First-generation somatostatin receptor ligands and pregnancy: lesson from women with acromegaly

INTRODUCTION

Few data are available on the risks of first-generation somatostatin receptor ligands (SRLs) during pregnancy in women treated for acromegaly. Current recommendations suggest the withdrawal of treatment at diagnosis of pregnancy. The aims of this literature review were to evaluate the teratogenic effects and the potential impact of SRLs on maternal and fetal outcomes by comparing acromegalic patients treated or not during pregnancy.

PATIENTS AND METHODS

This study concerns 141 pregnancies in 127 women with acromegaly: 67 pregnancies in 62 women treated with SRLs during pregnancy and 74 pregnancies in 65 women not medically treated during pregnancy. A second analysis was then realized comparing women treated during 1st trimester only (36 pregnancies) and women treated longer (20 pregnancies).

RESULTS

One malformation (ureteral stenosis) was reported in a newborn of a woman treated with SRL during pregnancy. No difference was found concerning maternal outcomes (gestational diabetes, hypertension, headaches, and delivery mode) and fetal outcomes (birth term, height, and weight). These results were also confirmed for the second analysis.

CONCLUSIONS

This review of the literature did report one malformation without being able to prove a specific link with the first-generation SRL treatment. No significant impact on maternal and fetal outcomes is related to first-generation SRL treatment in women with acromegaly. The number of pregnancies is still low and more data are necessary to conclude on the total safety of this treatment during gestation. In the meantime, based on the nonthreatening data from this review of literature, SRL treatment can be continued and/or reintroduced during pregnancy if necessary (mainly for persistent headaches) in women with acromegaly.

Insuffisance surrénalienne chronique et infection par le COVID-19

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Conclusion

Clinical characteristics of familial hypocalciuric hypercalcaemia type 1: A multicentre study of 77 adult patients

OBJECTIVE

Familial hypocalciuric hypercalcaemia type 1 (FHH1), related to heterozygous loss-of-function mutations of the calcium-sensing receptor gene, is the main differential diagnosis for primary hyperparathyroidism. The aim of our study was to describe clinical characteristics of adult patients living in France with a genetically confirmed FHH1.

DESIGN AND PATIENTS

This observational, retrospective, multicentre study included 77 adults, followed up in 32 clinical departments in France, with a genetic FHH1 diagnosis between 2001 and 2012.

RESULTS

Hypercalcaemia was diagnosed at a median age of 53 years [IQR: 38-61]. The diagnosis was made after clinical manifestations, routine analysis or familial screening in 56, 34 and 10% of cases, respectively, (n = 58; data not available for 19 patients). Chondrocalcinosis was present in 11/51 patients (22%), bone fractures in 8/56 (14%) and renal colic in 6/55 (11%). The median serum calcium was 2.74 mmol/L [IQR: 2.63-2.86 mmol/L], the median plasma parathyroid hormone level was 4.9 pmol/L [3.1-7.1], and the median 24-hour urinary calcium excretion was 2.8 mmol/24 hours [IQR: 1.9-4.0]. Osteoporosis (dual X-ray absorptiometry) or kidney stones (renal ultrasonography) were found in 6/38 patients (16%) and 9/32 patients (28%), respectively. Fourteen patients (18%) underwent parathyroid surgery; parathyroid adenoma was found in three patients (21%) and parathyroid hyperplasia in nine patients (64%). No correlation between genotype and phenotype was established.

CONCLUSION

This large cohort study demonstrates that FHH1 clinical characteristics can be atypical in 33 patients (43%). Clinicians should be aware of this rare differential diagnosis in order to adopt an appropriate treatment strategy.

Gestational diabetes and acromegaly: Single-centre experience of 14 pregnancies

INTRODUCTION

The prevalence of gestational diabetes (GD) in women with acromegaly is rarely reported. The aims of this study were to evaluate the prevalence of GD in acromegalic women submitted to a systematic screening for GD and then to compare women with or without GD.

PATIENTS AND METHODS

We studied 14 pregnancies in 11 women (34.0 ± 3.6 years) treated with somatostatin analogues after a pituitary surgery (n = 6) or as primary (n = 5) therapy, and treatment was discontinued at the time of pregnancy diagnosis for 13 pregnancies. One woman was diagnosed with acromegaly during pregnancy and was treated with octreotide LAR between 12 and 18 weeks of gestation. Before pregnancy, no women had diabetes mellitus, and GH/IGF-1 hypersecretion was uncontrolled in 6 women.

RESULTS

Gestational diabetes was diagnosed during 7 pregnancies (50%) in 6 women (one woman had GD during her 2 pregnancies), according to fasting blood glucose (n = 5) or to an oral glucose tolerance test (n = 2). Before pregnancy, IGF-1 was not controlled in 4 GD+ and in 2 GD- women. Women with GD were not significantly older and had increased pregestational BMI (P = .02), with a more frequent family history of type 2 diabetes, no personal history of GD but of macrosomia for one patient.

CONCLUSION

The prevalence of GD in our women is higher than that reported in the literature, probably resulting from the systematic GD screening and to the age of women. Therefore, routine screening of GD should be considered in women with acromegaly, particularly in those with risk factors for GD and with uncontrolled IGF-1 levels before pregnancy.

Weight-loss with activation of brown fat: Suspect pheochromocytoma

INTRODUCTION

Excess catecholamine stimulates heat production in brown adipose tissue (BAT). Activation of BAT can be detected in patients presenting pheochromocytoma.

