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Lin AL, Rudneva VA, Richards AL, Zhang Y, Woo HJ, Cohen M, Tisnado J, Majd N, Wardlaw SL, Page-Wilson G, Sengupta S, Chow F, Goichot B, Ozer BH, Dietrich J, Nachtigall L, Desai A, Alano T, Ogilive S, Solit DB, Bale TA, Rosenblum M, Donoghue MTA, Geer EB, Tabar V. Genome-wide loss of heterozygosity predicts aggressive, treatment-refractory behavior in pituitary neuroendocrine tumors. Acta Neuropathol 2024; 147:85. [PMID: 38758238 DOI: 10.1007/s00401-024-02736-8] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Revised: 04/21/2024] [Accepted: 04/22/2024] [Indexed: 05/18/2024]
Abstract
Pituitary neuroendocrine tumors (PitNETs) exhibiting aggressive, treatment-refractory behavior are the rare subset that progress after surgery, conventional medical therapies, and an initial course of radiation and are characterized by unrelenting growth and/or metastatic dissemination. Two groups of patients with PitNETs were sequenced: a prospective group of patients (n = 66) who consented to sequencing prior to surgery and a retrospective group (n = 26) comprised of aggressive/higher risk PitNETs. A higher mutational burden and fraction of loss of heterozygosity (LOH) was found in the aggressive, treatment-refractory PitNETs compared to the benign tumors (p = 1.3 × 10-10 and p = 8.5 × 10-9, respectively). Within the corticotroph lineage, a characteristic pattern of recurrent chromosomal LOH in 12 specific chromosomes was associated with treatment-refractoriness (occurring in 11 of 14 treatment-refractory versus 1 of 14 benign corticotroph PitNETs, p = 1.7 × 10-4). Across the cohort, a higher fraction of LOH was identified in tumors with TP53 mutations (p = 3.3 × 10-8). A machine learning approach identified loss of heterozygosity as the most predictive variable for aggressive, treatment-refractory behavior, outperforming the most common gene-level alteration, TP53, with an accuracy of 0.88 (95% CI: 0.70-0.96). Aggressive, treatment-refractory PitNETs are characterized by significant aneuploidy due to widespread chromosomal LOH, most prominently in the corticotroph tumors. This LOH predicts treatment-refractoriness with high accuracy and represents a novel biomarker for this poorly defined PitNET category.
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Affiliation(s)
- Andrew L Lin
- Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY, 10065, USA
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Multidisciplinary Pituitary and Skull Base Tumor Center, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Vasilisa A Rudneva
- Marie-Josée and Henry R. Kravis Center for Molecular Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Allison L Richards
- Marie-Josée and Henry R. Kravis Center for Molecular Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Yanming Zhang
- Department of Pathology and Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Hyung Jun Woo
- Marie-Josée and Henry R. Kravis Center for Molecular Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Marc Cohen
- Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY, 10065, USA
- Multidisciplinary Pituitary and Skull Base Tumor Center, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Jamie Tisnado
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Nazanin Majd
- Department of Neuro-Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sharon L Wardlaw
- Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Gabrielle Page-Wilson
- Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Soma Sengupta
- Department of Neurology and Neurosurgery, University of North Carolina, Chapel Hill, NC, USA
| | - Frances Chow
- Department of Neurology, Keck School of Medicine at University of Southern California Medical Center, Los Angeles, CA, USA
| | - Bernard Goichot
- Department of Endocrinology, Les Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Byram H Ozer
- Department of Oncology, Sibley Memorial Hospital/Johns Hopkins, Washington, DC, USA
| | - Jorg Dietrich
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Lisa Nachtigall
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Arati Desai
- Department of Medicine, University of Pennsylvania Medical Center, Philadelphia, PA, USA
| | - Tina Alano
- Marie-Josée and Henry R. Kravis Center for Molecular Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Shahiba Ogilive
- Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY, 10065, USA
| | - David B Solit
- Marie-Josée and Henry R. Kravis Center for Molecular Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Tejus A Bale
- Department of Pathology and Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Marc Rosenblum
- Department of Pathology and Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Mark T A Donoghue
- Marie-Josée and Henry R. Kravis Center for Molecular Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
| | - Eliza B Geer
- Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY, 10065, USA.
- Multidisciplinary Pituitary and Skull Base Tumor Center, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
| | - Viviane Tabar
- Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY, 10065, USA
- Multidisciplinary Pituitary and Skull Base Tumor Center, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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Slater J, Horick N, Nachtigall L, Parsons M, Zarrella G, Tritos N, Dietrich J, Pursley J, Fullerton B, Wang I, Oh K, Loeffler J, Yeap B, Shih H. RADT-24. PHASE II STUDY OF PROTON RADIATION THERAPY FOR LOWER GRADE GLIOMAS. Neuro Oncol 2022. [PMCID: PMC9660743 DOI: 10.1093/neuonc/noac209.214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Abstract
PURPOSE
To report preliminary results on outcomes of patients with lower grade gliomas (LGG) treated with proton therapy.
METHODS
Patients with grade II or IDH mutant grade III glioma and indications for radiation therapy were enrolled in a prospective single arm trial of proton therapy (PRT), receiving a dose of 54 Gy(RBE) or 59.4 Gy(RBE), respectively. Comprehensive baseline and regular post-treatment evaluations of neuroendocrine function, neurocognitive functions (NCF), quality of life (QOL), and progression-free survival (PFS) were performed.
RESULTS
Among 60 patients (median age 40.8) who received PRT, 28 (47%) were men, and 39 (65%) were WHO grade II. Eighteen patients (30%) were IDH mutant+1p/19q co-deleted, 36 (60%) were IDH mutant astrocytoma, and 6 (10%) were IDH wildtype. Treatment was at initial diagnosis (41; 68%) or progression (19; 32%). Median follow-up after PRT was 4.1 years. All current data are reported for 3 years from PRT. PFS at 3 years was 86% for all patients, 84% for grade II (n = 39), and 90% for favorable grade III gliomas (n = 21). PFS was 83% for IDH mutant astrocytoma, and 94% for IDH mutant+1p/19q co-deleted oligodendrogliomas. New endocrine dysfunction was detected in 3 patients (5%). There was one grade 4 case of brain necrosis (2%) but no grade 3 toxicities. NCF decline, defined by Z-score drop of >/= 1SD on clinical trials battery composite, occurred in 7% (n = 3/43). QOL assessment by FACT-Brain showed 16% with decline of >/= 10 points (n = 7/43).
