department between 1990 and 2018. Focusing on tumours with suprasellar extension, in particular, grade B, C and D adenomas according to Wilson-Hardy's classification, 376 patients who received the OST surgery were identified. Outcomes and complications were evaluated and compared with those obtained in patients who underwent a standard transsphenoidal approach (TSM).

RESULTS

Two-hundred and sixty-four of 376 patients (70.2%) were found to be suffering from a non-functioning pituitary adenoma, whereas 112 of 376 patients (29.8%) from a hormone-secreting PA. The mean craniocaudal diameter of the tumor was 30.6 ± 0.3 mm (range, 21-75 mm) and 151 patients (40.1%) had a cavernous sinus invasion too. An overall surgical remission rate of 50.3% was achieved in the OST group, whereas the recurrence rate was 10.5%. Patients were followed for a mean period of 68 ± 1.4 months (range, 6-96 months). Less postoperative intrasellar haemorrhages have been recorded in the OST group than the TSM one (1.1% vs. 4.6%, p = 0.02).

CONCLUSIONS

In experienced hands, OST represents an effective and safe treatment strategy for PA with suprasellar extension.

Macro Pituitary Adenoma and Frontal Calcified Cavernous Malformation: A Coincidence or a True Partnership?

Collision tumors are rare neoplasms composed of two different types of histological tissues in the same organ. The most frequent association with cerebral cavernous malformations (CCMs) are meningiomas, gliomas, and gangliogliomas, while the most frequent sellar collision is between pituitary adenoma (PA) and craniopharyngiomas, and still very few cases have been reported. We present the case of a 43-year-old woman who started two months ago with a fall from her height followed by severe headache and bilateral hemianopsia. An isointense, enhancing sellar tumor, and a right frontal lesion compatible with CCM were observed on MRI. Surgery was performed through anterior interhemispheric and endoscopic transnasal approaches for the cavernoma and the sellar tumor, respectively, removing both lesions and sending them to pathology. The sellar tumor corresponded to a PA showing positive immunohistochemistry for prolactin and follicle-stimulating hormone (FSH). In the post-op period, the patient developed a seizure and diabetes insipidus, for which she received appropriate treatment. Our findings were conclusive with a collision tumor, since both lesions presented two different histological tissues. Different densities were observed in both lesions using imaging studies, which were later confirmed with histopathology and immunohistochemistry.

TBX15 rs98422, DNM3 rs1011731, RAD51B rs8017304, and rs2588809 Gene Polymorphisms and Associations With Pituitary Adenoma

BACKGROUND

Pituitary adenoma (PA) is a benign tumor of parenchymal cells in the adenohypophysis, and it's development is strongly associated with genetic factors.This study aim was to find whether TBX15 rs98422, DNM3 rs1011731, RAD51B rs8017304, and rs2588809 single nucleotide polymorphisms can be associated with pituitary adenoma. While the TBX15 gene belongs to the T-box family of genes and is a transcription factor involved in many developmental processes, the DNM3 encodes a protein that is a member of the dynamin family with mechanochemical properties involved in actin-membrane processes, predominantly in membrane budding, and the RAD51B gene plays a significant role in homologous recombination in DNA repair for genome stability.

MATERIALS AND METHODS

The study enrolled 113 patients with pituitary adenoma and 283 healthy control subjects. DNA samples were extracted and purified from peripheral blood leukocytes. Genotyping was carried out using real-time polymerase chain reaction. The results were assessed using binomial logistic regression.

RESULTS

Our study revealed that RAD51B rs2588809 TT genotype could be associated with PA development in the co-dominant (OR=6.833; 95% CI=2.557-18.262; p<0.001) and recessive (OR=7.066; 95% CI=2.667-18.722; p<0.001) models. The same results were observed in females but not in males and PA without recurrence, while in PA with recurrence, no statistically significant results were obtained.

CONCLUSION

RAD51B rs2588809 TT genotype may increase the odds of PA development in women; it may also be associated with non-recurrent PA development.

Telomerase expression in clinically non-functioning pituitary adenomas

PURPOSE

Non-functioning pituitary adenomas (NFPA) are benign tumors, however, some are agressive. We aimed to assess if human telomerase reverse transcriptase (hTERT) is present in NFPA and if it can be used as a marker of aggressiveness and proliferation.

METHODS

Consecutive patients operated for NFPA whose fresh frozen tumors were available were included. We analyzed tumor's aggressiveness (based on radiological progression) and proliferation (based on Ki-67), as well as hTERT mRNA by quantitative real-time polymerase chain reaction (RT-qPCR).

RESULTS

We included 109 samples from 86 patients followed for a median period of 60 months (5-120 months). Aggressive tumors were present in 66% cases and proliferative tumors in 47.7%. Seven (6.4%) samples expressed hTERT: 3 (42.8%) had aggressive and proliferative tumors, 2 (28.6%) only exhibited aggressiveness and the remaining 2 (28.6%) only proliferation. From the aggressive and proliferative tumors, 14% and 16%, respectively, expressed hTERT. From the non-aggressive and non-proliferative tumors, 9% and 6%, respectively, expressed hTERT.

CONCLUSION

hTERT expression is present in a minority of NFPA and does not seem to be related to aggressiveness or proliferation in NFPA.

A neurosurgical assessment of the blood supply in the optochiasmatic system: a cadaveric-anatomic study

The chiasmal and subchiasmal surfaces are of critical importance in connection with the performance of surgical procedures owing to the critical blood supply to these areas. Recently, the perforating arteries providing the blood to the optic nerves and chiasm have gained attention as they significantly affect the morbidity from surgical approaches. Intraoperative preservation of these perforating arteries is considered critical to prevent further visual loss. Thirty autopsy specimens, including the optic apparatus, were examined for their perforating arteries feeding the optic chiasm and optic nerves. The optic nerves and chiasmal surfaces were divided into four zones based on the presence and numbers of perforating arteries as anterior superior-posterior superior surfaces and anterior inferior-posterior inferior surfaces. The superior surface of the optic chiasm was supplied by the A1 segments of the bilateral anterior cerebral arteries and by the perforating arteries originating from the anterior communicating artery. On the other hand, the inferior surface of the optic chiasm was fed by the bilateral posterior communicating arteries and by the supraclinoidal segments of the bilateral carotid arteries. We demonstrated the anatomical involvement of a large number of nourishing arteries in feeding the optic apparatus related to the perforating arteries by classifying them into zones based on the surgical approaches, which has been rarely reported in the literature.

The Implications of Endocrinology in Orthodontics – Literature Review

Endocrinopathies have a variety of orofacial presentations which span from dental malocclusion to facial disfigurement. These characteristics depend on the nature and severity of the condition. An orthodontist should understand the body’s physiological processes to be able to timely determine the optimum intervention and plan treatment stages accordingly in compromised individuals. Communication between the two specialties should be well coordinated and should help facilitate quality health care to the patient. This review was aimed to impart the basic knowledge and the pivotal guidelines for orthodontic management in these conditions. Systemic conditions require multidisciplinary management and the dental team should aim to provide quality oral health care to enhance the overall quality of life and the orthodontist plays a vital role in helping patients achieve physical and psychological health.