CASE STUDY

A 58-year-old female patient sought medical advice due to 13 kg weight loss over 2 years accompanied by sweating and high blood pressure. Thoracic-abdominal-pelvic CT-scan revealed a solid 40 mm mass in the left adrenal compartment with peri-adrenal nodules and a solid 80 mm mass at the lower end of the right kidney. ¹⁸FDG-PET scan exhibited intense uptake in the supraclavicular, intercostal, mediastinal, peri-renal, mesenteric, iliac and inguinal spaces. Renal tumor with locoregional infiltration and remote metastases was initially considered. Diagnosis of pheochromocytoma was subsequently confirmed by a 10-fold increase in urinary catecholamine, metanephrine and normetanephrine levels. Left adrenalectomy confirmed the diagnosis of pheochromocytoma, with 3 lymph-node metastases in the adjacent adipose tissue surrounded by brown fat. The patient was clinically asymptomatic with normal blood pressure at 3 months post-surgery. A weight gain of 6 kg was recorded, with normalisation of catecholamines/metanephrine/normetanephrine levels. Bilateral peri-renal infiltration (including the right renal mass) disappeared on CT-scan, and TEP-18-FDG no longer showed hypermetabolism. Recurrent mediastinal metastases were diagnosed 6 months after surgery.

CONCLUSION

Brown fat activation may mislead diagnosis of pheochromocytoma, suggesting multi-metastatic extra-adrenal tumor, if clinicians are not aware of it.

Medical therapy in patients with endogenous hypoglycaemia: Is euglycaemia achievable?

CONTEXT

While the only curative treatment for patients with endogenous hypoglycaemia related to inappropriate insulin or to insulin growth factor 2 (IGF2) secretion is surgery, medical treatment to normalize plasma glucose levels can be useful.

OBJECTIVE

The aim of this prospective single centre study was to assess whether patients with endogenous hypoglycaemia, considered euglycaemic with medical treatments, experienced asymptomatic hypo- or hyperglycaemic excursions.

PATIENTS AND METHODS

All patients with endogenous hypoglycaemia related to inappropriate insulin or to IGF2 secretion between 2012 and 2016 and considered normoglycaemic with medical treatment (absence of clinical hypoglycaemia and self-monitoring blood glucose in the normal range) were enroled and underwent a six-day continuous glucose monitoring (CGM) recording.

RESULTS

Twenty-seven patients (inappropriate insulin secretion n = 25 and IGF2 secretion n = 2), treated with diazoxide (n = 16), somatostatin analogues (n = 7), glucocorticoids (n = 3) or a combination of these treatments (n = 1) were enroled. Twenty-five CGMs were analysed. CGM confirmed normoglycaemia in 11/25 patients (44%). Hypoglycaemias below 0.60 g/L were present in seven patients (28%) and were associated with hyperglycaemic excursions above 1.40 g/L in five patients. Seven patients (28%) had only hyperglycaemic excursions. Based on these results, treatment was modified in 14 patients (56%).

CONCLUSION

Despite the disappearance of hypoglycaemia-related clinical symptoms and normalization of blood glucose self-monitoring data, 56% of the patients with endogenous hypoglycaemia treated with medical therapy experienced asymptomatic hypo- and/or hyperglycaemia. Continuous glucose monitoring could be a useful approach to reveal and prevent hypo- or hyperglycaemic excursions.

Is there a correlation between malaria incidence and IRS coverage in western Zambezi region, Namibia?

Setting: A comparison of routine Namibia National Malaria Programme data (reported) vs. household survey data (administrative) on indoor residual spraying (IRS) in western Zambezi region, Namibia, for the 2014-2015 malaria season. Objectives: To determine 1) IRS coverage (administrative and reported), 2) its effect on malaria incidence, and 3) reasons for non-uptake of IRS in western Zambezi region, Namibia, for the 2014-2015 malaria season. Design: This was a descriptive study. Results: IRS coverage in western Zambezi region was low, ranging from 42.3% to 52.2% for administrative coverage vs. 45.9-66.7% for reported coverage. There was no significant correlation between IRS coverage and malaria incidence for this region (r = -0.45, P = 0.22). The main reasons for households not being sprayed were that residents were not at home during spraying times or that spray operators did not visit the households. Conclusions: IRS coverage in western Zambezi region, Namibia, was low during the 2014-2015 malaria season because of poor community engagement and awareness of times for spray operations within communities. Higher IRS coverage could be achieved through improved community engagement. Better targeting of the highest risk areas by the use of malaria surveillance will be required to mitigate malaria transmission.

Significant prevalence of NR3C1 mutations in incidentally discovered bilateral adrenal hyperplasia: results of the French MUTA-GR Study

BACKGROUND

Recently discovered mutations of NR3C1 gene, encoding for the GR, in patients with glucocorticoid resistance and bilateral adrenal incidentalomas prompted us to investigate whether GR mutations might be associated with adrenal hyperplasia.

OBJECTIVE

The multicenter French Clinical Research Program (Muta-GR) was set up to determine the prevalence of GR mutations and polymorphisms in patients harboring bilateral adrenal incidentalomas associated with hypertension and/or biological hypercortisolism without clinical Cushing's signs.

RESULTS

One hundred patients were included in whom NR3C1 sequencing revealed five original heterozygous GR mutations that impaired GR signaling in vitro. Mutated patients presented with mild glucocorticoid resistance defined as elevated urinary free cortisol (1.7 ± 0.7 vs 0.9 ± 0.8 upper limit of normal range, P = 0.006), incomplete 1 mg dexamethasone suppression test without suppressed 8-AM adrenocorticotrophin levels (30.9 ± 31.2 vs 16.2 ± 17.5 pg/mL) compared to the non-mutated patients. Potassium and aldosterone levels were lower in mutated patients (3.6 ± 0.2 vs 4.1 ± 0.5 mmol/L, P = 0.01, and 17.3 ± 9.9 vs 98.6 ± 115.4 pg/mL, P = 0.0011, respectively) without elevated renin levels, consistent with pseudohypermineralocorticism. Ex vivo characterization of mutated patients' fibroblasts demonstrated GR haploinsufficiency as revealed by below-normal glucocorticoid induction of FKBP5 gene expression. There was no association between GR polymorphisms and adrenal hyperplasia in this cohort, except an over-representation of BclI polymorphism.