CONCLUSIONS
At 3 years post-treatment, LGG patients receiving PRT have a high PFS, similarly to previous reports on photon therapy, few new neuroendocrine deficiencies, modest treatment toxicities, and minimal decline in NCF or QOL. These positive outcomes may be attributable to limited integral dose to the brain by use of PRT, demonstrating its value in treatment of LGG patients with long survival expectations.
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Affiliation(s)
| | - Nora Horick
- Massachusetts General Hospital Biostatistics Center , Boston, MA , USA
| | | | - Michael Parsons
- Division of Neuro-Oncology, MGH Cancer Center, Massachusetts General Hospital and Harvard Medical School , Boston, MA , USA
| | - Giuliana Zarrella
- Psychology Assessment Center, Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School , Boston, MA , USA
| | | | - Jorg Dietrich
- Division of Neuro-Oncology, MGH Cancer Center, Massachusetts General Hospital and Harvard Medical School , Boston, MA , USA
| | - Jennifer Pursley
- Department of Radiation Oncology, Massachusetts General Hospital , Boston, MA , USA
| | - Barbara Fullerton
- Department of Radiation Oncology, Massachusetts General Hospital , Boston, MA , USA
| | - Irene Wang
- Massachusetts General Hospital , Boston, MA , USA
| | - Kevin Oh
- Department of Radiation Oncology, Massachusetts General Hospital , Boston, MA , USA
| | - Jay Loeffler
- Department of Radiation Oncology, Massachusetts General Hospital , Boston , USA
| | - Beow Yeap
- Massachusetts General Hospital Biostatistics Center , Boston, MA , USA
| | - Helen Shih
- Division of Neuro-Oncology, MGH Cancer Center, Massachusetts General Hospital and Harvard Medical School , Boston, MA , USA
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Samson S, Nachtigall L, Fleseriu M, Molitch ME, Giustina A, Haviv A, Biermasz N, Kennedy L, Jensterle M, Manning P, Elenkova A, Melmed S, Strasburger CJ. LBMON178 2nd Year Outcomes Of The Open-label Extension Of Chiasma Optimal, A Phase 3 Study Of Oral Octreotide Capsules In Acromegaly. J Endocr Soc 2022. [PMCID: PMC9627109 DOI: 10.1210/jendso/bvac150.984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Background Oral octreotide capsules (OOC) are an approved treatment option in the United States for patients with acromegaly who have previously responded to injectable somatostatin receptor ligands (iSRLs). Safety and efficacy of OOC was demonstrated in the CHIASMA OPTIMAL trial (NCT03252353), showing maintenance of response and a safety profile consistent with iSRLs. Results from the first 48 weeks of the open-label extension (OLE) of this trial suggested that this effect was durable for the long-term. Objective Report efficacy and safety through the second year of the OLE. Methods Eligible patients had the option to enroll in the OLE of CHIASMA OPTIMAL following the double-blind placebo-controlled (DPC) period. Endpoints in the second year of the OLE were exploratory, including: the proportion of patients completing week 96 of the OLE, the proportion of responders entering year 2 who remained responders of those with evaluable data (response defined as average Insulin-like growth factor I [IGF-I] ≤1. 0 × upper limit of normal [ULN] at last 2 visits between weeks 84-96), and changes in IGF-I and growth hormone (GH) from OLE baseline to OLE week 96 in those completing the DPC period on study drug. Results Thirty-two patients from the core period (DPC groups: n=14, placebo; n=18, OOC) entered year 2 of the OLE and 31 (97%) completed. OOC dose at the start of year 2 was 40 mg/d, n=3; 60 mg/d, n=8; and 80 mg/d, n=21. For patients who had non-missing data response rate at 96 weeks was 100% (17/17) for patients who entered year 2 as responders, and 93% (27/29) for patients overall. Mean IGF-I for patients from the OOC group who completed the DPC period on study drug (n=14) was 0.81 × ULN at baseline of OLE and 0.78 × ULN at week 96, (change, −0. 03 × ULN). Mean GH (n=12) was 0.43 ng/mL and 0.44 ng/mL at baseline and week 96, respectively (change, 0. 01 ng/mL). For patients who completed the DPC period on placebo (n=8), mean IGF-I was 1. 05 and 0.77 × ULN at OLE baseline and week 96, respectively (change, −0.28); mean GH (n=5) was 1. 06 and 0.34 ng/mL at OLE baseline and week 96, respectively (change, −0.72 ng/mL). Median exposure to OOC was 2.1 years, with exposure >3 years for 5 patients. Throughout the OLE period, 50% of patients experienced adverse events (AEs), with no serious AEs. One patient discontinued treatment due to an AE (headache). The safety profile was consistent with that reported for OOC; no new patterns were observed with increased exposure. Conclusion Maintenance of biochemical response with OOC was durable up to 96 weeks. The safety profile of OOC was consistent with that of iSRLs. No new safety signals were observed with increased exposure duration. Presentation: Monday, June 13, 2022 12:30 p.m. - 2:30 p.m.
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Colling C, Nachtigall L, Biller BMK, Miller KK. The biochemical diagnosis of adrenal insufficiency with modern cortisol assays: Reappraisal in the setting of opioid exposure and hospitalization. Clin Endocrinol (Oxf) 2022; 96:21-29. [PMID: 34498295 DOI: 10.1111/cen.14587] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 08/19/2021] [Accepted: 08/24/2021] [Indexed: 12/20/2022]
Abstract
OBJECTIVE We aimed to (1) examine the diagnosis of opioid-induced adrenal insufficiency, and (2) investigate the diagnostic value of a morning cortisol <83 nmol/L (3 µg/dl) for the diagnosis of adrenal insufficiency, using newer more specific cortisol assays and cut-offs. DESIGN Retrospective study (5/2015-10/2020). PARTICIPANTS Cohort 1 (N = 75): adults who underwent cosyntropin stimulation testing and opioid exposure for >30 days. Cohort 2 (N = 854): adults, with or without opioid exposure, who had a morning cortisol level measured the same day as stimulation testing. MEASUREMENTS Peak cortisol during cosyntropin stimulation testing. Sensitivity and specificity of morning serum cortisol for adrenal insufficiency. RESULTS The prevalence of adrenal insufficiency in patients with chronic opioid exposure who underwent cosyntropin stimulation testing was 4.0% using a cortisol cutoff of <405 nmol/L (14.7 µg/dl) versus 19% using the traditional cutoff of <500 nmol/L (18.1 µg/dl). For hospitalized patients with and without opioid-exposure, 14 of 22 (64%) patients with morning cortisol levels of <83 nmol/L (3 µg/dl) passed cosyntropin stimulation testing. A morning cortisol level of <348 nmol/L (12.6 µg/dl) had 100% sensitivity (95% confidence interval: 84.5%-100%) for the diagnosis of adrenal insufficiency. CONCLUSION Applying a cutoff of <405 nmol/L (14.7 µg/dl), opioid-induced adrenal insufficiency is rare. Nearly 1 out of 6 patients would be reclassified as having adrenal insufficiency applying the guideline-recommended cutoff of <500 nmol/L (18.1 µg/dl). Serum morning cortisol <83 nmol/L (3 µg/dl) is not a valid diagnostic test for adrenal insufficiency in hospitalized patients, whether or not receiving opioids.
