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Tng EL, Teo AED, Aung AT. Macroprolactinoma with secondary resistance to dopamine agonists: a case report and review of the literature. J Med Case Rep 2023; 17:96. [PMID: 36927797 PMCID: PMC10021939 DOI: 10.1186/s13256-023-03820-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Accepted: 02/14/2023] [Indexed: 03/18/2023] Open
Abstract
BACKGROUND Resistance to dopamine agonists is not uncommonly seen in prolactinomas. However, development of resistance to dopamine agonists after an initial period of robust treatment response is rare, and only 39 cases have been reported in the past four decades. We describe a Chinese man with this rare condition and explored the postulated mechanisms that may explain this phenomenon. We compiled similar cases that were previously reported and compared their etiology, progress, and response to treatment. On the basis of these cases, we derived a list of differential diagnoses to consider in patients with secondary resistance to dopamine agonists. CASE PRESENTATION A 63-year-old Chinese man presented with blurred vision and was subsequently diagnosed with a macroprolactinoma. He had initial response to cabergoline but developed secondary resistance to it after 5 years. The prolactinoma continued to grow, and his serum prolactin remained markedly elevated despite adherence to escalating dosages of cabergoline up to 6 mg/week. The patient finally underwent transsphenoidal surgery and was found to have a sparsely granulated lactotroph tumor with Ki-67 index of 5%. Postoperatively, there was improvement in his serum prolactin level, although he still required treatment with cabergoline at 6 mg/week. CONCLUSIONS Surgery can facilitate disease control in patients with prolactinomas that develop secondary resistance to dopamine agonists. Malignant prolactinoma is an important differential diagnosis in this group of patients, especially when serum prolactin remains markedly elevated despite resolution or stability of the primary pituitary lesion, suggesting a metastatic source of prolactin secretion.
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Affiliation(s)
- Eng-Loon Tng
- Department of Medicine, Ng Teng Fong General Hospital, 1 Jurong East Street 21, Tower A Level 8, Singapore, 609606, Singapore.
| | - Ada Ee Der Teo
- Department of Medicine, Division of Endocrinology, National University Health System, 1E Kent Ridge Road, NUHS Tower Block Level 10, Singapore, 119228, Singapore
| | - Aye Thida Aung
- Ministry of Health Holdings, 1 Maritime Square, #11-25 HarbourFront Centre, Singapore, 099253, Singapore
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Puar TH, Khoo CM, Tan CJ, Tong AKT, Tan MCS, Teo AED, Ng KS, Wong KM, Reilhac A, O'Doherty J, Gomez-Sanchez CE, Kek PC, Yee S, Tan AWK, Chuah MB, Lee DHM, Wang KW, Zheng CQ, Shi L, Robins EG, Foo RSY. 11C-Metomidate PET-CT versus adrenal vein sampling to subtype primary aldosteronism: a prospective clinical trial. J Hypertens 2022; 40:1179-1188. [PMID: 35703880 DOI: 10.1097/hjh.0000000000003132] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Adrenal vein sampling (AVS) is recommended to subtype primary aldosteronism, but it is technically challenging. We compared 11C-Metomidate-PET-computed tomography (PET-CT) and AVS for subtyping of primary aldosteronism. METHODS Patients with confirmed primary aldosteronism underwent both AVS and 11C-Metomidate PET-CT (post-dexamethasone). All results were reviewed at a multidisciplinary meeting to decide on final subtype diagnosis. Primary outcome was accuracy of PET versus AVS to diagnosis of unilateral primary aldosteronism based on post-surgical biochemical cure. Secondary outcome was accuracy of both tests to final subtype diagnosis. RESULTS All 25 patients recruited underwent PET and successful AVS (100%). Final diagnosis was unilateral in 22 patients, bilateral in two and indeterminate in one due to discordant lateralization. Twenty patients with unilateral primary aldosteronism underwent surgery, with 100% complete biochemical success, and 75% complete/partial clinical success. For the primary outcome, sensitivity of PET was 80% [95% confidence interval (95% CI): 56.3-94.3] and AVS was 75% (95% CI: 50.9-91.3). For the secondary outcome, sensitivity and specificity of PET was 81.9% (95% CI: 59.7-94.8) and 100% (95% CI: 15.8-100), and AVS was 68.2% (95% CI: 45.1-86.1) and 100% (95% CI: 15.8-100), respectively. Twelve out of 20 (60%) patients had both PET and AVS lateralization, four (20%) PET-only, three (15%) AVS-only, while one patient did not lateralize on PET or AVS. Post-surgery outcomes did not differ between patients identified by either test. CONCLUSION In our pilot study, 11C-Metomidate PET-CT performed comparably to AVS, and this should be validated in larger studies. PET identified patients with unilateral primary aldosteronism missed on AVS, and these tests could be used together to identify more patients with unilateral primary aldosteronism. VIDEO ABSTRACT http://links.lww.com/HJH/B918.