A Novel Expression Profile of Cell Cycle and DNA Repair Proteins in Nonfunctioning Pituitary Adenomas

The molecular mechanisms underlying the formation of nonfunctioning pituitary adenomas (NFAs) are largely unknown. In this study, we aimed to understand the relationship between NFAs and functional pituitary adenomas and the possible role of proteins involved in cell cycle, senescence, and DNA damage control mechanisms in the etiology of NFA. We analyzed pATM-S1981, pRb-S608, Rb, pE2F1-S364, p16, E2F1, p73, cyclin D1, and CHEK2 protein expression (in a group of 20 patients with acromegaly, 18 patients with Cushing's disease (CD), and 29 NFA patients) by immunohistochemistry and their relevant mRNA expression by qRT-PCR (in a group of 7 patients with acromegaly, 7 patients with CD, and 7 NFA patients). The clinical and histopathological results on the patients were statistically evaluated. pE2F1-S364 protein expression in the CD group was significantly lower than that in the NFA and acromegaly groups (p = 0.025, p = 0.034, respectively). However, the expression of the p16 protein was lower than in the NFA group than in the CD and acromegaly groups (p = 0.030, p = 0.033, respectively), and E2F1 protein expression was significantly higher in the NFA group than in the CD group (p = 0.025). p73 protein expression in patients with acromegaly was significantly higher (p = 0.031) than that in the CD group. CHEK2 mRNA expression in the CD group was significantly higher than that in the acromegaly group (p = 0.012). The selective and tumor-specific associations between E2F1, pE2F1-S364, CHEK2, and p73 mRNA and protein levels indicate their involvement in pituitary adenoma formation in NFA, CD, and acromegaly patients.

Spontaneous Pituitary Adenomas in Squirrel Monkeys (Saimiri sciureus)

On postmortem examination, 2 geriatric captive male squirrel monkeys (Saimiri sciureus) were found to have pituitary masses that were unassociated with previous experimental manipulation. Both animals were euthanized due to apparently unrelated clinical reasons. Histopathology and immunohistochemical staining classified these tumors as thyrotrophic and corticotrophic pituitary adenomas. These cases represent the first reports of this tumor type in squirrel monkeys.

Predicting the regrowth of clinically non-functioning pituitary adenoma with a statistical model

BACKGROUND

Compared with clinically functioning pituitary adenoma (FPA), clinically non-functioning pituitary adenoma (NFPA) lacks of detectable hypersecreting serum hormones and related symptoms which make it difficult to predict the prognosis and monitoring for postoperative tumour regrowth. We aim to investigate whether the expression of selected tumour-related proteins and clinical features could be used as tumour markers to effectively predict the regrowth of NFPA.

METHOD

Tumour samples were collected from 295 patients with NFPA from Beijing Tiantan Hospital. The expression levels of 41 tumour-associated proteins were assessed using tissue microarray analyses. Clinical characteristics were analysed via univariate and multivariate logistic regression analyses. Logistic regression algorithm was applied to build a prediction model based on the expression levels of selected proteins and clinical signatures, which was then assessed in the testing set.

RESULTS

Three proteins and two clinical signatures were confirmed to be significantly related to the regrowth of NFPA, including cyclin-dependent kinase inhibitor 2A (CDKN2A/p16), WNT inhibitory factor 1 (WIF1), tumour growth factor beta (TGF-β), age and tumour volume. A prediction model was generated on the training set, which achieved a fivefold predictive accuracy of 81.2%. The prediction ability was validated on the testing set with an accuracy of 83.9%. The area under the receiver operating characteristic curves (AUC) for the signatures were 0.895 and 0.881 in the training and testing sets, respectively.

CONCLUSION

The prediction model could effectively predict the regrowth of NFPA, which may facilitate the prognostic evaluation and guide early interventions.

Effect of Hormone Levels and Aging on Cognitive Function of Patients with Pituitary Adenomas Prior to Medical Treatment

BACKGROUND

Cognitive impairments have been reported in patients with pituitary adenomas (PAs). The aim of this research was to demonstrate the effects of hormones and age on cognitive decline in patients with PAs.

METHODS

A total of 64 patients with PA and 69 healthy control subjects (HCs) were recruited for this study. Both PAs and HCs were divided into a younger group (<50 years of age) and an older group (≥50 years of age). Neurocognitive domains were assessed using the Wechsler Adult Intelligence Scale-Chinese Revision (WAIS-RC) and Wechsler Memory Scale-Chinese Revision (WMS-RC) tests. Furthermore, we also investigated the relationship between cognitive domains and tumor volume, and the hormone levels and age of patients with PA.

RESULTS

Several of the cognitive impairments found on the WAIS-RC and WMS-RC tests were more frequently observed in untreated patients with PA. Importantly, no significant correlations were found between cognitive domains and tumor volume after controlling age, sex, and educational levels. Furthermore, several significant correlations were found between cognitive domains and hormone levels, such as free thyroxine and adrenocorticotropic hormone, after controlling age, sex, and educational levels. Finally, the age of the patients was found to correlate with a decrease in memory after controlling sex and educational levels.

CONCLUSIONS

Our findings demonstrate a significant decline in the cognitive performance of patients with PA prior to medical treatment, especially in older patients, which suggests that hormones and age have the ability to interact and aggravate cognitive decline in patients with PA.

Use of optical fluorescence agents during surgery for pituitary adenomas: current state of the field

INTRODUCTION

Differentiation of normal pituitary from abnormal tumor tissue remains a surgical challenge despite improvements in optical visualization technology for pituitary adenoma (PA) surgery. During neurosurgical procedures for other tumor types, 5-aminolevulinic acid (5-ALA) has become a focus of investigation based on its high specificity in differentiating tumor tissue. However, the role of 5-ALA and other optical fluorescent agents in PA surgery remains less clear.

OBJECTIVE

To perform a systematic review on the use of various optical fluorescent agents in PA surgery.

METHOD

Using PRISMA guidelines, a systematic literature review to identify reports describing 5-ALA and other optical agents for fluorescence-guided surgery for PA was performed. Eleven research studies met inclusion criteria and were reviewed.

RESULTS

In two studies, 5-ALA was not shown to be effective in aiding PA resection using standard neurosurgical endoscopic/microscopic approaches. 5-ALA photodynamic therapy was evaluated in two in-vitro models with inconsistent results. Intraoperative use of indocyanine green (ICG) concluded with varying results, but showed a tendency towards improved differentiation of functional PA. OTL38 showed potential for intraoperative identification of nonfunctioning PA, particularly in tumors with high folate receptor expression. One study reported clinically useful fluorescence following sodium fluorescein administration.

CONCLUSION

We conclude that selected optical fluorescent agents, including ICG and folate receptors, are most likely to hold promise for clinical use in differentiating PA from normal tissue.

Relationship between postoperative volume of macroadenomas and clinical outcome after endoscopic trans-sphenoidal resection

PURPOSE

Although symptoms are expected to improve after the resection of pituitary macroadenomas, tumor resection volume does not always correlate with the patient's symptoms. Our objectives were to assess the pre and postoperative volumes of pituitary macroadenomas before, immediately after surgery and at follow-up, and to explore possible associations and correlations among these changes and symptoms.

MATERIALS AND METHODS

We retrospectively reviewed the clinical records and the preoperative and postoperative magnetic resonance imaging studies at 24 hours and at 3, 6 and 9 months follow-up of 146 patients who underwent surgery for pituitary macroadenomas. We measured tumor volumes before and after surgery and compared changes with symptom improvement.