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Affiliation(s)
- Caitlin Colling
- Neuroendocrine Unit, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Lisa Nachtigall
- Neuroendocrine Unit, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Beverly M K Biller
- Neuroendocrine Unit, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Karen K Miller
- Neuroendocrine Unit, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
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Faje A, Reynolds K, Zubiri L, Lawrence D, Cohen JV, Sullivan RJ, Nachtigall L, Tritos N. Hypophysitis secondary to nivolumab and pembrolizumab is a clinical entity distinct from ipilimumab-associated hypophysitis. Eur J Endocrinol 2019; 181:211-219. [PMID: 31176301 DOI: 10.1530/eje-19-0238] [Citation(s) in RCA: 90] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2019] [Accepted: 06/06/2019] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Little has been published describing hypophysitis after nivolumab or pembrolizumab treatment. We aimed to (i) assess the risk of hypophysitis following nivolumab or pembrolizumab treatment, (ii) characterize the clinical presentation and outcomes in these patients and (iii) compare these patients to hypophysitis following ipilimumab and ipilimumab plus nivolumab (combo). We hypothesized that headaches, pituitary enlargement on MRI and multiple anterior pituitary hormone deficiencies would occur less often in the nivolumab/pembrolizumab group versus ipilimumab or combo hypophysitis patients. DESIGN AND METHODS We conducted a multi-center retrospective review utilizing the Research Patient Database registry to evaluate individuals diagnosed with hypophysitis following treatment with nivolumab/pembrolizumab (n = 22), ipilimumab (n = 64) and combo (n = 20). Encounter notes, radiologic imaging and laboratory results for these patients were comprehensively reviewed. RESULTS Hypophysitis was rare following treatment with nivolumab/pembrolizumab (0.5%, 17/3522) compared to ipilimumab (13.6%, 34/250), P < 0.0001. Hypophysitis was diagnosed later in nivolumab/pembrolizumab (median: 25.8 weeks, interquartile range (IR): 18.4-44.0) compared to ipilimumab (9.3, IR: 7.2-11.1) or combo patients (12.5, IR: 7.4-18.6), P < 0.0001 for both. Headache and pituitary enlargement occurred less commonly in nivolumab/pemrolizumab patients (23% and 5/18, respectively) compared to ipilimumab (75%, 60/61) and combo (75%, 16/17) treatment groups (P < 0.0001 versus ipilimumab and P = 0.001 versus combo for headache and P < 0.0001 for both for enlargement). CONCLUSIONS This study represents the first comprehensive cohort analysis of nivolumab or pembrolizumab-associated hypophysitis in a large patient group. Hypophysitis occurs rarely with these medications, and these patients have a distinct phenotype compared to hypophysitis after treatment with ipilimumab or ipilimumab plus nivolumab.
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Affiliation(s)
- Alexander Faje
- Neuroendocrine Unit, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Kerry Reynolds
- Division of Oncology, Massachusetts General Hospital Cancer Center, Boston, Massachusetts, USA
| | - Leyre Zubiri
- Division of Oncology, Massachusetts General Hospital Cancer Center, Boston, Massachusetts, USA
| | - Donald Lawrence
- Center for Melanoma, Massachusetts General Hospital Cancer Center, Boston, Massachusetts, USA
| | - Justine V Cohen
- Center for Melanoma, Massachusetts General Hospital Cancer Center, Boston, Massachusetts, USA
| | - Ryan J Sullivan
- Center for Melanoma, Massachusetts General Hospital Cancer Center, Boston, Massachusetts, USA
| | - Lisa Nachtigall
- Neuroendocrine Unit, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Nicholas Tritos
- Neuroendocrine Unit, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
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Aulinas A, Plessow F, Asanza E, Silva L, Marengi DA, Fan W, Abedi P, Verbalis J, Tritos NA, Nachtigall L, Faje AT, Miller KK, Lawson EA. Low Plasma Oxytocin Levels and Increased Psychopathology in Hypopituitary Men With Diabetes Insipidus. J Clin Endocrinol Metab 2019; 104:3181-3191. [PMID: 30882859 PMCID: PMC6570634 DOI: 10.1210/jc.2018-02608] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Accepted: 03/12/2019] [Indexed: 11/19/2022]
Abstract
CONTEXT Oxytocin (OT) and vasopressin share anatomical pathways of synthesis and secretion, and patients with central diabetes insipidus (CDI) presumably are at risk for OT deficiency. However, an OT-deficient state in hypopituitary patients has not been established. OBJECTIVES We hypothesized that men with CDI compared to patients with similar anterior pituitary deficiencies (APD) but no CDI and healthy controls (HC) of similar age and body mass index, would have lower plasma OT levels, associated with increased psychopathology. DESIGN Cross-sectional. SETTING Clinical research center. PARTICIPANTS Sixty-two men (20 CDI, 20 APD, 22 HC), age 18 to 60 years. INTERVENTIONS Frequent sampling of blood every 5 minutes for OT over 1 hour and validated questionnaires to assess psychopathology. MAIN OUTCOMES Pooled plasma OT levels; depressive, anxiety, and alexithymia symptoms; and quality of life. RESULTS The mean 1-hour pool of fasting OT levels was lower in CDI compared with APD and HC (P = 0.02 and P = 0.009, respectively), with no differences between APD and HC (P = 0.78). Symptoms of depression, anxiety, and alexithymia were more pronounced in CDI than in HC (P = 0.001, P = 0.004, and P = 0.02, respectively). Although CDI and APD reported worse physical health compared with HC (P = 0.001 and P = 0.005) with no differences between APD and CDI, only CDI reported worse mental health compared with HC (P = 0.009). CONCLUSIONS We have demonstrated low plasma OT levels and increased psychopathology in hypopituitary men with CDI, suggestive of a possible OT-deficient state. Larger studies of both sexes are required to confirm these findings and clinically characterize hypopituitary patients with OT deficiency.