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Affiliation(s)
- Troy H Puar
- Department of Endocrinology, Changi General Hospital (CGH)
- Duke-NUS Medical School
| | - Chin Meng Khoo
- Division of Endocrinology, National University Health System (NUHS)
- Yong Loo Lin School of Medicine, National University of Singapore (NUS)
| | | | - Aaron Kian Ti Tong
- Department of Nuclear Medicine and Molecular Imaging, Singapore General Hospital (SGH)
| | | | | | - Keng Sin Ng
- Department of Radiology, CGH
- Department of Diagnostic Radiology, Mount Alvernia Hospital
| | | | | | - Jim O'Doherty
- Clinical Imaging Research Centre (CIRC), NUS, Singapore
| | - Celso E Gomez-Sanchez
- Division of Endocrinology, Medical Service, G.V. (Sonny) Montgomery VA Medical Center and Department of Pharmacology and Medicine, University of Mississippi Medical Centre, Mississippi, USA
| | | | - Szemen Yee
- Division of Endocrinology, Ng Teng Fong General Hospital
| | | | | | | | - Kuo Weng Wang
- Wang Kuo Weng Diabetes and Endocrine Practice, Gleneagles Medical Center
| | - Charles Qishi Zheng
- Duke-NUS Medical School
- Department of Epidemiology, Singapore Clinical Research Institute
| | - Luming Shi
- Duke-NUS Medical School
- Department of Epidemiology, Singapore Clinical Research Institute
| | - Edward George Robins
- Clinical Imaging Research Centre (CIRC), NUS, Singapore
- Department of Radiochemistry, Singapore Bioimaging Consortium
| | - Roger Sik Yin Foo
- Yong Loo Lin School of Medicine, National University of Singapore (NUS)
- Cardiovascular Research Institute, NUHS
- Genome Institute of Singapore
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Teo AED, Garg S, Johnson TI, Zhao W, Zhou J, Gomez-Sanchez CE, Gurnell M, Brown MJ. Physiological and Pathological Roles in Human Adrenal of the Glomeruli-Defining Matrix Protein NPNT (Nephronectin). Hypertension 2017; 69:1207-1216. [PMID: 28416583 PMCID: PMC5424579 DOI: 10.1161/hypertensionaha.117.09156] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Revised: 02/07/2017] [Accepted: 03/15/2017] [Indexed: 01/08/2023]
Abstract
Supplemental Digital Content is available in the text. Primary aldosteronism is a common cause of hypertension, which becomes refractory if undiagnosed, but potentially curable when caused by an aldosterone-producing adenoma (APA). The discovery of somatic mutations and differences in clinical presentations led to recognition of small but common zona glomerulosa (ZG)–like adenomas, distinct from classical large zona fasciculata–like adenomas. The inverse correlation between APA size and aldosterone synthase expression prompted us to undertake a systematic study of genotype–phenotype relationships. After a microarray comparing tumor subtypes, in which NPNT (nephronectin) was the most highly (>12-fold) upregulated gene in ZG-like APAs, we aimed to determine its role in physiological and pathological aldosterone production. NPNT was identified by immunohistochemistry as a secreted matrix protein expressed exclusively around aldosterone-producing glomeruli in normal adrenal ZG and in aldosterone-dense ZG-like APAs; the highest expression was in ZG-like APAs with gain-of-function CTNNB1 mutations, whose removal cured hypertension in our patients. NPNT was absent from normal zona fasciculata, zona fasciculata–like APAs, and ZG adjacent to an APA. NPNT production was regulated by canonical Wnt pathway, and NPNT overexpression or silencing increased or reduced aldosterone, respectively. NPNT was proadhesive in primary adrenal and APA cells but antiadhesive and antiapoptotic in immortalized adrenocortical cells. The discovery of NPNT in the adrenal helped recognition of a common subtype of APAs and a pathway by which Wnt regulates aldosterone production. We propose that this arises through NPNT’s binding to cell-surface integrins, stimulating cell–cell contact within glomeruli, which define ZG. Therefore, NPNT or its cognate integrin could present a novel therapeutic target.