RESULTS

The mean preoperative tumor volume was 24.66 cm³ (standard deviation 65.18 cm³, 95% confidence interval (CI) 14-35.32). The most common symptoms were visual/cranial nerve abnormalities (65%) and headaches (56%). Immediately after surgery, symptoms persisted without significant changes in all patients. A progressive tumor volume decrease was noted during follow-up, and symptoms improved in 78% of patients. Despite no imaging evidence of chiasm or cavernous sinus compression, 32 patients showed no symptom improvement. Patients with symptoms for more than 1 year (mean duration of symptoms 26 months, SD 24.3, 95% CI 22.03-29.97 months) had a higher risk of the persistence of symptoms compared to patients with a mean duration of symptoms of less than 1 year (odds ratio 2.5, 95% CI 2.4-3, P < 0.005).

CONCLUSIONS

The duration of symptoms prior of surgery is a more important factor than tumor resection volume alone when considering the long-term outcome of symptoms. Furthermore, lack of symptom improvement in the immediate postoperative period does not necessarily represent an inadequate resection.

Function of cell-cycle regulators in predicting silent pituitary adenoma progression following surgical resection

The present study investigated the use of cell-cycle regulators for predicting the progression of silent pituitary adenoma (SPA) following surgical resection, via immunohistochemical analysis of tumor samples obtained by surgical resection. The medical records of patients diagnosed with SPA between January 2000 and December 2013 in the Samsung Changwon Hospital, Sungkyunkwan University School of Medicine (Changwon, South Korea) were reviewed. Immunohistochemical staining was performed on sections of the archived, paraffin-embedded tissues obtained by surgery, with all tissues stained for cell-cycle regulatory proteins p16, p15, p21, cyclin-dependent kinase (CDK)4, CDK6, retinoblastoma protein (pRb) and cyclin D1, as well as E3 ubiquitin-protein ligase mib1 (MIB-1) antigen and p53. The primary end-point was to investigate the expression of cell-cycle regulatory proteins in SPA. The secondary end-point was to estimate the progression-free survival of patients with SPA following surgical resection and to identify its association with the expression of cell-cycle regulatory proteins. Of the 127 SPA samples, 44 (34.6%) were from patients with progression during a mean follow-up period of 62.4 months (range, 24.2–118.9 months). Immunohistochemical overexpression was identified in 61 samples (48.0%) for p16, 38 samples (29.9%) for p15, 19 samples (15.0%) for p21, 49 samples (38.6%) for CDK4, 17 samples (13.4%) for CDK6, 57 samples (44.9%) for pRb and in 65 samples (51.2%) for cyclin D1. Multivariate analysis revealed that null cell adenoma [95% confidence interval (CI), 0.276–0.808], somatotroph SPAs (95% CI, 1.296–3.121), corticotroph SPAs (95% CI, 1.811–4.078), pluripotent SPAs (95% CI, 2.264–5.194), decreased expression of p16 (95% CI, 2.724–5.588), overexpression of pRb (95% CI, 2.557–5.333), cyclin D1 (95% CI, 1.894–4.122) and MIB-1 (95% CI, 1.561–4.133), increased mitotic index (95% CI, 1.228–4.079), increased p53 expression (95% CI, 1.307–4.065) and invasion into the cavernous sinus (95% CI, 3.842–7.502) predicted SPA progression following resection. The results of the present study suggested that specific cell-cycle regulators, including p16, cyclin D1 and pRb, were associated with SPA progression.

GH-secreting pituitary macroadenoma (acromegaly) associated with progressive dental malocclusion and refractory CPAP treatment

Background

A link between progressive dental malocclusion, the use of a continuous positive airway pressure mask and GH-secreting pituitary macroadenoma (acromegaly) has not been previously reported. The present clinicopathological analysis stresses that tooth malposition should not be seen exclusively as a local process.

Case presentation

A 62-year-old caucasian man with no relevant medical history reported difficulty chewing food and perceived voice alteration during his annual periodontal check-up. He also referred stiffness of the tongue, face, and submandibular area. The patient had been diagnosed with obstructive sleep apnea syndrome two years previously, since when he had worn a continuous positive airway pressure device during sleep. Exploration of the occlusion revealed significant changes: an atypical left lateral and anterior open bite with major buccoversion of teeth 33, 34, 35, 36. Inspection of the soft tissue revealed only macroglossia, although external palpation indicated a subcutaneous stiffness of the submandibular area. General analytical tests, including hormone profiles, and magnetic resonance imaging confirmed the diagnosis of acromegaly induced by a pituitary adenoma. Intrasellar tumor resection via transsphenoidal approach was performed. After surgery, the patient already noted a marked improvement of all symptoms associated with the acromegaly. Desaturation data also evolved favourably and the pulmonologist advised the patient to abandon the continuous positive airway pressure treatment.

Conclusion

Progressive dental malocclusion may be associated with a systemic disease and the use of a nasal mask with premaxillary support may distort the diagnosis of acromegaly.

Novel aspects in histopathology of the pituitary gland

The sellar and parasellar region is a complex anatomical area in which several diseases may develop. The pituitary gland may be affected by a wide range of conditions having similar clinical characteristics. Diagnosis of these lesions requires a multidisciplinary approach including, in addition to clinical, laboratory, imaging, and surgical findings, histological diagnosis of pituitary adenomas to guide therapeutic management. As the result of development in recent years of new immunohistochemical techniques, histopathological classification has become more complex and wide, and not only continues to be the gold standard in diagnosis, but also has prognostic implications. The aim of this review is to provide a clear and simple update of the main concepts of histological diagnosis of the most common pituitary conditions, especially for professionals in direct contact with such diseases.

Novel aspects in histopathology of the pituitary gland

The sellar and parasellar region is a complex anatomical area in which several diseases may develop. The pituitary gland may be affected by a wide range of conditions having similar clinical characteristics. Diagnosis of these lesions requires a multidisciplinary approach including, in addition to clinical, laboratory, imaging, and surgical findings, histological diagnosis of pituitary adenomas to guide therapeutic management. As the result of development in recent years of new immunohistochemical techniques, histopathological classification has become more complex and wide, and not only continues to be the gold standard in diagnosis, but also has prognostic implications. The aim of this review is to provide a clear and simple update of the main concepts of histological diagnosis of the most common pituitary conditions, especially for professionals in direct contact with such diseases.

Does MMP-9 Gene Polymorphism Play a Role in Pituitary Adenoma Development?

Purpose. To determine if the MMP-9 genotype has an influence on development of pituitary adenoma (PA). Methodology. The study enrolled n = 86 patients with PA and n = 526 healthy controls (reference group). The genotyping of MMP-9 was carried out using the real-time polymerase chain reaction method. Results. Our data demonstrated that the MMP-9 (–1562) C/C genotype was more frequent in PA group than in healthy controls (81.4% versus 64.6%, p = 0.002); C/C genotype was more frequently present in PA females compared to healthy control females, 81.5% versus 64.6%, p = 0.018, as well. MMP-9 (–1562) C/C genotype was frequently observed for all subgroups: noninvasive and invasive, nonrecurrence, and inactive PA compared to healthy controls: 81.8% versus 64.6%, p = 0.021; 81.0% versus 64.6%, p = 0.041; 81.8% versus 64.6%, p = 0.005; 100.0% versus 64.6%, p < 0.001, respectively. MMP-9 (–1562) C/C genotype was more frequent in inactive PA compared to active PA: 100.0% versus 71.4%; p < 0.001. Conclusion. MMP-9 (–1562) C/C genotype plays a role in nonrecurrence, inactive, and invasive as well as in nonivasive PA development.