CONCLUSION

The 5% prevalence of heterozygous NR3C1 mutations discovered in our series is higher than initially thought and encourages GR mutation screening in patients with adrenal incidentalomas to unambiguously differentiate from Cushing's states and to optimize personalized follow-up.

Virilizing oncocytic adrenocortical carcinoma: clinical and immunohistochemical studies

CONTEXT

Oncocytic tumors of the adrenal cortex are rare, mostly nonfunctioning and benign.

SETTING

Report virilizing oncocytic adrenocortical carcinoma in a 50-year-old woman.

PATIENT

She presented a recent and progressive virilization syndrome, associated with high blood pressure. Hormonal evaluation showed elevated serum testosterone and delta-4-androstenedione levels, normal urinary free cortisol level and incomplete suppression of cortisol at the 1 mg dexamethasone suppression test. CT scan of the abdomen revealed a 35 mm left adrenal mass.

INTERVENTION

The patient underwent a left adrenalectomy, and the histological study showed a 3 cm oncocytic adrenocortical carcinoma with signs of malignancy.

RESULTS

Immunohistochemical study revealed that tumor cells expressed the steroidogenic enzymes involved into androgen synthesis (3βHSD and P450c17α), P450 aromatase and luteinizing hormone (LH) receptors. Post-operatively, signs of virilization improved rapidly, serum testosterone and delta-4-androstenedione levels returned to normal, as did the dexamethasone suppression test. During follow-up CT-scan and 18-FDG PET/CT showed a right ovary mass, corresponding to a follicular cyst associated with hyperthecosis. The patient is alive with no recurrence 48 months after adrenal surgery.

CONCLUSION

Oncocytic adrenocortical carcinomas, although extremely rare, should be considered in women with a virilization syndrome. In this woman immunohistochimical studies revealed the presence of steroidogenic enzymes involved into androgen synthesis and aromatization, and LH receptors could be implicated in this pathology.

Local recurrence of pheochromocytoma in multiple endocrine neoplasia type 2A: a diagnostic and therapeutic challenge

In a patient with multiple endocrine neoplasia type 2A (MEN2A), an inverted physiological ratio between urinary normetanephrines and metanephrines is an early marker of recurrence in epinephrine‐secreting pheochromocytoma, and 131I MIBG treatment appears to be a useful therapeutic option in order to avoid multiple invasive surgical procedures in pheochromocytomatosis.

Primary Medical Treatment of Thyrotropin-Secreting Pituitary Adenomas by First-Generation Somatostatin Analogs: A Case Study of Seven Patients

BACKGROUND

The first-choice treatment of thyrotropin (TSH)-secreting pituitary adenomas is surgical adenomectomy, with 40-60% of patients cured after surgery. The presence of somatostatin receptors on the adenomatous cells suggests that first-generation somatostatin analogs (octreotide, lanreotide) could be used as an adjuvant treatment to surgery for TSH-secreting pituitary adenomas. The aim of this study is to describe the efficacy and safety of primary medical treatment with first-generation somatostatin analogs in patients with a TSH-secreting pituitary adenoma.

METHODS

Retrospective study on 7 patients (5 women, 2 men) aged 57±14 years with pure TSH (n=4) or mixed TSH/GH (n=3) secreting pituitary adenomas primarily treated with first generation somatostatin analogs. Magnetic resonance imaging revealed a microadenoma in 3 patients and a macroadenoma in 4 patients. The follow-up period was 8.5±7.3 years.

RESULTS

At initial diagnosis, the patients presented with thyrotoxicosis with elevated free thyroxine (26.5±6.5 pg/mL) and free triiodothyronine (7.3±0.9 pg/mL) levels and a mean TSH of 4.3±1.4 mU/L. During somatostatin analog treatment, free thyroid hormones and TSH levels normalized after 4.4±3.9 and 7.0±8.4 months, respectively. At the time of the last visit, 6 patients were biochemically controlled. Adenoma volume decreased in 6 patients and a decrease in adenoma volume persisted in 2 patients several years after initiation of somatostatin analog treatment. Safety of treatment was good and no patients discontinued somatostatin analogs due to side effects.

CONCLUSION

This study confirms the efficacy of primary medical treatment with first-generation somatostatin analogs in terms of hormonal control and tumor volume reduction in patients with TSH-secreting pituitary adenomas, and its good safety profile. First-generation somatostatin analogs may serve as a medical alternative to surgical treatment, especially in patients where surgery is contraindicated or in subjects presenting with invasive macroadenomas that render complete surgical resection difficult.

Decreased IGF-1 concentration during the first trimester of pregnancy in women with normal somatotroph function

INTRODUCTION

A decrease of insulin-like growth factor-I levels (IGF-I) has been reported during the first trimester of pregnancy in women with acromegaly before the secretion of placental growth hormone (GH) progressively increases IGF-1 concentration.

STUDY DESIGN

To evaluate variations of concentrations of IGF-1, insulin-like growth factor (IGF)-binding protein-3 (IGF-BP3) and GH during the first trimester of pregnancy in women with normal somatotroph function.

PATIENTS AND METHODS

Sixteen women (median age 31 years) with as who were followed for benign thyroid disorders (n = 15) or prolactin-secreting microadenoma (n = 1) were evaluated before and in the first trimester of pregnancy. Serum concentrations of GH, IGF-1, IGF-BP3, TSH and estradiol (E2) were measured before and in the first trimester (5.4 ± 2.2 weeks of gestation).