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Affiliation(s)
- Ada Ee Der Teo
- From the Clinical Pharmacology Unit, Centre for Clinical Investigation, Addenbrooke's Hospital (A.E.D.T., S.G., J.Z., M.J.B.), Tissue Bank, Department of Histopathology, Addenbrooke's Hospital (W.Z.), NIHR Cambridge Biomedical Research Centre, Addenbrooke's Hospital (M.G.), MRC Cancer Unit, Hutchison/MRC Research Centre (T.I.J.), and Metabolic Research Laboratories, Wellcome Trust-MRC Institute of Metabolic Science (M.G.), University of Cambridge, United Kingdom; Centre for Clinical Pharmacology, William Harvey Research Institute, Barts and the London School of Medicine & Dentistry, Queen Mary University of London, United Kingdom (J.Z., M.J.B.); Division of Endocrinology, Department of Medicine, The University of Mississippi Medical Centre, Jackson (C.E.G.-S.); and Research and Medicine Services, G.V. (Sonny) Montgomery VA Medical Centre, Jackson, MS (C.E.G.-S.)
| | - Sumedha Garg
- From the Clinical Pharmacology Unit, Centre for Clinical Investigation, Addenbrooke's Hospital (A.E.D.T., S.G., J.Z., M.J.B.), Tissue Bank, Department of Histopathology, Addenbrooke's Hospital (W.Z.), NIHR Cambridge Biomedical Research Centre, Addenbrooke's Hospital (M.G.), MRC Cancer Unit, Hutchison/MRC Research Centre (T.I.J.), and Metabolic Research Laboratories, Wellcome Trust-MRC Institute of Metabolic Science (M.G.), University of Cambridge, United Kingdom; Centre for Clinical Pharmacology, William Harvey Research Institute, Barts and the London School of Medicine & Dentistry, Queen Mary University of London, United Kingdom (J.Z., M.J.B.); Division of Endocrinology, Department of Medicine, The University of Mississippi Medical Centre, Jackson (C.E.G.-S.); and Research and Medicine Services, G.V. (Sonny) Montgomery VA Medical Centre, Jackson, MS (C.E.G.-S.)
| | - Timothy Isaac Johnson
- From the Clinical Pharmacology Unit, Centre for Clinical Investigation, Addenbrooke's Hospital (A.E.D.T., S.G., J.Z., M.J.B.), Tissue Bank, Department of Histopathology, Addenbrooke's Hospital (W.Z.), NIHR Cambridge Biomedical Research Centre, Addenbrooke's Hospital (M.G.), MRC Cancer Unit, Hutchison/MRC Research Centre (T.I.J.), and Metabolic Research Laboratories, Wellcome Trust-MRC Institute of Metabolic Science (M.G.), University of Cambridge, United Kingdom; Centre for Clinical Pharmacology, William Harvey Research Institute, Barts and the London School of Medicine & Dentistry, Queen Mary University of London, United Kingdom (J.Z., M.J.B.); Division of Endocrinology, Department of Medicine, The University of Mississippi Medical Centre, Jackson (C.E.G.-S.); and Research and Medicine Services, G.V. (Sonny) Montgomery VA Medical Centre, Jackson, MS (C.E.G.-S.)
| | - Wanfeng Zhao
- From the Clinical Pharmacology Unit, Centre for Clinical Investigation, Addenbrooke's Hospital (A.E.D.T., S.G., J.Z., M.J.B.), Tissue Bank, Department of Histopathology, Addenbrooke's Hospital (W.Z.), NIHR Cambridge Biomedical Research Centre, Addenbrooke's Hospital (M.G.), MRC Cancer Unit, Hutchison/MRC Research Centre (T.I.J.), and Metabolic Research Laboratories, Wellcome Trust-MRC Institute of Metabolic Science (M.G.), University of Cambridge, United Kingdom; Centre for Clinical Pharmacology, William Harvey Research Institute, Barts and the London School of Medicine & Dentistry, Queen Mary University of London, United Kingdom (J.Z., M.J.B.); Division of Endocrinology, Department of Medicine, The University of Mississippi Medical Centre, Jackson (C.E.G.-S.); and Research and Medicine Services, G.V. (Sonny) Montgomery VA Medical Centre, Jackson, MS (C.E.G.-S.)