Rapid Mass Spectrometry Imaging to Assess the Biochemical Profile of Pituitary Tissue for Potential Intraoperative Usage

Pituitary adenomas are relatively common intracranial neoplasms that are frequently treated with surgical resection. Rapid visualization of pituitary tissue remains a challenge as current techniques either produce little to no information on hormone-secreting function or are too slow to practically aid in intraoperative or even perioperative decision-making. Matrix-assisted laser desorption/ionization mass spectrometry imaging (MALDI MSI) represents a powerful method by which molecular maps of tissue samples can be created, yielding a two-dimensional representation of the expression patterns of small molecules and proteins from biologic samples. In this chapter, we review the use of MALDI MSI, its application to the characterization of the pituitary gland, and its potential applications for guiding the management of pituitary adenomas.

Effect of Gonadotropin and Adrenocorticotropic Hormone Secretion on Invasiveness of Clinically Nonfunctioning Pituitary Adenomas: A Cell Culture Study

OBJECTIVE

The aim of this study was to clarify the correlation between clinical features (especially cyst formation and cavernous sinus invasion) and minor secretion of anterior pituitary hormones, especially adrenocorticotropic hormone (ACTH) and gonadotropin, by clinically nonfunctioning pituitary adenomas (CNFPAs) in cell culture.

METHODS

We examined anterior pituitary hormones secreted by samples from 63 cases of CNFPAs grown in cell culture. Magnetic resonance imaging, including determination of the Knosp grade, cystic changes, and intraoperative cavernous sinus invasion, was performed.

RESULTS

Detection of minor hormone secretion using cell culture showed that 61.9% (39/63) of CNFPAs secreted luteinizing hormone, follicle-stimulating hormone, and thyroid-stimulating hormone, 44.4% (28/63) secreted ACTH, 57.1% (36/63) secreted prolactin, and 28.6% (18/63) secreted growth hormone; only 1 case of the null-cell adenoma was observed (1.6%). Cystic changes, Knosp grade 4 status, and cavernous sinus invasion were predominantly observed in cases of ACTH-secreting adenomas. Gonadotropin-secreting adenomas showed opposite characteristics to ACTH-secreting adenomas.

CONCLUSIONS

Minor secretion of ACTH and gonadotropin may be related to clinical features, especially cystic changes and invasiveness of CNFPAs, suggesting that our cell culture method could be helpful for elucidating the mechanisms of pituitary cyst formation and the invasiveness of CNFPAs.

Mucin 1 and poly I:C activates dendritic cells and effectively eradicates pituitary tumors as a prophylactic vaccine

Pituitary tumors are the most common type of cancer within the central nervous system. In the present study, the expression levels of mucin 1 (Muc1) were examined in invasive and non‑invasive pituitary tumor samples, and the results of immunohistochemical staining and Western blot analysis demonstrated marked positive expression of Muc1. In addition, Muc1 + polyinosinic:polycytidylic acid (poly I:C) was found to stimulate the expression levels of the surface molecules cluster of differentiation (CD)40, CD83 and CD80, and HLA‑DRm and decreased the expression of CD14 in the dendritic cells, determined using fluorescence‑activated cell sorting. The secretions of interleukin (IL)‑6, tumor necrosis factor‑α and IL‑1β cytokines were also significantly induced, in a dose‑dependent manner. In in vivo experiments, a higher percentage of CD3+CD4+ T lymphocytes was detected, and the levels of interferon‑γ and IL‑2 in the splenocytes were also upregulated. Furthermore, the combination treatment of Muc1 with poly I:C increased anti‑Muc1 IgM and anti‑Muc1 IgG titers, and altered the balance of IgG2a and IgG1, all of which increased the T helper (Th)1 polarized immune response. Thus, the tumor antigen, Muc1, with poly I:C may produce potent protective effects, which polarize immune responses towards Th1, and elicit antitumor immunity to inhibit the progression of pituitary tumors.

The pituitary TGFβ1 system as a novel target for the treatment of resistant prolactinomas

Prolactinomas are the most frequently observed pituitary adenomas and most of them respond well to conventional treatment with dopamine agonists (DAs). However, a subset of prolactinomas fails to respond to such therapies and is considered as DA-resistant prolactinomas (DARPs). New therapeutic approaches are necessary for these tumors. Transforming growth factor β1 (TGFβ1) is a known inhibitor of lactotroph cell proliferation and prolactin secretion, and it partly mediates dopamine inhibitory action. TGFβ1 is secreted to the extracellular matrix as an inactive latent complex, and its bioavailability is tightly regulated by different components of the TGFβ1 system including latent binding proteins, local activators (thrombospondin-1, matrix metalloproteases, integrins, among others), and TGFβ receptors. Pituitary TGFβ1 activity and the expression of different components of the TGFβ1 system are regulated by dopamine and estradiol. Prolactinomas (animal models and humans) present reduced TGFβ1 activity as well as reduced expression of several components of the TGFβ1 system. Therefore, restoration of TGFβ1 inhibitory activity represents a novel therapeutic approach to bypass dopamine action in DARPs. The aim of this review is to summarize the large literature supporting TGFβ1 important role as a local modulator of pituitary lactotroph function and to provide recent evidence of the restoration of TGFβ1 activity as an effective treatment in experimental prolactinomas.

Single-Cell Phenotypic Characterization of Human Pituitary GHomas and Non-Functioning Adenomas Based on Hormone Content and Calcium Responses to Hypothalamic Releasing Hormones

Human pituitary tumors are generally benign adenomas causing considerable morbidity due to excess hormone secretion, hypopituitarism, and other tumor mass effects. Pituitary tumors are highly heterogeneous and difficult to type, often containing mixed cell phenotypes. We have used calcium imaging followed by multiple immunocytochemistry to type growth hormone secreting (GHomas) and non-functioning pituitary adenomas (NFPAs). Individual cells were typed for stored hormones and calcium responses to classic hypothalamic releasing hormones (HRHs). We found that GHomas contained growth hormone cells either lacking responses to HRHs or responding to all four HRHs. However, most GHoma cells were polyhormonal cells responsive to both thyrotropin-releasing hormone (TRH) and GH-releasing hormone. NFPAs were also highly heterogeneous. Some of them contained ACTH cells lacking responses to HRHs or polyhormonal gonadotropes responsive to LHRH and TRH. However, most NFPAs were made of cells storing no hormone and responded only to TRH. These results may provide new insights on the ontogeny of GHomas and NFPAs.