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Affiliation(s)
- Anna Aulinas
- Neuroendocrine Unit, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Franziska Plessow
- Neuroendocrine Unit, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Elisa Asanza
- Neuroendocrine Unit, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Lisseth Silva
- Neuroendocrine Unit, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Dean A Marengi
- Neuroendocrine Unit, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - WuQiang Fan
- Neuroendocrine Unit, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Parisa Abedi
- Neuroendocrine Unit, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Joseph Verbalis
- Division of Endocrinology and Metabolism, Georgetown University Medical Center, Washington, DC
| | - Nicholas A Tritos
- Neuroendocrine Unit, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Lisa Nachtigall
- Neuroendocrine Unit, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Alexander T Faje
- Neuroendocrine Unit, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Karen K Miller
- Neuroendocrine Unit, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Elizabeth A Lawson
- Neuroendocrine Unit, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
- Correspondence and Reprint Requests: Elizabeth A. Lawson, MD, MMSc, Neuroendocrine Unit, Massachusetts General Hospital, 55 Fruit Street, Boston, Massachusetts 02114. E-mail:
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Lines K, Nachtigall L, Dichtel L, Cranston T, Khairi S, Boon H, Abedi P, Zhang X, Kooblall K, Stevenson M, Klibanski A, Thakker R. MON-335 Phenocopy of Multiple Endocrine Neoplasia Type 1 (MEN1) Due to a Germline Cell Division Cycle 73 (CDC73) Variant. J Endocr Soc 2019. [PMCID: PMC6550911 DOI: 10.1210/js.2019-mon-335] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Multiple endocrine neoplasia type 1 (MEN1) is an autosomal dominant disorder characterized by the combined occurrence of parathyroid tumors, and neuroendocrine tumors (NETs) of the pituitary and pancreas. MEN1 is caused by germline mutations of the tumor suppressor gene MEN1, which are found in >75% of MEN1 patients. The remaining patients may have mutations involving: as yet unidentified genes; or other genes with known involvement in endocrine tumors, e.g. cyclin dependent kinase inhibitor 1B (CDKN1B) which is associated with MEN4. Here, we report a patient who had primary hyperparathyroidism, acromegaly, and a pancreatic NET that showed immuno-staining for glucagon and chromogranin A, which are consistent with MEN1. However, mutational analysis did not identify a MEN1 mutation, and analysis of other genes was undertaken, after informed consent was obtained from the patient. These genes include: CDKN1B; CDKN1A; CDKN2B; CDKN2C;cell cycle division 73 (CDC73), causative for hyperparathyroidism-jaw tumour (HPT-JT) syndrome, an autosomal dominant disorder characterised by occurrence of parathyroid tumors, ossifying fibromas of the jaw, renal tumours and uterine tumors; calcium sensing receptor (CASR), causative for familial hypocalciuric hypercalcemia type 1 (FHH1); and aryl-hydrocarbon receptor-interacting protein (AIP), causative for familial pituitary tumors. This revealed a heterozygous c.1138C>T (p.Leu380Phe) missense mutation of CDC73. This is likely a disease-causing mutation as: 1) the p.Leu380Phe substitution is not present in >120,000 alleles of The Exome Aggregation Consortium (ExAc) database; 2) involves an evolutionary conserved Leu380 residue; and 3) is situated within the parafibromin domain predicted to interact with the polymerase associated factor 1 (PAF1) and RNA polymerase II, (POLR2A) complex. In addition, RNA-Scope analysis, to detect specific CDC73 mRNA transcripts in paraffin embedded sections, of the patient’s pancreatic NET revealed that CDC73 mRNA expression was significantly decreased by >13% (p<0.005) in the tumor cells, compared to normal adjacent islets. Thus, our results suggest the spectrum of tumours associated with CDC73 mutations also includes pancreatic NETs, and demonstrate that CDC73 mutations may result in a phenocopy of MEN1.
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Affiliation(s)
- Kate Lines
- OCDEM, University of Oxford, Oxford, , United Kingdom
| | - Lisa Nachtigall
- Neuroendocrine Unit, Massachusetts General Hospital, Boston, MA, United States
| | - Laura Dichtel
- Neuroendocrine Unit, Neuroendocrine Unit, Massachusetts General Hospital, Boston, MA, United States
| | - Treena Cranston
- Genetics Laboratories, OCDEM, University of Oxford, Oxford, , United Kingdom
| | - Shafaq Khairi
- Neuroendocrine Unit, Massachusetts General Hospital, Boston, MA, United States
| | - Hannah Boon
- OCDEM, University of Oxford, Oxford, , United Kingdom
| | - Parisa Abedi
- Neuroendocrine Unit, Massachusetts General Hospital, Boston, MA, United States
| | - Xun Zhang
- Neuroendocrine Unit, Massachusetts General Hospital, Boston, MA, United States
| | | | | | - Anne Klibanski
- Neuroendo Dept, Neuroendocrine Unit, Massachusetts General Hospital, Boston, MA, United States
| | - Rajesh Thakker
- Nuffield Dept of Med, OCDEM, University of Oxford, Oxford, , United Kingdom
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Jordan JT, Miller JJ, Cushing T, Curry WT, Shih HA, Nachtigall L, Loeffler J, Dietrich J. P21.07 Temozolomide for Progressive Pituitary Adenomas Refractory to Surgery and Radiation: A Case Series. Neuro Oncol 2016. [DOI: 10.1093/neuonc/now188.295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Faje AT, Sullivan R, Lawrence D, Tritos NA, Fadden R, Klibanski A, Nachtigall L. Ipilimumab-induced hypophysitis: a detailed longitudinal analysis in a large cohort of patients with metastatic melanoma. J Clin Endocrinol Metab 2014; 99:4078-85. [PMID: 25078147 DOI: 10.1210/jc.2014-2306] [Citation(s) in RCA: 275] [Impact Index Per Article: 27.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
CONTEXT Ipilimumab (Ipi) is approved by the Food and Drug Administration for the treatment of unresectable or metastatic melanoma. Little is known about Ipi-induced hypophysitis (IH), an important treatment complication. OBJECTIVE The objectives of the study were as follows: 1) to examine the prevalence of IH, 2) to characterize the clinical course and treatment outcomes in IH, 3) to identify the risk factors for the development of IH, and 4) to determine optimal strategies for the management of IH. DESIGN This was a retrospective review. SETTING The study was conducted at a tertiary referral center. SUBJECTS One hundred fifty-four adult patients with metastatic melanoma were evaluated at Massachusetts General Hospital and were treated with Ipi between March 2008 and December 2013. INTERVENTION(S) The intervention included treatment with Ipi. MAIN OUTCOME MEASURE(S) Pituitary magnetic resonance imaging, pituitary hormone assessment, and patient survival were measured. RESULTS IH was diagnosed in 17 patients (11%). Male gender (P = .02) and older age (P = .005), but not the cumulative dose of Ipi, were risk factors for IH. All patients with IH had anterior hypopituitarism (none had diabetes insipidus). Hypopituitarism was persistent in most individuals (76%). Diffuse pituitary enlargement was observed exclusively in all cases of IH and, upon retrospective review of magnetic resonance imaging scans, this finding preceded the clinical diagnosis of hypophysitis in eight patients. Pituitary enlargement resolved rapidly (within 40 d in seven of seven patients). Median survival in patients with IH was 19.4 vs 8.8 months (P = .05) in the remainder of the cohort. CONCLUSIONS Male gender and older age are risk factors for IH. Pituitary enlargement is sensitive and specific for IH in the appropriate setting, can precede the clinical diagnosis, and resolves rapidly. Anterior pituitary function recovery is uncommon. The incidence of hypophysitis may positively predict survival in melanoma patients treated with Ipi.
