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Azuma M, Khant ZA, Kadota Y, Takeishi G, Watanabe T, Yokogami K, Takeshima H, Hirai T. Added Value of Contrast-enhanced 3D-FLAIR MR Imaging for Differentiating Cystic Pituitary Adenoma from Rathke's Cleft Cyst. Magn Reson Med Sci 2021; 20:404-409. [PMID: 33487606 PMCID: PMC8922349 DOI: 10.2463/mrms.mp.2020-0127] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
PURPOSE Half of the surgically proven Rathke's cleft cysts (RCCs) can be preoperatively misdiagnosed as cystic pituitary adenoma (CPA). We aimed to evaluate the usefulness of contrast-enhanced (CE) 3D T2 fluid-attenuated inversion-recovery (3D T2-FLAIR) imaging for differentiating between CPA and RCC. METHODS This retrospective study included six patients with RCC (all pathologically confirmed) and six patients with CPA (five pathologically confirmed, one clinically diagnosed). The 12 patients underwent pre- and post-contrast T1-weighted (T1W)- and 3D T2-FLAIR imaging at 3T. Based on the degree of enhancement of the lesion wall, two radiologists independently scored the images using a 3-point grading system. Interobserver agreement was calculated by using the κ coefficient. The statistical significance of grading differences was analyzed with the Mann-Whitney U-test. Another neuroradiologist first interpreted conventional MR images (1st session), and then the reader read images to which the 3D T2-FLAIR images had been added (2nd session). Sensitivity, specificity, and accuracy of the reader's interpretation were calculated. RESULTS Interobserver agreement for post-contrast T1W- and 3D T2-FLAIR images was excellent (κ = 1.000 and 0.885, respectively). Although the mean enhancement grade on post-contrast T1W images of RCCs and CPAs was not significantly different, on post-contrast 3D T2-FLAIR images it was significantly higher for RCCs and CPAs (P < 0.05). Three CPAs (50%) showed remarkable, donut-like enhancement along the inner margin of the cyst on CE-3D T2-FLAIR images; this was not the case on CE-T1W images. The sensitivity, specificity, and accuracy of the 2nd session were 1.00, 0.83, and 0.92, respectively, which were improved compared to the 1st session (1.00, 0.50, and 0.75, respectively). CONCLUSION CE-3D FLAIR imaging is useful for discriminating CPAs and RCCs.
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Affiliation(s)
- Minako Azuma
- Department of Radiology, Faculty of Medicine, University of Miyazaki
| | - Zaw Aung Khant
- Department of Radiology, Faculty of Medicine, University of Miyazaki
| | - Yoshihito Kadota
- Department of Radiology, Faculty of Medicine, University of Miyazaki
| | - Go Takeishi
- Department of Neurosurgery, Faculty of Medicine, University of Miyazaki
| | - Takashi Watanabe
- Department of Neurosurgery, Faculty of Medicine, University of Miyazaki
| | - Kiyotaka Yokogami
- Department of Neurosurgery, Faculty of Medicine, University of Miyazaki
| | - Hideo Takeshima
- Department of Neurosurgery, Faculty of Medicine, University of Miyazaki
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Negm HM, Al-Mahfoudh R, Pai M, Singh H, Cohen S, Dhandapani S, Anand VK, Schwartz TH. Reoperative endoscopic endonasal surgery for residual or recurrent pituitary adenomas. J Neurosurg 2017; 127:397-408. [DOI: 10.3171/2016.8.jns152709] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVERegrowth of the lesion after surgical removal of pituitary adenomas is uncommon unless subtotal resection was originally achieved in the first surgery. Treatment for recurrent tumor can involve surgery or radiotherapy. Locations of residual tumor may vary based on the original approach. The authors evaluated the specific sites of residual or recurrent tumor after different transsphenoidal approaches and describe the surgical outcome of endoscopic endonasal transsphenoidal reoperation.METHODSThe authors analyzed a prospectively collected database of a consecutive series of patients who had undergone endoscopic endonasal surgeries for residual or recurrent pituitary adenomas after an original transsphenoidal microscopic or endoscopic surgery. The site of the recurrent tumor and outcome after reoperation were noted and correlated with the primary surgical approach. The chi-square or Fisher exact test was used to compare categorical variables, and the Mann-Whitney U-test was used to compare continuous variables between surgical groups.RESULTSForty-one patients underwent surgery for residual/recurrent pituitary adenoma from 2004 to 2015 at Weill Cornell Medical College. The previous treatment was a transsphenoidal microscopic (n = 22) and endoscopic endonasal (n = 19) surgery. In 83.3% patients (n = 30/36) there was postoperative residual tumor after the initial surgery. A residual tumor following endonasal endoscopic surgery was less common in the sphenoid sinus (10.5%; 2/19) than it was after microscopic transsphenoidal surgery (72.7%; n =16/22; p = 0.004). Gross-total resection (GTR) was achieved in 58.5%, and either GTR or near-total resection was achieved in 92.7%. Across all cases, the average extent of resection was 93.7%. The rate of GTR was lower in patients with Knosp-Steiner Grade 3–4 invasion (p < 0.0005). Postoperative CSF leak was seen in only one case (2.4%), which stopped with lumbar drainage. Visual fields improved in 52.9% (n = 9/17) of patients and were stable in 47% (n = 8/17). Endocrine remission was achieved in 77.8% (n = 14/18) of cases, 12 by surgery alone and 2 by adjuvant medical (n = 1) and radiation (n = 1) therapy. New diabetes insipidus occurred in 4.9% (n = 2/41) of patients—in one of whom an additional single anterior hormonal axis was compromised—and 9.7% (n = 4/41) of patients had a new anterior pituitary hormonal insufficiency.CONCLUSIONSEndonasal endoscopic reoperation is extremely effective at removing recurrent or residual pituitary adenomas that remain after a prior surgery, and it may be preferable to radiation therapy particularly in symptomatic patients. Achievement of GTR is less common when lateral cavernous sinus invasion is present. The locations of residual/recurrent tumor were more likely sphenoidal and parasellar following a prior microscopic transsphenoidal surgery and sellar following a prior endonasal endoscopic surgery.
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Affiliation(s)
- Hazem M. Negm
- Departments of 1Neurological Surgery,
- 4Department of Neurosurgery, Menoufia University, Menoufia, Egypt
| | - Rafid Al-Mahfoudh
- Departments of 1Neurological Surgery,
- 5South East Neurosurgery and Spinal Surgery, Brighton and Sussex University Hospitals NHS Trust, East Sussex, United Kingdom
| | - Manish Pai
- Departments of 1Neurological Surgery,
- 6Tata Main Hospital, Jamshedpur, India
| | - Harminder Singh
- Departments of 1Neurological Surgery,
- 9Stanford University School of Medicine, Stanford, California
| | - Salomon Cohen
- Departments of 1Neurological Surgery,
- 7Department of Neurosurgery, National Institute of Neurology and Neurosurgery, “Manuel Velasco Suarez,” Mexico City, Mexico
| | - Sivashanmugam Dhandapani
- Departments of 1Neurological Surgery,
- 8Department of Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India; and
| | | | - Theodore H. Schwartz
- Departments of 1Neurological Surgery,
- 2Otolaryngology, and
- 3Neuroscience, Weill Cornell Medical College, NewYork-Presbyterian Hospital, New York, New York
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Santi D, Spaggiari G, Casarini L, Fanelli F, Mezzullo M, Pagotto U, Granata ARM, Carani C, Simoni M. Central hypogonadism due to a giant, "silent" FSH-secreting, atypical pituitary adenoma: effects of adenoma dissection and short-term Leydig cell stimulation by luteinizing hormone (LH) and human chorionic gonadotropin (hCG). Aging Male 2017; 20:96-101. [PMID: 28067604 DOI: 10.1080/13685538.2016.1276161] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
We present a case report of an atypical giant pituitary adenoma secreting follicle-stimulating hormone (FSH). A 55-year-old patient presented for erectile dysfunction, loss of libido and fatigue. The biochemical evaluation showed very high FSH serum levels in the presence of central hypogonadism. Neither testicular enlargement nor increased sperm count was observed, thus a secretion of FSH with reduced biological activity was supposed. The histological examination after neuro-surgery showed an atypical pituitary adenoma with FSH-positive cells. Hypogonadism persisted and semen analyses impaired until azoospermia in conjunction with the reduction in FSH levels suggesting that, at least in part, this gonadotropin should be biologically active. Thus, we hypothesized a concomitant primary testicular insufficiency. The patient underwent short-term treatment trials with low doses of either recombinant luteinizing hormone (LH) or human chorionic gonadotropin (hCG) in three consecutive treatment schemes, showing an equal efficacy in stimulating testosterone (T) increase. This is the first case of atypical, giant FSH-secreting pituitary adenoma with high FSH serum levels without signs of testicular hyperstimulation, in presence of hypogonadism with plausible combined primary and secondary etiology. Hypophysectomized patients may represent a good model to assess both pharmacodynamics and effective dose of LH and hCG in the male.