Invasion of the cavernous sinus space in pituitary adenomas: endoscopic verification and its correlation with an MRI-based classification

OBJECT An important prognostic factor for the surgical outcome and recurrence of a pituitary adenoma is its invasiveness into parasellar tissue, particularly into the space of the cavernous sinus (CS). The aims of this study were to reevaluate the existing parasellar classifications using an endoscopic technique and to evaluate the clinical and radiological outcomes associated with each grade. METHODS The authors investigated 137 pituitary macroadenomas classified radiologically at least on one side as Grade 1 or higher (parasellar extension) and correlated the surgical findings using an endoscopic technique, with special reference to the invasiveness of the tumor into the CS. In each case, postoperative MRI was performed to evaluate the gross-total resection (GTR) rate and the rate of endocrinological remission (ER) in functioning adenomas. RESULTS The authors found a 16% rate of CS invasion during surgery for these macroadenomas. Adenomas radiologically classified as Grade 1 were found to be invasive in 1.5%, and the GTR/ER rate was 83%/88%. For Grade 2 adenomas, the rate of invasion was 9.9%, and the GTR/ER rate was 71%/60%. For Grade 3 adenomas, the rate of invasion was 37.9%, and the GTR/ER rate was 75%/33%. When the superior compartment of the CS (Grade 3A) was involved, the authors found a rate of invasion that was lower (p < 0.001) than that when the inferior compartment was involved (Grade 3B). The rate of invasion in Grade 3A adenomas was 26.5% with a GTR/ER rate of 85%/67%, whereas for Grade 3B adenomas, the rate of surgically observed invasion was 70.6% with a GTR/ER rate of 64%/0%. All of the Grade 4 adenomas were invasive, and the GTR/ER rate was 0%. A comparison of microscopic and endoscopic techniques revealed no difference in adenomas with Grade 1 or 4 parasellar extension. In Grade 2 adenomas, however, the CS was found by the endoscopic technique to be invaded in 9.9% and by microscopic evaluation to be invaded in 88% (p < 0.001); in Grade 3 adenomas, the difference was 37.9% versus 86%, respectively (p = 0.002). Grade 4 adenomas had a statistically significant lower rate of GTR than those of all the other grades. In case of ER only, Grade 1 adenomas had a statistically significant higher rate of remission than did Grade 3B and Grade 4 adenomas. CONCLUSIONS The proposed classification proved that with increasing grades, the likelihood of surgically observed invasion rises and the chance of GTR and ER decreases. The direct endoscopic view confirmed the low rate of invasion of Grade 1 adenomas but showed significantly lower rates of invasion in Grade 2 and 3 adenomas than those previously found using the microscopic technique. In cases in which the intracavernous internal carotid artery was encased (Grade 4), all the adenomas were invasive and the GTR/ER rate was 0%/0%. The authors suggest the addition of Grades 3A and 3B to distinguish the strikingly different outcomes of adenomas invading the superior CS compartments and those invading the inferior CS compartments.

High response rates and prolonged survival in patients with corticotroph pituitary tumors and refractory Cushing disease from capecitabine and temozolomide (CAPTEM): a case series

BACKGROUND AND IMPORTANCE

Rarely, corticotrophic pituitary tumors take on an aggressive form characterized by rapid growth, invasion into local structures, compression of cranial nerves, and possible spread to distant sites. When conventional surgery, radiation therapy, and hormones fail to control progression and symptoms, alternative therapies are needed. A novel chemotherapeutic regimen of capecitabine and temozolomide (CAPTEM), originally designed in our laboratory, demonstrated dramatic antineoplastic effects against corticotrophic pituitary tumors.

CLINICAL PRESENTATION

We present a case series of 4 patients with aggressive, adrenocorticotrophic hormone--producing pituitary tumors who had previously depleted all surgical, radiation, and hormonal therapies and were then treated with CAPTEM. Dramatic clinical improvements in neurological deficits and Cushing symptoms were evident in all patients after treatment was initiated. Confirmed by radiographic imaging, 2 of 4 patients demonstrated complete regression of disease, 1 patient had a 75% regression, and the fourth patient has ongoing stable disease for > 4.5 years at the time of this writing. Immunohistochemical analysis of patients' tumor samples showed low O-methyguanyl methyltransferase expression and adequate levels of mismatch repair enzymes (MLH-1, MSH-2, MSH-6, and PMS-2), which are important for the in vivo efficacy of CAPTEM.

CONCLUSION

This is the first report of prolonged antitumor response to and radiographic complete remissions as a result of CAPTEM in patients with aggressive pituitary tumors who had exhausted all other therapies.

Craniocaudal extension as an indication of surgical outcome in transsphenoidal surgery for pituitary adenomas

Transsphenoidal approach is considered the treatment of choice for pituitary adenoma removal. Suprasellar extension is regarded a drawback for complete removal of these tumors through this approach. Evaluate the correlation between the preoperative radiologic craniocaudal extension on MRI of pituitary adenomas and the extent of tumor removal. A retrospective study. Tertiary care hospital. 560 patients underwent transsphenoidal removal of pituitary adenomas. The degree of removal of pituitary tumor in the follow-up imaging of the patients was correlated with the preoperative extension in mid-Coronal T1 W Gd. Tumors with suprasellar extension can be classified into: Type I tumors with extension confined to the sellar boundaries, resulted in complete removal in all cases (100%), type II tumors with suprasellar extension reaching the floor of the 3rd ventricle, resulted in complete removal in 70.2% of the cases, type III tumors with suprasellar extension above the 3rd ventricle, had only 13.5% of complete removal. Integration of radiologic findings into a scheme for the preoperative determination of possibility of total removal of the tumor through transsphenoidal approach, can give better correlation to the surgical outcome of pituitary tumors.

Growth hormone is a cellular senescence target in pituitary and nonpituitary cells

Premature proliferative arrest in benign or early-stage tumors induced by oncoproteins, chromosomal instability, or DNA damage is associated with p53/p21 activation, culminating in either senescence or apoptosis, depending on cell context. Growth hormone (GH) elicits direct peripheral metabolic actions as well as growth effects mediated by insulin-like growth factor 1 (IGF1). Locally produced peripheral tissue GH, in contrast to circulating pituitary-derived endocrine GH, has been proposed to be both proapoptotic and prooncogenic. Pituitary adenomas expressing and secreting GH are invariably benign and exhibit DNA damage and a senescent phenotype. We therefore tested effects of nutlin-induced p53-mediated senescence in rat and human pituitary cells. We show that DNA damage senescence induced by nutlin triggers the p53/p21 senescent pathway, with subsequent marked induction of intracellular pituitary GH in vitro. In contrast, GH is not induced in cells devoid of p53. Furthermore we show that p53 binds specific GH promoter motifs and enhances GH transcription and secretion in senescent pituitary adenoma cells and also in nonpituitary (human breast and colon) cells. In vivo, treatment with nutlin results in up-regulation of both p53 and GH in the pituitary gland, as well as increased GH expression in nonpituitary tissues (lung and liver). Intracrine GH acts in pituitary cells as an apoptosis switch for p53-mediated senescence, likely protecting the pituitary adenoma from progression to malignancy. Unlike in the pituitary, in nonpituitary cells GH exerts antiapoptotic properties. Thus, the results show that GH is a direct p53 transcriptional target and fulfills criteria as a p53 target gene. Induced GH is a readily measurable cell marker for p53-mediated cellular senescence.

Clusterin and FOXL2 act concordantly to regulate pituitary gonadotroph adenoma growth

Pituitary tumors grow slowly and despite their high prevalence are invariably benign. We therefore studied mechanisms underlying pituitary tumor growth restraint. Pituitary tumor transforming gene (PTTG), the index human securin, a hallmark of pituitary tumors, triggers pituitary cell proliferation and murine pituitary tumor development. We show that human gonadotroph cell pituitary tumors, unlike other secreting tumor types, express high levels of gonadotroph-specific forkhead transcription factor FOXL2, and both PTTG and Forkhead box protein L2 (FOXL2) stimulate gonadotroph clusterin (Clu) expression. Both Clu RNA isoforms are abundantly expressed in these nonhormone-secreting human tumors, and, when cultured, these tumor cells release highly abundant levels of secreted Clu. FOXL2 directly stimulates the Clu gene promoter, and we show that PTTG triggers ataxia telangiectasia mutated kinase/IGF-I/p38MAPK DNA damage/chromosomal instability signaling, which in turn also induces Clu expression. Consequently, Clu restrains pituitary cell proliferation by inducing cyclin dependent kinase inhibitors p16 and p27, whereas Clu deletion down-regulates p16 and p27 in the Clu(-/-) mouse pituitary. FOXL2 binds and suppresses the PTTG promoter, and Clu also suppresses PTTG expression, thus neutralizing protumorigenic PTTG gonadotroph tumor cell properties. In vivo, murine gonadotroph LβT2 tumor cell xenografts overexpressing Clu and FOXL2 both grow slower and elicit smaller tumors. Thus, gonadotroph tumor cell proliferation is determined by the interplay between cell-specific FOXL2 with PTTG and Clu.