RESULTS

Before pregnancy, somatotroph and thyroid functions (median TSH 1.2 mU/L) were normal in all women. At the first trimester IGF-1 levels decreased significantly (before = 210 ng/mL, first trimester = 145 ng/mL, p < 0.001) with no significant change in GH (before = 1.5 ng/mL, first trimester = 0.84 ng/mL) or IGF-BP3 levels (before = 2.3 ng/mL, first trimester = 2.2 ng/mL), while estradiol levels increased significantly (before = 46.5 pg/100 mL, first trimester = 448.5 pg/100 mL, p < 0.001).

CONCLUSION

In women with normal somatotroph function, IGF-1 levels decrease in the first trimester of pregnancy without changes in GH or IGF-BP3 levels. These results confirm liver resistance to GH as a consequence of the physiological increase of estrogens during the first trimester.

Increased plasma β-hydroxybutyrate levels during the fasting test in patients with endogenous hyperinsulinaemic hypoglycaemia

OBJECTIVE

The objective of the present study was to determine whether a plasma β-hydroxybutyrate (BOHB) level >2700 μmol/l during the 72-h fasting test is sufficient to rule out the diagnosis of endogenous hyperinsulinaemic hypoglycaemia (EHH).

RESEARCH DESIGN AND METHODS

We retrospectively studied BOHB levels in 39 patients with EHH who had undergone a 72-H fasting test to make the diagnosis of EHH, and we compared EHH patients with BOHB levels 2700 MOL/L (group 1), EHH PATIENTS with BOHB levels 2700 MOL/L (group 2) and 59 controls (median glycaemia: 3.2  mmol/l and median BOHB: 6095 μmol/l).

RESULTS

During a 72-h fasting test, nine patients (group 1) had BOHB levels >2700  μmol/l (median 6140 and range 2957-7824) and 30 patients (group 2) had BOHB levels <2700 μmol/l (median 542 and range 0-2607). In group 1, four patients had undergone partial pancreatectomy previously and were evaluated for the recurrence of hypoglycaemia, whereas none of the group 2 patients had been operated. The duration of the fasting test was longer in group 1 than in group 2 (P<0.0001), and at the end of the fasting test, plasma glucose concentrations were not significantly different (P=0.0617), but insulin (P=0.004), C-peptide (P=0.0015) and proinsulin (P=0.0038) levels were significantly lower in group 1 patients than in group 2 patients, suggesting lower insulin secretion and/or impaired glycaemic counter-regulation.

CONCLUSION

During a fasting test, a BOHB level >2700 μmol/l is observed in some EHH patients, suggesting that BOHB levels cannot rule out the recurrence of EHH, in particular, after partial pancreatectomy.

Retroperitoneoscopic adrenalectomy: comparison of retrograde and antegrade approach among a series of 279 cases

OBJECTIVE

To compare the results of retroperitoneal laparoscopic adrenalectomy using the antegrade and retrograde approach.

MATERIALS AND METHODS

We performed an analysis of a single-center series of 279 retroperitoneal laparoscopic adrenalectomies from 1996 to 2010. We compared 172 cases performed with an antegrade approach and 107 with a retrograde approach without dissection of the renal hilum and initial control of the adrenal vein in comparable populations.

RESULTS

The operative time was shorter in the group treated with the retrograde technique, 101±51 vs 140±40 minutes, respectively (Student's t test, P<.001). Blood loss was similar in both groups, 85±224 vs 80±126 mL, respectively (P=NS). Hemodynamic instability was defined as the maximal systolic blood pressure minus the minimal systolic blood pressure divided the maximal systolic blood pressure. It was lower in the group who underwent the retrograde technique (32.7 vs 37.6 mL; Student's t test, P=.005) with a lower perioperative consumption of ephedrine (2.2 vs 5.1 mg, P=.004) and atropine (0.09 vs 0.22 mg, P=.026). No difference was found between the 2 groups in the frequency of perioperative complications or postoperative mortality (1 death in each group of causes unrelated to the surgery).

CONCLUSION

Retroperitoneal laparoscopic adrenalectomy using a retrograde approach is a safe and reproducible technique. It makes it possible to perform adrenalectomy without dissection of the renal hilum, with a reduction in the operative time. The good hemodynamic stability observed with this technique makes it very attractive for the treatment of pheochromocytoma.

Virilizing sclerosing-stromal tumor of the ovary in a young woman with McCune Albright syndrome: clinical, pathological, and immunohistochemical studies

CONTEXT

McCune-Albright syndrome (MAS) is characterized by polyostotic fibrous dysplasia, café-au-lait skin pigmentations, and gonadotropin-independent sexual precocious puberty, resulting from a somatic postzygotic activating mutation of the GNAS1 gene.

SETTING

We report a virilizing sclerosing-stromal tumor of the ovary in a young female with MAS.

PATIENT

She presented polyostotic fibrous dysplasia of the left upper and lower limbs and a café-au-lait skin spot in the posterior area of the neck. She had a history of precocious puberty, diagnosed at the age of 6 years and treated with cyproterone acetate until the age of 10 years; then she developed central puberty with severe oligomenorrhea. At the age of 23 years, she was hospitalized for a virilization syndrome including hirsutism, acne, deepening of the voice, amenorrhea, and clitoromegaly. Serum levels of T were dramatically increased (1293 ng/dl; normal range, 10-80). The abdominal computed tomography scan revealed a solid mass located on the left ovary.

INTERVENTION

An ovariectomy was performed, and histological examination revealed a sclerosing-stromal tumor with pseudolobular pattern.