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Affiliation(s)
- Daniele Santi
- a Unit of Endocrinology, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia , Modena , Italy
- b Unit of Endocrinology, Department of Medicine, Endocrinology, Metabolism and Geriatrics, Azienda USL of Modena , Modena , Italy
| | - Giorgia Spaggiari
- a Unit of Endocrinology, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia , Modena , Italy
- b Unit of Endocrinology, Department of Medicine, Endocrinology, Metabolism and Geriatrics, Azienda USL of Modena , Modena , Italy
| | - Livio Casarini
- a Unit of Endocrinology, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia , Modena , Italy
- c Center for Genomic Research, University of Modena and Reggio Emilia , Modena , Italy , and
| | - Flaminia Fanelli
- d Endocrinology Unit and Centre for Applied Biomedical Research, Department of Medical and Surgical Sciences, S. Orsola-Malpighi Hospital, Alma Mater University of Bologna , Bologna , Italy
| | - Marco Mezzullo
- d Endocrinology Unit and Centre for Applied Biomedical Research, Department of Medical and Surgical Sciences, S. Orsola-Malpighi Hospital, Alma Mater University of Bologna , Bologna , Italy
| | - Uberto Pagotto
- d Endocrinology Unit and Centre for Applied Biomedical Research, Department of Medical and Surgical Sciences, S. Orsola-Malpighi Hospital, Alma Mater University of Bologna , Bologna , Italy
| | - Antonio R M Granata
- a Unit of Endocrinology, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia , Modena , Italy
- b Unit of Endocrinology, Department of Medicine, Endocrinology, Metabolism and Geriatrics, Azienda USL of Modena , Modena , Italy
| | - Cesare Carani
- a Unit of Endocrinology, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia , Modena , Italy
| | - Manuela Simoni
- a Unit of Endocrinology, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia , Modena , Italy
- b Unit of Endocrinology, Department of Medicine, Endocrinology, Metabolism and Geriatrics, Azienda USL of Modena , Modena , Italy
- c Center for Genomic Research, University of Modena and Reggio Emilia , Modena , Italy , and
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Park M, Ahn SS. Reply. AJNR Am J Neuroradiol 2016; 37:E29. [PMID: 26680458 DOI: 10.3174/ajnr.a4668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- M Park
- Department of Radiology, Research Institute of Radiological Science Yonsei University, College of Medicine Seoul, Korea
| | - S S Ahn
- Department of Radiology, Research Institute of Radiological Science Yonsei University, College of Medicine Seoul, Korea
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Chabot JD, Chakraborty S, Imbarrato G, Dehdashti AR. Evaluation of Outcomes After Endoscopic Endonasal Surgery for Large and Giant Pituitary Macroadenoma: A Retrospective Review of 39 Consecutive Patients. World Neurosurg 2015; 84:978-88. [DOI: 10.1016/j.wneu.2015.06.007] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2015] [Revised: 06/02/2015] [Accepted: 06/04/2015] [Indexed: 11/28/2022]