Expression of cell growth negative regulators MEG3 and GADD45γ is lost in most sporadic human pituitary adenomas

We aimed at the evaluation of MEG3 and GADD45γ expression in sporadic functioning and clinically non-functioning human pituitary adenomas, morphologically characterized by immunohistochemistry analysis and their association with clinical features. Thirty eight patients who had undergone hypophysectomy at São José Hospital of Irmandade Santa Casa de Misericórdia in Porto Alegre, Brazil, were included in this study. We evaluated tumor-type specific MEG3 and GADD45γ expression by qRT-PCR in the pituitary adenomas, and its association with clinical features, as age, gender and tumor size, obtained from medical records. The patients consisted of 21 males and 17 females and the mean age was 47 ± 14 (mean ± SD), ranging from 18 to 73 years-old. Of these 14 were clinically non-functioning, 10 GH-secreting, 9 PRL-secreting, and 5 ACTH-secreting pituitary adenomas. All samples were macroadenomas, except four ACTH-secreting tumors, which were microadenomas. In summary, MEG3 and GADD45γ expression was significantly lost in most clinically non-functioning adenomas (78 and 92%, respectively). Other assessed pituitary tumor phenotypes expressed both genes at significantly different levels, and, in some cases, with overexpression. There was no significant association between gene expression and the analyzed clinical features. Our results confirm the previous report, which indicated that MEG3 and GADD45γ expression is lost in the majority of human pituitary tumors, mainly in clinically-nonfunctioning adenomas. Functioning tumors had differences of relative expression levels. The two groups of tumors are probably genetically different and may have a different natural history.

GFAP-Cre-mediated transgenic activation of Bmi1 results in pituitary tumors

Bmi1 is a member of the polycomb repressive complex 1 and plays different roles during embryonic development, depending on the developmental context. Bmi1 over expression is observed in many types of cancer, including tumors of astroglial and neural origin. Although genetic depletion of Bmi1 has been described to result in tumor inhibitory effects partly through INK4A/Arf mediated senescence and apoptosis and also through INK4A/Arf independent effects, it has not been proven that Bmi1 can be causally involved in the formation of these tumors. To see whether this is the case, we developed two conditional Bmi1 transgenic models that were crossed with GFAP-Cre mice to activate transgenic expression in neural and glial lineages. We show here that these mice generate intermediate and anterior lobe pituitary tumors that are positive for ACTH and beta-endorphin. Combined transgenic expression of Bmi1 together with conditional loss of Rb resulted in pituitary tumors but was insufficient to induce medulloblastoma therefore indicating that the oncogenic function of Bmi1 depends on regulation of p16^INK4A/Rb rather than on regulation of p19^ARF/p53. Human pituitary adenomas show Bmi1 overexpression in over 50% of the cases, which indicates that Bmi1 could be causally involved in formation of these tumors similarly as in our mouse model.

Pathogenesis of pituitary tumors

Pituitary adenomas may hypersecrete hormones (including prolactin, growth hormone and adrenocorticotropic hormone, and rarely follicle-stimulating hormone, luteinizing hormone or TSH) or may be nonfunctional. Despite their high prevalence in the general population, these tumors are invariably benign and exhibit features of differentiated pituitary cell function as well as premature proliferative arrest. Pathogenesis of dysregulated pituitary cell proliferation and unrestrained hormone hypersecretion may be mediated by hypothalamic, intrapituitary and/or peripheral factors. Altered expression of pituitary cell cycle genes, activation of pituitary selective oncoproteins or loss of pituitary suppressor factors may be associated with aberrant growth factor signaling. Considerable information on the etiology of these tumors has been derived from transgenic animal models, which may not accurately and universally reflect human tumor pathophysiology. Understanding subcellular mechanisms that underlie pituitary tumorigenesis will enable development of tumor aggression markers as well as novel targeted therapies.

Lineage-specific restraint of pituitary gonadotroph cell adenoma growth

Although pituitary adenomas are usually benign, unique trophic mechanisms restraining cell proliferation are unclear. As GH-secreting adenomas are associated with p53/p21-dependent senescence, we tested mechanisms constraining non-functioning pituitary adenoma growth. Thirty six gonadotroph-derived non-functioning pituitary adenomas all exhibited DNA damage, but undetectable p21 expression. However, these adenomas all expressed p16, and >90% abundantly expressed cytoplasmic clusterin associated with induction of the Cdk inhibitor p15 in 70% of gonadotroph and in 26% of somatotroph lineage adenomas (p = 0.006). Murine LβT2 and αT3 gonadotroph pituitary cells, and αGSU.PTTG transgenic mice with targeted gonadotroph cell adenomas also abundantly expressed clusterin and exhibited features of oncogene-induced senescence as evidenced by C/EBPβ and C/EBPδ induction. In turn, C/EBPs activated the clusterin promoter ∼5 fold, and elevated clusterin subsequently elicited p15 and p16 expression, acting to arrest murine gonadotroph cell proliferation. In contrast, specific clusterin suppression by RNAis enhanced gonadotroph proliferation. FOXL2, a tissue-specific gonadotroph lineage factor, also induced the clusterin promoter ∼3 fold in αT3 pituitary cells. As nine of 12 pituitary carcinomas were devoid of clusterin expression, this protein may limit proliferation of benign adenomatous pituitary cells. These results point to lineage-specific pathways restricting uncontrolled murine and human pituitary gonadotroph adenoma cell growth.

Immunohistochemistry of COUP-TFI: an adjuvant diagnostic tool for the identification of corticotroph microadenomas

Cushing's disease is caused by an ACTH-producing pituitary tumor, and accounts for 10-15% of pituitary tumors. The majority of corticotroph tumors are microadenomas (<10 mm), and accurate histologic identification of these tumors can be challenging because of their small size and the presence of nests of normal corticotroph cells in the anterior pituitary. Retinoic acid has been shown to inhibit ACTH production and induce apoptosis in corticotroph tumor cells. The expression of the orphan nuclear receptor COUP-TFI antagonizes retinoic acid signaling and has been shown to be expressed in normal corticotroph cells, but absent in corticotroph tumor cell lines. We analyzed 34 corticotroph tumor specimens by immunohistochemistry using a goat polyclonal IgG antibody with epitope mapping to the N-terminus of human COUP-TFI. Segments of normal pituitary in each of the 34 specimens demonstrate COUP-TFI immunoreactivity in normal corticotroph cells. Twenty-nine of 34 ACTH producing tumors were immunonegative for COUP-TFI. All of the tumors measuring less than 5 mm by preoperative MRI were COUP-TFI immunonegative. Two tumors, measuring 9 and 11 mm, showed consistent (>90%) expression of COUP-TFI, and three adenomas (5, 11, and 18 mm) showed heterogenous (20-80%) expression of COUP-TFI. Immunohistochemistry of COUP-TFI may be a useful adjuvant diagnostic tool in distinguishing corticotroph microadenomas from nests of normal corticotroph cells in the anterior pituitary. Furthermore, this study identifies two unique corticotroph tumor populations which differ in their expression of COUP-TFI, the presence of which occurs more frequently in macroadenomas.