RESULTS

Immunohistochemical studies revealed that the tumor cells expressed all steroidogenic enzymes involved in androgen synthesis. Molecular analysis revealed that ovarian tumor cells harbored the Arg 201 activating mutation in the GNAS1 gene. After surgery, T levels returned to normal, the patient retrieved a normal gonadal function, and she was able to become pregnant.

CONCLUSION

This observation extends the clinical spectrum of ovarian pathology of women with MAS. However, the mechanisms causing this ovarian tumor remain unclear, even if the gsp oncogene has been implicated in the pathogenesis of some gonadal tumors.

Tamoxifen enhances the control of acromegaly treated with somatostatin analog lanreotide

We present the case of a 51-year old female patient with acromegaly that was resistant to somatostatin analogs and dopamine agonists. The patient was diagnosed with breast cancer requiring treatment with the anti-estrogen tamoxifen. Prior to initiating the treatment with tamoxifen, the IGF-I level was very high at 415% of the upper limit of normal for the patient's age and sex. During the tamoxifen treatment, the level of IGF-I dropped spectacularly down to normal levels. This observation highlights the effect of an anti-estrogen treatment in certain female patients with acromegaly.

Glucose status in patients with acromegaly receiving primary treatment with the somatostatin analog lanreotide

To describe glucose status changes in patients with acromegaly receiving somatostatin analog lanreotide as primary treatment. This retrospective, single-center study conducted during 1996-2008, included acromegalic patients receiving primary lanreotide treatment. Baseline and last follow-up visit assessments included glucose status (according to American Diabetes Association criteria), growth hormone (GH), and insulin-like growth factor-1 (IGF-1) levels. Glucose control was considered improved when fasting plasma glucose or antidiabetic treatments were reduced, and deteriorated if fasting glucose was the same/higher but with increased antidiabetic treatments. 42 patients (median age 50 years; range 29-75 years) were included. At baseline, 26 (62%) were normoglycemic, eight (19%) had impaired glucose tolerance/fasting glycemia, and eight (19%) had diabetes mellitus; family history of diabetes mellitus was significantly associated with abnormal glucose status. At final visit, the mean (SE) lanreotide dose was 108 (21) mg/month. Median treatment duration was 23 months, range 3-138 months, and 74% of patients received the 120-mg dose. Median GH levels decreased significantly (baseline, 12 [5-20] μg/l; final visit, 2.1 [1.0-4.7] μg/l; P < 0.0001); IGF-1 levels were age- and sex-normalized in 33% of patients. Glucose control deteriorated in seven patients (17%) and improved from abnormal levels in 10 (24%). Deterioration was associated with smaller GH decreases (median change, -3.4 μg/l vs. -10.7 μg/l, P = 0.014) and improvement with trend to lower BMI and younger age. During primary lanreotide treated acromegalic patients 60% had no change, 24% had an improvement and 17% had a worsening of glucose status. Deterioration was significantly associated with smaller GH decreases during primary lanreotide treatment.

Impact of growth hormone hypersecretion on the adult human kidney

Acromegaly is most often secondary to a GH-secreting pituitary adenoma with increased Insulin-like Growth Factor type 1 (IGF-1) level. The consequences of GH/IGF-1 hypersecretion reflect the diversity of action of these hormones. The genes of the GH receptor (GHR), IGF-1, IGF-1 receptor (IGF-1R) and IGF-binding proteins (IGF-BP) are physiologically expressed in the adult kidney, suggesting a potential role of the somatotropic axis on renal structure and functions. The expression of these proteins is highly organized and differs according to the anatomical and functional segments of the nephron suggesting different roles of GH and IGF-1 in these segments. In animals, chronic exposure to high doses of GH induces glomerulosclerosis and increases albuminuria. Studies in patients with GH hypersecretion have identified numerous targets of GH/IGF-1 axis on the kidney: 1) an impact on renal filtration with increased glomerular filtration rate (GFR), 2) a structural impact with an increase in kidney weight and glomerular hypertrophy, and 3) a tubular impact leading to hyperphosphatemia, hypercalciuria and antinatriuretic effects. Despite the increased glomerular filtration rate observed in patients with GH hypersecretion, GH is an inefficient treatment for chronic renal failure. GH and IGF-1 seem to be involved in the physiopathology of diabetic nephropathy; this finding offers the possibility of targeting the GH/IGF-1 axis for the prevention and the treatment of diabetic nephropathy.

Treatment with somatostatin analogs and chemoembolization of liver metastases for severe hypoglycemia in malignant insulinomas

BACKGROUND

Preventing hypoglycemia is of vital importance and a major challenge in patients with severe symptomatic hypoglycemia related to malignant unresectable insulinomas, but there is no consensus treatment.

PATIENTS

Five patients with malignant unresectable insulinomas were referred to our department for severe hypoglycemia. At referral the five patients were dependent on iv infusion of glucose solution. Patient 1 had a locally invasive 5-cm insulinoma, patients 2, 3 and 4 had multiple liver metastases and patient 5 had a 2.5-cm pancreatic tumor with multiple liver and lung metastases. Before referral to our department, 4/5 patients had been administered systemic chemotherapy and 3/5 therapeutic doses of radiolabeled octreotide without any benefit on blood glucose levels. Octreoscan scintigraphy was positive in 4 patients (patients 1-4). Diazoxide alone or combined with glucocorticoids had failed to control hypoglycemia. Continuous sc administration of octreotide (up to 1500 μg/day) resulted in normalization of blood glucose levels in patient 1. Chemoembolization of liver metastases normalized blood glucose levels in patient 2, minimized hypoglycemia in patients 3 and 4, and normalized blood glucose levels in patient 5 when followed by subcutaneous administration of octreotide (2000 μg/day). Chemoembolization had to be repeated four times in patient 3 to control blood glucose levels.