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Park M, Lee SK, Choi J, Kim SH, Kim SH, Shin NY, Kim J, Ahn SS. Differentiation between Cystic Pituitary Adenomas and Rathke Cleft Cysts: A Diagnostic Model Using MRI. AJNR Am J Neuroradiol 2015; 36:1866-73. [PMID: 26251436 DOI: 10.3174/ajnr.a4387] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2014] [Accepted: 02/24/2015] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Cystic pituitary adenomas may mimic Rathke cleft cysts when there is no solid enhancing component found on MR imaging, and preoperative differentiation may enable a more appropriate selection of treatment strategies. We investigated the diagnostic potential of MR imaging features to differentiate cystic pituitary adenomas from Rathke cleft cysts and to develop a diagnostic model. MATERIALS AND METHODS This retrospective study included 54 patients with a cystic pituitary adenoma (40 women; mean age, 37.7 years) and 28 with a Rathke cleft cyst (18 women; mean age, 31.5 years) who underwent MR imaging followed by surgery. The following imaging features were assessed: the presence or absence of a fluid-fluid level, a hypointense rim on T2-weighted images, septation, an off-midline location, the presence or absence of an intracystic nodule, size change, and signal change. On the basis of the results of logistic regression analysis, a diagnostic tree model was developed to differentiate between cystic pituitary adenomas and Rathke cleft cysts. External validation was performed for an additional 16 patients with a cystic pituitary adenoma and 8 patients with a Rathke cleft cyst. RESULTS The presence of a fluid-fluid level, a hypointense rim on T2-weighted images, septation, and an off-midline location were more common with pituitary adenomas, whereas the presence of an intracystic nodule was more common with Rathke cleft cysts. Multiple logistic regression analysis showed that cystic pituitary adenomas and Rathke cleft cysts can be distinguished on the basis of the presence of a fluid-fluid level, septation, an off-midline location, and the presence of an intracystic nodule (P = .006, .032, .001, and .023, respectively). Among 24 patients in the external validation population, 22 were classified correctly on the basis of the diagnostic tree model used in this study. CONCLUSIONS A systematic approach using this diagnostic tree model can be helpful in distinguishing cystic pituitary adenomas from Rathke cleft cysts.
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Affiliation(s)
- M Park
- From the Department of Radiology, Research Institute of Radiological Science (M.P., S.-K.L., J.K., S.S.A.)
| | - S-K Lee
- From the Department of Radiology, Research Institute of Radiological Science (M.P., S.-K.L., J.K., S.S.A.)
| | - J Choi
- Biostatistics Collaboration Unit, Medical Research Center (J.C.)
| | - S-H Kim
- Departments of Neurosurgery (S.-H.K.)
| | - S H Kim
- Pathology (S.H.K.), Yonsei University College of Medicine, Seoul, South Korea
| | - N-Y Shin
- Department of Radiology (N.-Y.S.), Ewha Womans University School of Medicine, Seoul, South Korea
| | - J Kim
- From the Department of Radiology, Research Institute of Radiological Science (M.P., S.-K.L., J.K., S.S.A.)
| | - S S Ahn
- From the Department of Radiology, Research Institute of Radiological Science (M.P., S.-K.L., J.K., S.S.A.)