Perioperative cortisol can predict hypothalamus-pituitary-adrenal status in clinically non-functioning pituitary adenomas

BACKGROUND

Peri-operative steroids are administered routinely to patients with pituitary adenoma undergoing transsphenoidal adenomectomy (TSA).

AIM

To evaluate hypothalamic-pituitary-adrenal (HPA) axis before and after programmed endoscopic TSA (E-TSA) in patients with clinically non-functioning pituitary macroadenoma (NFPA).

DESIGN

Open prospective.

SETTING

Tertiary referral hospitals.

PATIENTS

Seventy-two consecutive patients (20-87 yr, 37 males).

INTERVENTIONS

Adrenal steroid replacement therapy (ASRT) was given only in patients with hypocortisolism [08:00 h cortisol (F) <8 microg/dl].

MAIN OUTCOME MEASUREMENTS

After ETSA, achieving wide (>90%) selective resection of the adenoma in all, F and clinical picture were checked at day 2. The low-dose (1 microg) ACTH test (LDACTH) was performed at 6 weeks and repeated at 12 months.

RESULTS

Hypocortisolism was present pre-operatively in 14 patients (19.4%), persisted post-operatively in all but one, and was detected de novo at the post-operative day 2 control in 6 (10.3%). In all but one the post-operative day 2 basal F and peak F during LDACTH test were concordant. No patient whose F was > 8 microg/dl was treated with ASRT or developed symptoms of adrenal failure during the follow-up (1-11 yr, median 5).

CONCLUSIONS

HPA function is usually preserved in NFPA and is infrequently impaired after complete tumor removal by E-TSA. The 08:00 h. plasma cortisol evaluation before and 2 days after surgery, using as cut-off the value of 8 microg/dl, allows full evaluation of HPA status. Peri-operative steroid treatment should be given only in patients with hypocortisolism.

Malignant pituitary corticotroph adenomas: report of two cases and a comprehensive review of the literature

Corticotroph pituitary carcinomas are tumors, defined by the presence of distant metastases that determine their poor prognosis. The diagnosis and therapy of malignant corticotroph adenomas remains a clinical challenge. The molecular mechanisms of malignant transformation of pituitary adenomas are unclear, although they are believed to arise in an adenoma-to-carcinoma sequence. We describe two cases of malignant Cushing's disease with metastases in liver and bone, respectively. The primary pituitary tumors were treated by a combination of radiotherapy and transsphenoidal surgery, but recurred several times in both patients. The time interval between the diagnosis of Cushing's disease and the discovery of metastases was 32 and 17 years, respectively. In the first case the patient died within 6 months after diagnosis of metastasis, whereas the second patient is alive at a follow-up of 2 years after the discovery of the metastasis. Furthermore, we reviewed all available cases of corticotroph pituitary carcinomas reported in the literature and analyzed their clinical features and therapeutical management. In conclusion, frequent relapses of Cushing's disease, aggressive growth of macroadenoma, Nelson's syndrome after adrenalectomy or persistently high ACTH levels should prompt the clinician to consider the possibility of pituitary corticotroph carcinomas.

Study of the telomerase hTERT fraction, PCNA and CD34 expression on pituitary adenomas. Association with clinical and demographic characteristics

To determine the frequency of human telomerase reverse transcriptase (hTERT) catalytic fraction expression and its association with clinical and demographic characteristics of the patient, as well as with the expression of CD34 and proliferating cell nuclear antigen (PCNA) indexes on adenohypophyseal hormone tissues. A transverse study was realized with 49 cases of hypophyseal adenoma with analysis type cases and controls. The different adenohypophyseal hormones [prolactin (PRL), growth hormone (GH), follicle stimulating hormone, luteinizing hormone, thyroid gland stimulant hormone, adrenocorticotropic hormone (ACTH)], the catalytic fraction of the telomerase hTERT, the PCNA index and the CD34 density were determined by means of immunohistochemical techniques. The clinical, demographic and histopathological characteristics of the patients with and without hTERT expression were compared by means of Pearson's Chi-squared, Fisher's exact test and Mann-Whitney's U. Twenty-eight point six percent of the adenomas had positive expression for hTERT. The variables significantly correlated with hTERT's expression were younger age of presentation, diagnostic of adenoma producer, higher PCNA index, higher CD34 density, increased GH on serum and the expression on PRL tissue, GH and ACTH. Tobacco history had a negative association with hTERT's expression. The telomerase could be a marker of cellular proliferation associated with angiogenesis and hormonal activity. Evaluation of these variables could provide information about their biological behavior.

Gene expression profiling in human null cell pituitary adenoma tissue

It is estimated that up to one in five individuals develops pituitary gland tumors, despite the common occurrence of these tumors, the pathogenetic mechanisms underlying their development mainly remain unknown. We studied the gene expression in null cell adenomas compared with normal pituitary by expressed sequence tags (EST) sequencing and cDNA microarray on large scale. Both approaches of EST sequencing and microarray analysis showed that 17 genes were differentially expressed in human null cell pituitary adenoma tissues, among which 14 genes were overexpressed and three genes were underpressed. Five of the genes with potential oncogenic significance by RT-real time quantitative PCR. Synaptotagmin (SYT) are integral membrane proteins of synaptic vesicles considered to serve as Ca(2+) sensors in the process of vesicular trafficking and exocytosis. Calcium binding to participates in triggering neurotransmitter release at the synapse. In view of our finding that SYT is overexpressed in null cell adenomas, these tumors may be capable of secreting some unknown hormones or peptides. ATP5B and MDH1 were involved in the energy metabolism, whose overexpression in null cell adenomas provide us with a new perspective of exploring the oncogenesis of these tumors. All of these data may contribute to the understanding of null cell adenoma formation and development.

Pituitary action of cytokines: focus on BMP-4 and gp130 family

The anterior pituitary can develop benign tumors of different sizes, classified as micro- and macroadenomas, frequently associated with high levels of hormone production, leading to different associated syndromes like Cushing's disease, acromegaly or prolactinomas. Much work has been done in order to understand the signaling pathways and the factors and hormones involved in the pituitary tumorigenic process. In recent years, much evidence has been collected and it is now well documented that cytokines of the gp130 family, such as interleukin-6, that use gp130 as a common signaling protein stimulate not only the proliferation but also the hormone secretion of pituitary cells. Experiments in vivo have shown that the overexpression of the gp130 receptor resulted in pituitary abnormal growth. Moreover, it has been recently described that bone morphogenetic protein-4 (BMP-4), a member of the TGF-beta family, has a stimulatory role on lactosomatotropic cells promoting the development of prolactinomas but it has an inhibitory action on the corticotropic lineage. This inhibitory action prevents Cushing's disease progression. Furthermore, BMP-4 mediates the antiproliferative action of retinoic acid in these cells. The present review highlights the most recent work about gp130 and TGF-beta cytokine families and their role in pituitary tumorigenesis.