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Affiliation(s)
- Alexander T Faje
- Neuroendocrine Unit (A.T.F., N.A.T., A.K., L.N.), Massachusetts General Hospital and Harvard Medical School, and Center for Melanoma (R.S., D.L., R.F.), Massachusetts General Hospital Cancer Center, Boston, Massachusetts 02114
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Shih H, Sherman J, Nachtigall L, Colvin M, Fullerton B, Winrich B, Batchelor T, Thornton L, Daartz J, Mancuso S, Oh K, Curry W, Loeffler J, Yeap B. AT-52 * PROSPECTIVE EARLY RESULTS OF LOW GRADE GLIOMA PATIENTS TREATED WITH PROTON THERAPY. Neuro Oncol 2014. [DOI: 10.1093/neuonc/nou237.51] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Abstract
CONTEXT Temozolomide (TMZ) is an alkylating agent primarily used to treat tumors of the central nervous system. We describe 2 patients with apparent TMZ-induced central diabetes insipidus. Using our institution's Research Patient Database Registry, we identified 3 additional potential cases of TMZ-induced diabetes insipidus among a group of 1545 patients treated with TMZ. CASE PRESENTATIONS A 53-year-old male with an oligoastrocytoma and a 38-year-old male with an oligodendroglioma each developed symptoms of polydipsia and polyuria approximately 2 months after the initiation of TMZ. Laboratory analyses demonstrated hypernatremia and urinary concentrating defects, consistent with the presence of diabetes insipidus, and the patients were successfully treated with desmopressin acetate. Desmopressin acetate was withdrawn after the discontinuation of TMZ, and diabetes insipidus did not recur. Magnetic resonance imaging of the pituitary and hypothalamus was unremarkable apart from the absence of a posterior pituitary bright spot in both of the cases. Anterior pituitary function tests were normal in both cases. Using the Research Patient Database Registry database, we identified the 2 index cases and 3 additional potential cases of diabetes insipidus for an estimated prevalence of 0.3% (5 cases of diabetes insipidus per 1545 patients prescribed TMZ). CONCLUSIONS Central diabetes insipidus is a rare but reversible side effect of treatment with TMZ.
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Affiliation(s)
- Alexander T Faje
- MD, BUL 457, Neuroendocrine Unit, Massachusetts General Hospital, 55 Fruit Street, Boston, Massachusetts 02114.
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Sheth SA, Mian MK, Neal J, Tritos NA, Nachtigall L, Klibanski A, Biller BMK, Swearingen B. Transsphenoidal surgery for cushing disease after nondiagnostic inferior petrosal sinus sampling. Neurosurgery 2012; 71:14-22. [PMID: 22353796 DOI: 10.1227/neu.0b013e31824f8e2e] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Inferior petrosal sinus sampling (IPSS) is a useful technique for confirming a pituitary source of adrenocorticotropic hormone (ACTH) overproduction in Cushing disease. Uncertainty remains regarding the appropriate course of therapy when an ectopic tumor is predicted by IPSS but none can be found and in circumstances when the procedure cannot be successfully completed owing to technical or anatomic limitations. OBJECTIVE To determine an appropriate course of action after nondiagnostic IPSS. METHODS We reviewed 288 IPSS procedures in 283 patients between 1986 and 2010 at our center. An IPS:peripheral ACTH ratio ≥ 2 at baseline or ≥ 3 after corticotrophin-releasing hormone was considered predictive of a pituitary source of ACTH. A procedure was considered nondiagnostic if the procedure was successfully performed and the results predicted an ectopic source but none could be found despite extensive imaging or if the IPS could not be bilaterally cannulated because of technical difficulties or anatomic variants. RESULTS The sensitivity, specificity, positive predictive value, and negative predictive value of IPSS for detecting a pituitary source in Cushing disease were 94%, 50%, 98%, and 29%, respectively. We identified 3 categories of nondiagnostic IPSS comprising 44 of the total procedures. These patients underwent exploratory transsphenoidal surgery, and in 42 of these patients (95%), a pituitary source was surgically proven, with a remission rate of 83%. CONCLUSION Transsphenoidal surgery should be considered in cases of ACTH-dependent Cushing disease and noncentralized or technically unsuccessful IPSS without evidence of ectopic tumor.
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Affiliation(s)
- Sameer A Sheth
- Department of Neurosurgery, Massachusetts General Hospital, Boston, MA, USA.