CONCLUSION

Chemoembolization of liver metastases and high-dose octreotide in responsive patients (alone or combined with chemoembolization) can control severe hypoglycemia in patients with symptomatic malignant unresectable insulinomas; the efficacy of octreotide can be improved after chemoembolization of liver metastases.

Clinical and metabolic characteristics of acromegalic patients with high IGF1/normal GH levels during somatostatin analog treatment

CONTEXT

Divergence between GH and IGF1 values are often reported in treated acromegalic patients, but the mechanisms of this discrepancy have not been completely explored.

OBJECTIVE

To evaluate the frequency of divergence between GH and IGF1 values and identify the role of clinical and metabolic factors in treated patients with acromegaly, according to the latest criteria of Cure published in July 2010.

DESIGN

Retrospective study of patients' records between October 2002 and March 2008. Patients were grouped according to their mean GH and IGF1 values as 'controlled' (normal GH and IGF1), 'divergent' (high IGF1 and normal GH) and 'uncontrolled' (high GH and IGF1), and compared with respect to their clinical characteristics and metabolic markers.

RESULTS

Patients (n=104) were grouped as 'controlled' (n=20), 'divergent' (n=43) and 'uncontrolled' (n=41). More patients in the divergent group (93%) and uncontrolled group (98%) were treated with somatostatin analogs than in the controlled group (65%; P=0.001 for the comparison of the three groups). Patients in the divergent group had higher fasting blood glucose (0.94 g/l (interquartile range: 0.83-1.17)) and systolic blood pressure (130 mmHg (120-140) compared with the controlled group (0.84 g/l (0.80-0.92); P=0.017) and 120 mmHg (interquartile range: 110-130; P=0.029). In patients with divergent IGF1/GH levels, fasting glucose and GH were both strongly associated with IGF1.

CONCLUSION

Totally 41% of treated acromegalic patients had a high IGF1 and normal GH level. In these divergent patients treated with somatostatin analogs, these clinical and metabolic parameters might either play a causal role or be a marker for disease activity.

Virilising ovarian tumour: a case associating a Sertoli-Leydig cell tumour and a Brenner tumour

Ovarian Sertoli-Leydig cell tumours (SLCT), also termed arrhenoblastomas, are the most frequent virilising tumours in women of reproductive age. Very rare secretory Brenner tumours (BT) have been described, generally after the menopause. A 31-year-old woman sought medical advice for secondary amenorrhoea, progressive hirsutism and a 5-year history of virilisation syndrome with clitoromegaly. Testosterone was markedly high (285 ng/dl, N<85) with moderate elevation of delta 4-androstenedione (D4AD) (311 ng/dl, N <270), dehydroepiandrosterone sulfate (DHEAS) (366 μg/dl, N <340) and 17-hydroxyprogesterone (17OHP) (275 ng/dl). LH was 9 IU/l, FSH 4.3 IU/l, estradiol 60 pg/ml and progesterone 314 ng/100 ml. Cortisol was decreased (1.3 μg/dl) after the dexamethasone suppression test. Pelvic MRI showed a 5-cm right ovarian tumour with a 2.5 cm nodular component and cystic areas, and two nodules measuring 11 mm and 15 mm above the right and left ovaries. After right ovariectomy by laparoscopy, pathological examination concluded on a 3-cm SLCT and a 2-cm BT; the nodules above the ovaries were dysembryoplastic cysts. Postoperatively, testosterone level was normal after 24 h (26 ng/dl), estradiol and progesterone rapidly decreased, cyclic secretion then resumed and the patient menstruated at day 27. To our knowledge, this is the first report of an ovarian tumour associating a Sertoli-Leydig cell tumour and a Brenner tumour in a patient with virilisation syndrome which resolved after ovariectomy.

Bayesian methods for meta-analysis of causal relationships estimated using genetic instrumental variables

Genetic markers can be used as instrumental variables, in an analogous way to randomization in a clinical trial, to estimate the causal relationship between a phenotype and an outcome variable. Our purpose is to extend the existing methods for such Mendelian randomization studies to the context of multiple genetic markers measured in multiple studies, based on the analysis of individual participant data. First, for a single genetic marker in one study, we show that the usual ratio of coefficients approach can be reformulated as a regression with heterogeneous error in the explanatory variable. This can be implemented using a Bayesian approach, which is next extended to include multiple genetic markers. We then propose a hierarchical model for undertaking a meta-analysis of multiple studies, in which it is not necessary that the same genetic markers are measured in each study. This provides an overall estimate of the causal relationship between the phenotype and the outcome, and an assessment of its heterogeneity across studies. As an example, we estimate the causal relationship of blood concentrations of C-reactive protein on fibrinogen levels using data from 11 studies. These methods provide a flexible framework for efficient estimation of causal relationships derived from multiple studies. Issues discussed include weak instrument bias, analysis of binary outcome data such as disease risk, missing genetic data, and the use of haplotypes.

Maffucci syndrome and adrenal cortex tumor

We report the second known case of Maffucci syndrome associated with an adrenal cortex tumor. Endocrine tumors have been reported in patients with multiple enchondromas, although the underlying mechanism of this combination is unknown. Maffucci syndrome is characterized by abnormalities of several mesodermal derivates. Therefore, routine evaluation for involvement of the adrenal cortex may be warranted to improve our knowledge of this syndrome and of its pathophysiology.