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Roemmler-Zehrer J, Geigenberger V, Störmann S, Ising M, Pfister H, Sievers C, Stalla GK, Schopohl J. Specific behaviour, mood and personality traits may contribute to obesity in patients with craniopharyngioma. Clin Endocrinol (Oxf) 2015; 82:106-14. [PMID: 24923438 DOI: 10.1111/cen.12523] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2013] [Revised: 12/21/2013] [Accepted: 06/03/2014] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Patients with craniopharyngioma (CP) often suffer from obesity, but the underlying causes are still not fully understood. We compared CP to patients with nonfunctioning pituitary adenoma (NFPA) and to a control group (CG) using standardized questionnaires to investigate whether behavioural, mood or personality traits contribute to obesity. METHODS We compared 31 patients with CP (42% male, 53 ± 15·1 years) to 26 patients with NFPA (71% male, 63·2 ± 10·3 years) and to age- and gender-matched local CG (ratio 2:1). Normative data from the literature are included for reference. Patients were asked to complete eleven standardized questionnaires. Two questionnaires were used to evaluate eating disorders (FEV, EDE-Q), one depression (BDI), one anxiety (STAI), three health-related quality of life (SF-36, EuroQoL, QoL-AGHDA), one sleepiness (Epworth Sleepiness Scale), two personality (EPQ-RK, TPQ) and one body image (FKB-20). RESULTS Patients with CP scored significantly higher in conscious hunger perception (FEV, CP 5·8 ± 3·2 scores, NFPA 3·6 ± 3·3 scores, CG 3·0 ± 2·5, P < 0·001). They had similar scores for BDI compared with NFPA, but higher scores to CG (P < 0·001, CP 10·6 ± 8·3, NFPA 7·5 ± 5·7, CG 4·96 ± 4·2). CP and NFPA scored higher than CG for anxiety and personality traits such as harm avoidance, fatigability and asthenia and slightly higher for neuroticism. No differences were seen for EDE-Q, quality of life, daytime sleepiness and body image between CP and NFPA. However, differences could be observed to normative data from the literature. CONCLUSION Obesity in patients with CP might be influenced by eating disorders, negative mood alterations and increased anxiety-related personality traits.
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Affiliation(s)
- J Roemmler-Zehrer
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Munich, Germany
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Kopczak A, Renner U, Karl Stalla G. Advances in understanding pituitary tumors. F1000PRIME REPORTS 2014; 6:5. [PMID: 24592317 PMCID: PMC3883424 DOI: 10.12703/p6-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Pituitary tumors are common in the general population. Since neuroimaging techniques have improved, pituitary tumors are more often diagnosed incidentally. About 16.7% of the general population show changes in the pituitary gland. Predominantly, pituitary tumors are benign pituitary adenomas. Pituitary carcinomas or aggressive pituitary tumors are extremely rare. They might develop from benign adenomas. New genetic and epigenetic abnormalities help us to understand pituitary tumorigenesis and might lead to therapeutical targeting drugs in the future. Macroadenomas (>1 cm) can lead to visual field disturbances, compression of cranial nerves, hypopituitarism, and infiltration of the cavernous sinuses. The functional status of the pituitary tumor is important. About half to one third of all pituitary tumors are non-functioning pituitary adenomas. The other pituitary tumors show a specific pattern of hormone secretion. About 25% to 41% of all pituitary tumors are prolactinomas, acromegaly with production of growth hormone represents 10% to 15% of adenomas, Cushing's disease with production of adrenocorticotropic hormone accounts for 10%, and other hormonal characteristics are less common. Transsphenoidal resection and total adenomectomy are desirable. Radiosurgery has enriched the surgical treatment options. Surgical treatment is the intervention of choice except for prolactinomas, where pharmaceutical treatment is recommended. Pharmaceutical treatment consists of dopamine agonists such as cabergoline and somatostatin analogues that include octreotide and pasireotide; retinoic acid is of theoretical interest while peroxisome proliferator-activated receptor-gamma-ligands are not clinically useful. In acromegaly, pegvisomant is a further treatment option. Temozolomide should be considered in aggressive pituitary tumors. In general, pharmaceutical options developed recently have extended the repertoire of treatment possibilities of pituitary tumors.