| | - Junhua Zhou
- From the Clinical Pharmacology Unit, Centre for Clinical Investigation, Addenbrooke's Hospital (A.E.D.T., S.G., J.Z., M.J.B.), Tissue Bank, Department of Histopathology, Addenbrooke's Hospital (W.Z.), NIHR Cambridge Biomedical Research Centre, Addenbrooke's Hospital (M.G.), MRC Cancer Unit, Hutchison/MRC Research Centre (T.I.J.), and Metabolic Research Laboratories, Wellcome Trust-MRC Institute of Metabolic Science (M.G.), University of Cambridge, United Kingdom; Centre for Clinical Pharmacology, William Harvey Research Institute, Barts and the London School of Medicine & Dentistry, Queen Mary University of London, United Kingdom (J.Z., M.J.B.); Division of Endocrinology, Department of Medicine, The University of Mississippi Medical Centre, Jackson (C.E.G.-S.); and Research and Medicine Services, G.V. (Sonny) Montgomery VA Medical Centre, Jackson, MS (C.E.G.-S.)
| | - Celso Enrique Gomez-Sanchez
- From the Clinical Pharmacology Unit, Centre for Clinical Investigation, Addenbrooke's Hospital (A.E.D.T., S.G., J.Z., M.J.B.), Tissue Bank, Department of Histopathology, Addenbrooke's Hospital (W.Z.), NIHR Cambridge Biomedical Research Centre, Addenbrooke's Hospital (M.G.), MRC Cancer Unit, Hutchison/MRC Research Centre (T.I.J.), and Metabolic Research Laboratories, Wellcome Trust-MRC Institute of Metabolic Science (M.G.), University of Cambridge, United Kingdom; Centre for Clinical Pharmacology, William Harvey Research Institute, Barts and the London School of Medicine & Dentistry, Queen Mary University of London, United Kingdom (J.Z., M.J.B.); Division of Endocrinology, Department of Medicine, The University of Mississippi Medical Centre, Jackson (C.E.G.-S.); and Research and Medicine Services, G.V. (Sonny) Montgomery VA Medical Centre, Jackson, MS (C.E.G.-S.)
| | - Mark Gurnell
- From the Clinical Pharmacology Unit, Centre for Clinical Investigation, Addenbrooke's Hospital (A.E.D.T., S.G., J.Z., M.J.B.), Tissue Bank, Department of Histopathology, Addenbrooke's Hospital (W.Z.), NIHR Cambridge Biomedical Research Centre, Addenbrooke's Hospital (M.G.), MRC Cancer Unit, Hutchison/MRC Research Centre (T.I.J.), and Metabolic Research Laboratories, Wellcome Trust-MRC Institute of Metabolic Science (M.G.), University of Cambridge, United Kingdom; Centre for Clinical Pharmacology, William Harvey Research Institute, Barts and the London School of Medicine & Dentistry, Queen Mary University of London, United Kingdom (J.Z., M.J.B.); Division of Endocrinology, Department of Medicine, The University of Mississippi Medical Centre, Jackson (C.E.G.-S.); and Research and Medicine Services, G.V. (Sonny) Montgomery VA Medical Centre, Jackson, MS (C.E.G.-S.)
| | - Morris Jonathan Brown
- From the Clinical Pharmacology Unit, Centre for Clinical Investigation, Addenbrooke's Hospital (A.E.D.T., S.G., J.Z., M.J.B.), Tissue Bank, Department of Histopathology, Addenbrooke's Hospital (W.Z.), NIHR Cambridge Biomedical Research Centre, Addenbrooke's Hospital (M.G.), MRC Cancer Unit, Hutchison/MRC Research Centre (T.I.J.), and Metabolic Research Laboratories, Wellcome Trust-MRC Institute of Metabolic Science (M.G.), University of Cambridge, United Kingdom; Centre for Clinical Pharmacology, William Harvey Research Institute, Barts and the London School of Medicine & Dentistry, Queen Mary University of London, United Kingdom (J.Z., M.J.B.); Division of Endocrinology, Department of Medicine, The University of Mississippi Medical Centre, Jackson (C.E.G.-S.); and Research and Medicine Services, G.V. (Sonny) Montgomery VA Medical Centre, Jackson, MS (C.E.G.-S.).
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