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Lin E, Wexler TL, Nachtigall L, Tritos N, Swearingen B, Hemphill L, Loeffler J, Biller BMK, Klibanski A, Miller KK. Effects of growth hormone deficiency on body composition and biomarkers of cardiovascular risk after definitive therapy for acromegaly. Clin Endocrinol (Oxf) 2012; 77:430-8. [PMID: 22315983 PMCID: PMC3366162 DOI: 10.1111/j.1365-2265.2012.04361.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Both growth hormone (GH) excess and GH deficiency are associated with abnormalities in body composition and biomarkers of cardiovascular risk in patients with pituitary disorders. However, the effects of developing GH deficiency after definitive treatment of acromegaly are largely unknown. OBJECTIVE To determine whether development of GH deficiency after definitive therapy for acromegaly is associated with increased visceral adiposity and biomarkers of cardiovascular risk compared with GH sufficiency after definitive therapy for acromegaly. DESIGN Cross-sectional. PATIENTS We studied three groups of subjects, all with a history of acromegaly (n = 76): subjects with subsequent GH deficiency (GHD; n = 31), subjects with subsequent GH sufficiency (GHS; n = 25) and subjects with active acromegaly (AA; n = 20). No study subjects were receiving somatostatin analogues, dopamine agonists or hGH. MEASUREMENTS Body composition (by DXA), abdominal adipose tissue depots (by cross-sectional CT), total body water (by bioimpedance analysis) and carotid intima-media thickness (IMT) were measured. Fasting morning serum was collected for high-sensitivity C-reactive protein (hsCRP), lipids and lipoprotein levels. An oral glucose tolerance test was performed, and homoeostasis model of assessment-insulin resistance (HOMA-IR) was calculated. RESULTS Abdominal visceral adipose tissue, total adipose tissue and total body fat were higher in subjects with GHD than GHS or AA (P < 0·05). Subcutaneous abdominal fat was higher, and fibrinogen and IMT were lower in GHD (but not GHS) than AA (P < 0·05). Patients with GHD had the highest hsCRP, followed by GHS, and hsCRP was lowest in AA (P < 0·05). Fasting glucose, 120-min glucose, fasting insulin, HOMA-IR and per cent total body water were lower in GHD and GHS than AA (P < 0·05). Triglycerides were higher in GHS than AA (P < 0·05). Lean body mass, mean arterial pressure, total cholesterol, HDL and LDL were comparable among groups. CONCLUSIONS Development of GHD after definitive treatment of acromegaly may adversely affect body composition and inflammatory biomarkers of cardiovascular risk but does not appear to adversely affect glucose homoeostasis, lipids and lipoproteins, or other cardiovascular risk markers.
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Affiliation(s)
- E Lin
- Department of Neuroendocrine Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
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Miller KK, Wexler T, Fazeli P, Gunnell L, Graham GJ, Beauregard C, Hemphill L, Nachtigall L, Loeffler J, Swearingen B, Biller BMK, Klibanski A. Growth hormone deficiency after treatment of acromegaly: a randomized, placebo-controlled study of growth hormone replacement. J Clin Endocrinol Metab 2010; 95:567-77. [PMID: 20061426 PMCID: PMC2840863 DOI: 10.1210/jc.2009-1611] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
CONTEXT The effects of GH replacement therapy in patients who develop GH deficiency (GHD) after cure of acromegaly have not been established in a placebo-controlled study. OBJECTIVE The objective of the study was to determine whether GH replacement improves body composition, cardiovascular risk markers and quality of life in patients with GHD and prior acromegaly. DESIGN This was a 6-month, randomized, placebo-controlled study. SETTING The study was conducted at a clinical translational science center. STUDY PARTICIPANTS Participants included 30 subjects with prior acromegaly and current GHD. INTERVENTION INTERVENTIONs included GH or placebo. MAIN OUTCOME MEASURES Body composition (dual-energy x-ray absorptiometry and cross-sectional computed tomography at L4), cardiovascular risk markers (high-sensitivity C-reactive protein (hsCRP), total, high-density lipoprotein and low-density lipoprotein cholesterol, fibrinogen, and carotid intimal-medial thickness), and quality of life were measured. RESULTS The mean GH dose at 6 months was 0.58 +/- 0.26 mg/d. Total fat mass, visceral adipose tissue (-15.3 +/- 18.6 vs. 1.3 +/- 12.5%, P = 0.01), and total abdominal fat decreased, and fat-free mass increased, in the GH vs. placebo group. Mean hsCRP levels decreased, but there was no GH effect on other cardiovascular risk markers. There was no change in glycosylated hemoglobin or homeostasis model assessment insulin resistance index. Quality of life improved with GH. Side effects were minimal. CONCLUSIONS This is the first randomized, placebo-controlled study of the effects of GH replacement therapy on body composition and cardiovascular end points in patients who have developed GH deficiency after treatment for acromegaly, a disease complicated by metabolic and body composition alterations and increased cardiovascular risk. GH replacement decreased visceral adipose tissue, increased fat-free mass, decreased hsCRP, and improved quality of life in patients with GHD after cure of acromegaly, with minimal side effects and without an increase in insulin resistance.
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Affiliation(s)
- Karen K Miller
- Neuroendocrine Unit, Bulfinch 457B, Massachusetts General Hospital, Boston, Massachusetts 02114, USA.
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Kessel B, Nachtigall L, Plouffe L, Siddhanti S, Rosen A, Parsons A. Effect of raloxifene on sexual function in postmenopausal women. Climacteric 2009. [DOI: 10.1080/cmt.6.3.248.256] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Wexler T, Gunnell L, Omer Z, Kuhlthau K, Beauregard C, Graham G, Utz AL, Biller B, Nachtigall L, Loeffler J, Swearingen B, Klibanski A, Miller KK. Growth hormone deficiency is associated with decreased quality of life in patients with prior acromegaly. J Clin Endocrinol Metab 2009; 94:2471-7. [PMID: 19366847 PMCID: PMC2708960 DOI: 10.1210/jc.2008-2671] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
CONTEXT Both GH deficiency (GHD) and GH excess are associated with a decreased quality of life. However, it is unknown whether patients with GHD after treatment for acromegaly have a poorer quality of life than those with normal GH levels after cure of acromegaly. OBJECTIVE The aim of the study was to determine whether patients with GHD and prior acromegaly have a poorer quality of life than those with GH sufficiency after cure of acromegaly. DESIGN AND SETTING We conducted a cross-sectional study in a General Clinical Research Center. STUDY PARTICIPANTS Forty-five patients with prior acromegaly participated: 26 with GHD and 19 with GH sufficiency. INTERVENTION There were no interventions. MAIN OUTCOME MEASURES We evaluated quality of life, as measured by 1) the Quality of Life Adult Growth Hormone Deficiency Assessment (QoL-AGHDA); 2) the Short-Form Health Survey (SF-36); and 3) the Symptom Questionnaire. RESULTS Mean scores on all subscales of all questionnaires, except for the anger/hostility and anxiety subscales of the Symptom Questionnaire, showed significantly impaired quality of life in the GH-deficient group compared with the GH-sufficient group. Peak GH levels after GHRH-arginine stimulation levels were inversely associated with QoL-AGHDA scale scores (R = -0.53; P = 0.0005) and the Symptom Questionnaire Depression subscale scores (R = -0.35; P = 0.031) and positively associated with most SF-36 subscale scores. CONCLUSIONS Our data are the first to demonstrate a reduced quality of life in patients who develop GHD after cure of acromegaly compared to those who are GH sufficient. Further studies are warranted to determine whether GH replacement would improve quality of life for patients with GHD after cure from acromegaly.