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Affiliation(s)
- Anna Kopczak
- Max Planck Institute of Psychiatry, Clinical Neurendocrinology GroupKraepelinstraße 2-10, 80804 MunichGermany
| | - Ulrich Renner
- Max Planck Institute of Psychiatry, Clinical Neurendocrinology GroupKraepelinstraße 2-10, 80804 MunichGermany
| | - Günter Karl Stalla
- Max Planck Institute of Psychiatry, Clinical Neurendocrinology GroupKraepelinstraße 2-10, 80804 MunichGermany
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Barbieri F, Thellung S, Würth R, Gatto F, Corsaro A, Villa V, Nizzari M, Albertelli M, Ferone D, Florio T. Emerging Targets in Pituitary Adenomas: Role of the CXCL12/CXCR4-R7 System. Int J Endocrinol 2014; 2014:753524. [PMID: 25484899 PMCID: PMC4248486 DOI: 10.1155/2014/753524] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2014] [Accepted: 10/21/2014] [Indexed: 12/15/2022] Open
Abstract
Chemokines are chemotactic regulators of immune surveillance in physiological and pathological conditions such as inflammation, infection, and cancer. Several chemokines and cognate receptors are constitutively expressed in the central nervous system, not only in glial and endothelial cells but also in neurons, controlling neurogenesis, neurite outgrowth, and axonal guidance during development. In particular, the chemokine CXCL12 and its receptors, CXCR4 and CXCR7, form a functional network that controls plasticity in different brain areas, influencing neurotransmission, neuromodulation, and cell migration, and the dysregulation of this chemokinergic axis is involved in several neurodegenerative, neuroinflammatory, and malignant diseases. CXCR4 primarily mediates the transduction of proliferative signals, while CXCR7 seems to be mainly responsible for scavenging CXCL12. Importantly, the multiple intracellular signalling generated by CXCL12 interaction with its receptors influences hypothalamic modulation of neuroendocrine functions, although a direct modulation of pituitary functioning via autocrine/paracrine mechanisms was also reported. Both CXCL12 and CXCR4 are constitutively overexpressed in pituitary adenomas and their signalling induces cell survival and proliferation, as well as hormonal hypersecretion. In this review we focus on the physiological and pathological functions of immune-related cyto- and chemokines, mainly focusing on the CXCL12/CXCR4-7 axis, and their role in pituitary tumorigenesis. Accordingly, we discuss the potential targeting of CXCR4 as novel pharmacological approach for pituitary adenomas.
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Affiliation(s)
- Federica Barbieri
- Department of Internal Medicine and Medical Specialties and Center of Excellence for Biomedical Research (CEBR), University of Genova, Viale Benedetto XV, 2-16132 Genova, Italy
- *Federica Barbieri:
| | - Stefano Thellung
- Department of Internal Medicine and Medical Specialties and Center of Excellence for Biomedical Research (CEBR), University of Genova, Viale Benedetto XV, 2-16132 Genova, Italy
| | - Roberto Würth
- Department of Internal Medicine and Medical Specialties and Center of Excellence for Biomedical Research (CEBR), University of Genova, Viale Benedetto XV, 2-16132 Genova, Italy
| | - Federico Gatto
- Department of Internal Medicine and Medical Specialties and Center of Excellence for Biomedical Research (CEBR), University of Genova, Viale Benedetto XV, 2-16132 Genova, Italy
| | - Alessandro Corsaro
- Department of Internal Medicine and Medical Specialties and Center of Excellence for Biomedical Research (CEBR), University of Genova, Viale Benedetto XV, 2-16132 Genova, Italy
| | - Valentina Villa
- Department of Internal Medicine and Medical Specialties and Center of Excellence for Biomedical Research (CEBR), University of Genova, Viale Benedetto XV, 2-16132 Genova, Italy
| | - Mario Nizzari
- Department of Internal Medicine and Medical Specialties and Center of Excellence for Biomedical Research (CEBR), University of Genova, Viale Benedetto XV, 2-16132 Genova, Italy
| | - Manuela Albertelli
- Department of Internal Medicine and Medical Specialties and Center of Excellence for Biomedical Research (CEBR), University of Genova, Viale Benedetto XV, 2-16132 Genova, Italy
| | - Diego Ferone
- Department of Internal Medicine and Medical Specialties and Center of Excellence for Biomedical Research (CEBR), University of Genova, Viale Benedetto XV, 2-16132 Genova, Italy
| | - Tullio Florio
- Department of Internal Medicine and Medical Specialties and Center of Excellence for Biomedical Research (CEBR), University of Genova, Viale Benedetto XV, 2-16132 Genova, Italy
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