Oncogenesis and mutagenesis of pituitary tumors

Although pituitary tumors may be present in up to 10% of the population, the pathophysiology of these lesions is not well characterized. Pituitary tumors are composed of monoclonal cell populations with disrupted control of replication pathways. The oncogenes and tumor suppressor genes that are common in other malignancies (i.e. jun, fos, myc, and p53) are rarely involved in the development of these tumors. However, oncogenes, such as gsp, can be present in up to 40% of hormonally active adenomas. The process of pituitary oncogenesis further appears to involve oncogenes such as cyclin E, cyclin D1, and the pituitary tumor transforming gene (PTTG). Finally, the cAMP signaling cascade plays a significant role in generation of both benign and malignant pituitary tumors. In this review, the biology of pituitary adenomas is explored with a special emphasis on potential targets for the development of targeted therapeutics.

Late development of intraventricular papillary pituitary carcinoma after irradiation of prolactinoma

BACKGROUND

Intracranial dissemination of pituitary adenomas is a rare event that does not equate malignancy. Most of the cases have been reported as metastases from pituitary carcinoma. A case of papillary pituitary carcinoma developed 12 years after radiotherapy for prolactin-secreting hormone pituitary adenoma is presented.

CASE DESCRIPTION

A 37-year-old woman was admitted for the second time with neurologic disturbance and hypertension. A gadolinium-enhanced magnetic resonance scan of the brain demonstrated a 50-mm enhanced mass (absent on previous studies) on the lateral ventricle, involving the left temporal lobe. The patient underwent a craniotomy and biopsy of the lesion that was consistent with pituitary carcinoma; it was immunoreactive to follicle-stimulating hormone, adrenocorticotropic hormone, pituitary tumor-transforming gene, and epithelial cell adhesion molecule. Transmission electron microscopy analysis confirmed the secretory pituitary tumor diagnosis.

CONCLUSIONS

The tumor was considered a primary pituitary papillary carcinoma. The clinical course indicated that this tumor was the seedling of a pituitary tumor, although it could be interpreted as metastases from a pituitary carcinoma.

Bone morphogenetic protein-4 inhibits corticotroph tumor cells: involvement in the retinoic acid inhibitory action

The molecular mechanisms governing the pathogenesis of ACTH-secreting pituitary adenomas are still obscure. Furthermore, the pharmacological treatment of these tumors is limited. In this study, we report that bone morphogenetic protein-4 (BMP-4) is expressed in the corticotrophs of human normal adenohypophysis and its expression is reduced in corticotrophinomas obtained from Cushing's patients compared with the normal pituitary. BMP-4 treatment of AtT-20 mouse corticotrophinoma cells has an inhibitory effect on ACTH secretion and cell proliferation. AtT-20 cells stably transfected with a dominant-negative form of the BMP-4 signal cotransducer Smad-4 or the BMP-4 inhibitor noggin have increased tumorigenicity in nude mice, showing that BMP-4 has an inhibitory role on corticotroph tumorigenesis in vivo. Because the activation of the retinoic acid receptor has an inhibitory action on Cushing's disease progression, we analyzed the putative interaction of these two pathways. Indeed, retinoic acid induces both BMP-4 transcription and expression and its antiproliferative action is blocked in Smad-4dn- and noggin-transfected Att-20 cells that do not respond to BMP-4. Therefore, retinoic acid induces BMP-4, which participates in the antiproliferative effects of retinoic acid. This new mechanism is a potential target for therapeutic approaches for Cushing's disease.

Effects of medical therapy on pituitary tumors

Previously surgery and irradiation were the only available procedures to treat patients with pituitary tumors. During the last few decades, novel drugs such as dopamine agonists and long-acting somatostatin analogs were developed and, an alternative medical therapy emerged. This paper summarizes the effect of medical therapy on the morphologic features of pituitary tumors and illustrates the ultrastructural alterations on electron micrographs. Currently drugs can be used in the management of pituitary tumors secreting GH, PRL, and/or TSH in excess. No medical therapy is available so far for ACTH-, FSH-, LH-, or alpha-subunit-secreting tumors as well as non-hormone-secreting pituitary tumors. Dopamine agonists are effective in the management of PRL-secreting tumors; they cause marked reversible tumor shrinkage in the substantial majority of patients. Long-acting somatostatin analogs are useful in the management of GH- and TSH-secreting pituitary tumors; they lead to mild to moderate tumor shrinkage in approximately 50% of cases. In patients treated with these drugs reduction of elevated blood hormone levels and amelioration of clinical symptoms ensue. It should be emphasized that no permanent cure is obtained. Blood hormone levels increase and the clinical symptoms reappear after discontinuation of treatment. Recently GH receptor blockers (pegvisomant) were introduced in the treatment of GH-producing pituitary adenomas. To the authors' knowledge the effect of these drugs on the morphology of pituitary tumors has not been revealed so far.

Best Practice No 172: pituitary gland pathology

This article reviews published evidence on the diagnosis and classification of pituitary gland tumours and the relevance of histological and genetic features to prognosis. Much of the literature is devoted to the histological, ultrastructural, and immunocytochemical classification of pituitary adenomas (extensively supported by multicentre studies), with little consensus on the identification of prognostic features in adenomas, particularly in relation to invasion. There is a lack of correspondence between clinical and pathological criteria to identify and classify invasion, and a need to reassess the nomenclature and diagnostic criteria for invasive adenomas and carcinomas. Recent cytogenetic, genetic, and molecular biological studies have identified no consistent abnormalities in relation to pituitary tumour progression, although many genes are likely to be involved. In light of these uncertainties, an approach to the diagnosis and classification of pituitary adenomas is suggested, based on robust criteria from earlier studies and incorporating provisional data that require reassessment in large prospective studies with an adequate clinicopathological database.

Cyclooxygenase-2 expression in human pituitary tumors

BACKGROUND

Cyclooxygenase-2 (COX-2) plays a role in progression of colon, breast, pancreas, and lung carcinomas. The authors investigated COX-2 expression in pituitary tumors.

METHODS

Expression of COX-2 was evaluated in 164 surgically removed human pituitary tumors. Correlation of COX-2 with MIB-1, a cell proliferation marker, as well as angiogenesis, patient age, gender, tumor type, size, invasiveness, and metastatic potential was investigated.

RESULTS

Cyclooxygenase-2 immunoreactivity was confined to the cytoplasm of tumor cells, whereas the nuclei were unlabeled. Few normal peritumoral adenohypophysial cells showed slight COX-2 cytoplasmic immunoreactivity. The staining intensity and the percentage of immunopositive cells were higher in tumors. Most pituitary tumors (96%) were COX-2-immunopositive. Expression was strong in 60 (44%), moderate in 39 (28%), and weak in 32 (24%). Male gonadotroph adenomas and null cell adenomas showed a high level of COX-2 expression. Growth hormone-producing adenomas, prolactin-producing adenomas, thyrotropic hormone-producing adenomas, female gonadotroph adenomas, silent adrenocorticotropic hormone-producing adenomas, and silent subtype 3 adenomas had a low level of COX-2 expression. Significant correlation was demonstrated with patient age, but not with tumor size, invasiveness, and MIB-1 labeling indices. Expression was medium to high in 76% of macroadenomas and in only 45% of microadenomas. Strong correlations were noted with angiogenesis markers, such as microvessel density and surface density.

CONCLUSIONS

Correlation with angiogenesis suggests that COX-2 may be involved in the regulation of angiogenesis in pituitary tumors. Phamacologic inhibition of COX-2 activity might suppress angiogenesis in pituitary tumors and may provide a novel approach for medical therapy.