Ectopic Cushing's syndrome due to a pheochromocytoma: a new case in the post-partum and review of literature

Cushing's syndrome due to AdrenoCorticoTropic Hormone (ACTH)-secreting pheochromocytoma has been rarely reported during pregnancy and post-partum. We report the case of a 30-year-old woman who presented 3 months after delivery acute psychiatric signs and rapid progressive features of Cushing's syndrome. Hormonal tests confirmed ACTH-dependant Cushing's syndrome. A computed tomography scan revealed a 25 x 30 mm tumoral mass in the left adrenal gland and octreoscan scintigraphy showed only an uptake of the radiolabelled octreotide by the adrenal tumor. Fractionated 24-h urinary catecholamines and metanephrines were in the normal range, except for slightly increased adrenalin levels. A left laparoscopic adrenalectomy was performed with acute pulmonary oedema following the anesthesia. Histological examination revealed a 3.5 x 2.5 cm adrenal tumor consistent with a pheochromocytoma without signs of malignancy. The tumor cells immunostained for ACTH and diffuse hyperplasia of adrenocortical cells was observed. After surgery and short stay in intensive care unit, clinical and biological signs rapidly improved and both anti-hypertensive treatment and insulin injections were withdrawn. Genetic testing did not reveal germline mutations in RET protooncogene, Von Hippel Lindau and succinate deshydrogenase genes.

Multiple endocrine neoplasia type 2a and germ line C634G RET mutation diagnosed in an 80-year-old patient

An 80-year-old man presented with progressive fatigue. Blood tests showed that serum calcium was increased (2.93 mmol/l, normal range 2.20-2.55 mmol/l) and serum concentration of intact parathyroid hormone (iPTH) inappropriately high (198 pg/ml, normal range 15-85 pg/ml). Neck ultrasonography and Tc-MIBI scintigraphy revealed a right parathyroid adenoma and a multinodular goiter. Serum calcitonin was significantly increased (220 pg/ml, normal range<10 pg/ml). Concomitantly, a chest-abdominal computed tomography was performed and revealed a 22 mm right adrenal incidentaloma. The urinary catecholamines and metabolites were two-fold above the upper limit of normal. After right adrenalectomy which confirmed the diagnosis of pheochromocytoma, the patient underwent total thyroidectomy with dissection of the central lymph node compartment and right parathyroidectomy. On histopathologic examination, both thyroid lobes presented 13 foci of MTC without lymph node metastasis and the parathyroid gland presented a benign adenoma without hyperplasia. The patient underwent screening and genetic testing revealing a germ line C634 G RET mutation. The diagnosis of Men2a at the age of 80 years and the absence of lymph node metastasis of the multiple MTC in a carrier of C634G mutation were unusual and argued for the possible role of genetic modifier(s) in this MEN 2a patient.

Primary sellar melanocytic tumor: report of new case and literature review

CONTEXT

Primary sellar melanocytic tumors are extremely rare, and they can mimic hormonally inactive pituitary macroadenoma both clinically and radiologically.

OBJECTIVES

The aim of this study was to describe a new case of primary sellar melanocytic tumor, and place it in the context of published literature.

DESIGN

This is a case report.

PATIENT

The case of a 61-year-old woman presenting with a 2-month history of fatigue and progressive bitemporal hemianopia is described. Endocrine investigation revealed anterior pituitary insufficiency and hyperprolactinemia without diabetes insipidus. Magnetic resonance imaging demonstrated a sellar tumor mass with suprasellar extension compressing the optic chiasm, and intense gadolinium enhancement. Transsphenoidal surgical excision of the pituitary tumor was undertaken. Histological examination showed a melanocytic tumor. An extensive search failed to find evidence of any other primary or secondary site. Due to the presence of significant tumor residue at 3-month follow-up, another surgical resection was done followed by post-operative stereotactic radiotherapy of the sellar region.

CONCLUSION

Primary sellar melanocytic tumors are exceptional lesions presenting most often as a tumor syndrome and/or anterior pituitary insufficiency mimicking a non-secreting pituitary macroadenoma. The management of these tumors consists of surgical removal of the tumor. However, surgery is often incomplete and stereotactic fractionated radiotherapy is frequently indicated.

Short- and long-term somatostatin analogue treatment in patients with hypoglycaemia related to endogenous hyperinsulinism

BACKGROUND

The long-term efficacy of somatostatin analogues on insulinomas has not been studied.

DESIGN

A prospective study to evaluate the response of octreotide in 21 patients with hypoglycaemia related to endogenous hyperinsulinism who were not treated by surgery.

RESULTS

Reasons for not undergoing surgery were: refusal (n = 3), old age with multiple diseases (n = 5), unlocalized insulinomas (n = 2), malignant unresectable insulinomas (n = 5), multiple insulinomas (n = 3) and diffuse beta-cell disease (n = 3). Hypoglycaemia was responsive to octreotide in 14 of the 21 patients. A short 100-microg octreotide test correctly predicted the efficacy of treatment in six patients with benign insulinomas. Octreoscan scintigraphy was positive in 6 of the 16 patients of whom three were responsive and three unresponsive to octreotide. Octreoscan scintigraphy was negative in 10 of the 16 patients, eight of whom were responsive to octreotide. Subcutaneous octreotide treatment was prolonged for > 6 months (7-144 months, 67 +/- 47 months) in 11 responsive patients. No tachyphylaxis was observed. However, the octreotide dose had to be increased in two patients after 3 and 18 months, respectively. Only one patient suffered from symptomatic biliary lithiasis after 3 years of treatment.

CONCLUSION

Long-term octreotide treatment can be used to control hypoglycaemia in patients with endogenous hyperinsulinism who are not eligible for surgery; octreotide efficacy on hypoglycaemia could be predicted by a short 100 microg-octreotide test in patients with benign insulinomas, but was not correctly predicted by Octreoscan scintigraphy.

Impaired quality of life of patients with acromegaly: control of GH/IGF-I excess improves psychological subscale appearance

INTRODUCTION

Acromegaly, a chronic disease caused by GH/IGF-I excess, has a major impact on quality of life (QoL).