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Affiliation(s)
- Tamara Wexler
- Neuroendocrine Unit, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts 02114, USA
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Nachtigall L, Lang E, Gut R, Utian W, Archer D, Simon J. An ultra-low dose (10μg) estradiol vaginal tablet improves signs and symptoms associated with vaginal atrophy. Fertil Steril 2008. [DOI: 10.1016/j.fertnstert.2008.07.1315] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
BACKGROUND The increased morbidity and mortality of acromegaly makes early diagnosis and therapy critical. However, whether the type of medical professional who first diagnoses acromegaly, the major complaint prompting medical attention, or the management paradigms used in the setting of novel medical therapies have changed over time has not been well explored. OBJECTIVES Our objective was to identify the medical professional who first suspected acromegaly and the complaint prompting the diagnosis, and if these have changed. Additional goals were to assess the interval from symptom onset to diagnosis of acromegaly and to compare treatment trends over consecutive decades. DESIGN This was a case-record retrospective study. SETTING The study was performed in a neuroendocrine clinical center at a tertiary care center. SUBJECTS A total of 100 patients (45 men and 55 women) with acromegaly referred from 1985-2005 was included in the study. RESULTS Acral changes (24%) and headaches (20%) were most prevalent presenting symptoms prompting diagnosis. Eighteen percent reported no symptoms of acromegaly at diagnosis. The primary care physician most often initiated the evaluation (44%). Comorbidities were more prevalent in older patients (P = 0.001). The interval between symptom onset and diagnosis decreased, compared with previous reports. Radiation therapy was used less frequently in the decade after 1994 than in the prior (16 vs. 33%; P < 0.05). CONCLUSIONS The primary care doctor plays the major role in diagnosis of acromegaly. The increased use of brain magnetic resonance imaging may contribute to the many incidentally discovered cases and to the shortened time interval to diagnosis. Presumably due to the availability of new medical therapies, the use of radiation therapy has decreased.
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Affiliation(s)
- Lisa Nachtigall
- Neuroendocrine Unit, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
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Beauregard C, Utz AL, Schaub AE, Nachtigall L, Biller BMK, Miller KK, Klibanski A. Growth hormone decreases visceral fat and improves cardiovascular risk markers in women with hypopituitarism: a randomized, placebo-controlled study. J Clin Endocrinol Metab 2008; 93:2063-71. [PMID: 18381581 PMCID: PMC2435650 DOI: 10.1210/jc.2007-2371] [Citation(s) in RCA: 81] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
CONTEXT Data regarding gender-specific efficacy of GH on critical endpoints are lacking. There are no randomized, placebo-controlled studies of physiological GH therapy solely in women. OBJECTIVE Our objective was to determine the effects of physiological GH replacement on cardiovascular risk markers and body composition in women with GH deficiency (GHD). DESIGN This was a 6-month, randomized, placebo-controlled, double-blind study. SETTING The study was conducted at the General Clinical Research Center. STUDY PARTICIPANTS 43 women with GHD due to hypopituitarism were included in the study. INTERVENTION Study participants were randomized to receive GH (goal mid-normal serum IGF-1) or placebo. MAIN OUTCOME MEASURES Cardiovascular risk markers, including high-sensitivity C-reactive protein, tissue plasminogen activator, and body composition, including visceral adipose tissue by cross-sectional computed tomography, were measured. RESULTS Mean daily GH dose was 0.67 mg. The mean IGF-1 sd score increased from -2.5 +/- 0.3 to -1.4 +/- 0.9 (GH) (P < 0.0001 vs. placebo). High-sensitivity C-reactive protein decreased by 38.2 +/- 9.6% (GH) vs.18.2 +/- 6.0% (placebo) (P = 0.03). Tissue plasminogen activator and total cholesterol decreased, and high-density lipoprotein increased. Homeostasis model assessment-insulin resistance and other markers were unchanged. Body fat decreased [-5.1 +/- 2.0 (GH) vs. 1.9 +/- 1.0% (placebo); P = 0.002] as did visceral adipose tissue [-9.0 +/- 5.9 (GH) vs. 4.3 +/- 2.7% (placebo); P = 0.03]. Change in IGF-1 level was inversely associated with percent change in visceral adipose tissue (r = -0.61; P = 0.002), total body fat (r = -0.69; P < 0.0001), and high-sensitivity C-reactive protein (r = -0.51; P = 0.003). CONCLUSIONS Low-dose GH replacement in women with GHD decreased total and visceral adipose tissue and improved cardiovascular markers, with a relatively modest increase in IGF-1 levels and without worsening insulin resistance.
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Kessel B, Nachtigall L, Plouffe L, Siddhanti S, Rosen A, Parsons A. Effect of raloxifene on sexual function in postmenopausal women. Climacteric 2003; 6:248-56. [PMID: 14567773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/27/2023]
Abstract
OBJECTIVE To determine the effects of raloxifene on sexual function in postmenopausal women with pre-existing vaginal atrophy treated with vaginal estrogen cream. METHODS A total of 187 naturally postmenopausal women, 42-80 years of age, with signs of genitourinary atrophy were enrolled in this 6-month, multicenter, parallel-group study. Subjects were randomized to oral raloxifene HCl 60 mg daily or matching placebo; the same subjects were also randomized to receive one application of either vaginal conjugated estrogen cream 0.5 g twice weekly for 6 months or non-hormonal vaginal moisturizer twice weekly for 3 months, followed by conjugated estrogen cream for 3 months. Both investigators and subjects were masked to the identity of the oral medication. The vaginal preparations were administered in an open-label fashion. The Sexual Activity Questionnaire (SAQ) was administered at baseline and at 3 and 6 months. Safety was assessed throughout the study. RESULTS A total of 102 women were sexually active at baseline and, of these, 82 were also sexually active at the 6-month end-point. At 6 months, raloxifene and placebo, in the presence of vaginal conjugated estrogen cream, were both associated with improvement from baseline in vaginal dryness and reduced discomfort during sexual activity. There were no significant differences between raloxifene and placebo groups in any SAQ item. Enjoyment of sexual activity significantly increased from baseline with raloxifene but not with placebo. No difference in adverse events was observed between groups. CONCLUSION Raloxifene had no negative effects on sexual function in postmenopausal women with vaginal atrophy who were treated concomitantly with vaginal estrogen cream.