OBJECTIVE

To evaluate QoL of acromegalic patients in relation to control status of the disease.

DESIGN AND METHODS

Single center observational study including 93 patients with acromegaly recruited to complete QoL questionnaire (AcroQol). QoL was evaluated at least 3 months after surgery and/or medical treatment. Patients were divided into two groups: controlled (I) and uncontrolled (II) according to the latest consensus acromegaly 'control' criteria and further subdivided into four subgroups according to the previous pituitary adenoma surgery (Ib and IIb) or without surgery (Ia and IIa).

RESULTS

Mean GH (0.81+/-0.47 ng/ml) and IGF-I (195+/-71 ng/ml) values in group I were significantly lower than in group II (GH, 7.01+/-12.05 ng/ml and IGF-I, 513+/-316 ng/ml; P<0.001). There was no difference in total AcroQol score, physical, or psychological scales between groups I and II. However, when adjusted to age and disease duration since diagnosis, patients of group I (63+/-20%) showed an improved psychological subscale appearance than those of group II (58+/-17%; P=0.035). In group II, IGF-I level was lower after surgery (IIa=588+/-353, IIb=410+/-225 ng/ml; P<0.038), and psychological subscale appearance was significantly better in subgroup IIb (64.9+/-18.1%) than in subgroup IIa who had medical treatment (53.9+/-14.3%; P=0.009).

CONCLUSION

QoL is severely impaired in acromegalic patients. Control of GH/IGF-I excess by surgery or medical treatment seems to have a positive impact on psychological subscale appearance.

Long-term (up to 18 years) effects on GH/IGF-1 hypersecretion and tumour size of primary somatostatin analogue (SSTa) therapy in patients with GH-secreting pituitary adenoma responsive to SSTa

CONTEXT

The role of somatostatin analogues (SSTa) in the treatment of acromegaly.

OBJECTIVE

To evaluate the antihormonal and antitumour efficacy of long-term (up to 18 years) primary treatment with SSTa in patients with GH-secreting pituitary adenoma responsive to SSTa.

DESIGN

An open, prospective, single-centre, clinical study.

PATIENTS

Thirty-six acromegalic patients, aged 17-75 years (postoral glucose tolerance test GH > 1 microg/l, increased IGF-1 for age and sex), were monitored in a single centre and treated with SSTa as first-line therapy. The mean pretreatment GH level was 13.5 +/- 3.1 microg/l, and IGF-1 (as a percentage of the value over the normal range) was 302 +/- 26%. The patients had macroadenoma (n = 25), microadenoma (n = 8) or empty sella turcica (n = 3). The mean duration of treatment was 8 years (range 3-18 years). Hormonal and morphological monitoring was undertaken after 6 months, and then the patients were followed annually.

RESULTS

After 1 year, the mean GH and IGF-1 levels had reduced considerably (GH: 2.4 +/- 0.3 microg/l; IGF-1; 174 +/- 14%, P < 0.01), and they continued to decrease over 10 years, with a mean GH level of 1.6 +/- 0.1 microg/l and IGF-1 of 123 +/- 18% (P = 0.02). GH < 2 microg/l, normal IGF-1, or both were observed in 25 (70%), 24 (67%) and 21 (58%) patients, respectively. The mean reduction in tumour volume was 43% (range 13-97%) and shrinkage > 20% was obtained in 21 patients (72%). SSTa treatment was well tolerated with few digestive or metabolic side-effects.

CONCLUSION

Long-term (up to 18 years) treatment with SSTa used as first-line therapy is effective from both an antihormonal and antitumour perspective, and is well tolerated in acromegalic patients.

[Fertility before and after treatment of patients with Leydig cell tumour]

OBJECTIVE

To determine the long-term fertility status of patients treated for Leydig cell testicular tumour.

MATERIAL AND METHODS

[corrected] In a series of 506 testicular tumours observed in the Midi-Pyrenées region between 1980 and 1998, 17 were Leydig cell tumours (3.3%) and constituted the study population. Andrological records were available for all patients. Information concerning fertility before and after orchidectomy was obtained by validated letter questionnaire. All patients completed the questionnaire.

RESULTS

The mean follow-up was 84 months (range: 36-173). The mean age at diagnosis was 32 years (range: 24-51). The presenting symptom was gynaecomastia in 9 cases (53%), enlarged testis in 4 cases (24%), scrotal pain in 2 cases (12%) and male infertility in 2 cases (12%). Before onset of their disease, 13/17 (76.5%) patients had tried to have a child and 6 (46.2%) had successfully fathered a child. After treatment of their Leydig cell tumour, 10/17 (58.8%) had tried to have a child and 7 (70%) were successful.

CONCLUSION

The population of men with Leydig cell tumour of the testis is a population with decreased fertility before treatment of the tumour. Resection of the tumour improves this situation, but 3 out of 10 patients remain infertile, indicating the need for semen storage measures in this population.

Lethal posttraumatic rupture of a pheochromocytoma: lesson from a postmortem diagnosis

Pheochromocytoma is challenging to diagnose, and a life-threatening situation may occur if pheochromocytoma is incorrectly diagnosed and treated. We report the first case of a lethal posttraumatic rupture of an undiagnosed pheochromocytoma in a 46-year-old man who presented with peripheral vasoconstriction and signs of peritoneal irritation after being kicked by a horse. Computed tomography, arteriography, and two exploratory laparotomies were performed. The patient died of multiorgan failure 8 h after the trauma. The diagnosis of ruptured pheochromocytoma of the left adrenal gland was made during the postmortem examination. Pheochromocytoma should be considered in cases of blunt abdominal trauma associated with unstable blood pressure, peripheral vasoconstriction and adrenal hematoma.