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Affiliation(s)
- B Kessel
- Department of Obstetrics, Gynecology and Women's Health, University of Hawaii, Queen's Medical Center, Honolulu, Hawaii 96813, USA
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Parsons A, Nachtigall L, Merritt D, Basson R, Heath H, Plouffe L. Vaginal Premarin® vs. Replens® in Women with Pre-existing Vaginal Atrophy Receiving Oral Placebo or Raloxifene: Effects on Objective Endpoints. Menopause 1999. [DOI: 10.1097/00042192-199906040-00073] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Nachtigall L. Towards better recognition of urogenital aging. Proceedings of the 8th International Congress on the Menopause held on November 5, 1996, in Sydney, Australia. Chairman's introduction. Am J Obstet Gynecol 1998; 178:S243-4. [PMID: 9609598 DOI: 10.1016/s0002-9378(98)70554-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- L Nachtigall
- New York University School of Medicine, New York, USA
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Habiby RL, Boepple P, Nachtigall L, Sluss PM, Crowley WF, Jameson JL. Adrenal hypoplasia congenita with hypogonadotropic hypogonadism: evidence that DAX-1 mutations lead to combined hypothalmic and pituitary defects in gonadotropin production. J Clin Invest 1996; 98:1055-62. [PMID: 8770879 PMCID: PMC507522 DOI: 10.1172/jci118866] [Citation(s) in RCA: 181] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
Adrenal hypoplasia congenita (AHC) is an X-linked disorder that typically presents with adrenal insufficiency during infancy. Hypogonadotropic hypogonadism (HHG) has been identified as a component of this disorder in affected individuals who survive into childhood. Recently, AHC was shown to be caused by mutations in DAX-1, a protein that is structurally similar in its carboxyterminal region to orphan nuclear receptors. We studied two kindreds with clinical features of AHC and HHG. DAX-1 mutations were identified in both families. In the JW kindred, a single base deletion at nucleotide 1219 was accompanied by an additional base substitution that resulted in a frameshift mutation at codon 329 followed by premature termination. In the MH kindred, a GGAT duplication at codon 418 caused a frameshift that also resulted in truncation of DAX-1. Baseline luteinizing hormone (LIT), follicle-stimulating hormone (FSH), and free-alpha-subunit (FAS) levels were determined during 24 h of frequent (q10 min) venous sampling. In patient MH, baseline LH levels were low, but FAS levels were within the normal range. In contrast, in patient JW, the mean LH and FSH were within the normal range during baseline sampling, but LH secretion was erratic rather than showing typical pulses. FAS was apulsatile for much of the day, but a surge was seen over a 3-4-h period. Pulsatile gonadotropin releasing hormone (GnRH) (25 ng/kg) was administered every 2 h for 7 d to assess pituitary responsiveness to exogenous GnRH. MH did not exhibit a gonadotropin response to pulsatile GnRH. JW exhibited a normal response to the first pulse of GnRH, but there was no increase in FAS. In contrast to the priming effect of GnRH in GnRH-deficient patients with Kallmann syndrome, GnRH pulses caused minimal secretory responses of LH and no FAS responses in patient JW. The initial LH response in patient JW implies a deficiency in hypothalamic GnRH. On the other hand, the failure to respond to pulsatile GnRH is consistent with a pituitary defect in gonadotropin production. These two cases exemplify the phenotypic heterogeneity of AHC/HHG, and suggest that DAX-1 mutations impair gonadotropin production by acting at both the hypothalamic and pituitary levels.
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Affiliation(s)
- R L Habiby
- Division of Endocrinology, Metabolism, and Molecular Medicine, Northwestern University Medical School, Chicago, Illinois 60611, USA
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Goldstein S, Nachtigall M, Snyder J, Nachtigall L. 90258939 Endometrial assessment by vaginal ultrasonography before endometrial sampling in patients with postmenopausal bleeding. Maturitas 1991. [DOI: 10.1016/0378-5122(91)90107-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Goldstein SR, Nachtigall M, Snyder JR, Nachtigall L. Endometrial assessment by vaginal ultrasonography before endometrial sampling in patients with postmenopausal bleeding. Am J Obstet Gynecol 1990; 163:119-23. [PMID: 2197861 DOI: 10.1016/s0002-9378(11)90683-8] [Citation(s) in RCA: 215] [Impact Index Per Article: 6.3] [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: 12/30/2022]
Abstract
Endometrial sampling is the mainstay of management of the postmenopausal patient with uterine bleeding. Thirty women with postmenopausal bleeding were studied prospectively. Before endometrial sampling, a vaginal probe ultrasonographic examination was performed. Eleven patients demonstrated a thin "pencil line" endometrial echo in which the maximum anteroposterior thickness on the long axis view was less than or equal to 5 mm. All eleven patients had minimal tissue obtained on biopsy and a pathology report of "tissue insufficient for diagnosis." Seventeen patients had an echogenic endometrium greater than or equal to 6 mm. Pathology reports of their samples revealed tissue insufficient for diagnosis (two cases), proliferative endometrium (six), secretory endometrium (three), hyperplastic endometrium (three), polyp (two), and endometrial cancer (one case). Two additional patients had no endometrial echo visualized because of associated myomas. These findings suggest (1) that the absence of significant endometrial tissue (echo less than or equal to 5 mm) on vaginal ultrasonography in cases with postmenopausal bleeding is uniformly associated with tissue insufficient for diagnosis, and (2) when endometrial thickness is greater than or equal to 6 mm the histologic diagnosis should be determined in the pathology laboratory.
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Affiliation(s)
- S R Goldstein
- Department of Obstetrics and Gynecology, New York University School of Medicine, NY
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Kable WT, Gallagher JC, Nachtigall L, Goldgar D. Lipid changes after hormone replacement therapy for menopause. J Reprod Med 1990; 35:512-8. [PMID: 2112606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Three regimens of hormone replacement therapy were administered to 62 postmenopausal women for a period of 12 weeks and evaluated for their effect on blood lipids. Each group was given a continuous dose of 0.625 mg of conjugated estrogens combined with either a continuous dose of 2.5 mg of medroxyprogesterone acetate or 5.0 mg of medroxyprogesterone acetate, or a cyclic dose of 5.0 mg of medroxyprogesterone acetate on days 17-28 of the cycle. After treatment there was a significant decrease in the total cholesterol (P less than .0007) and low density lipoprotein cholesterol (P less than .0001) together with a significant increase in high density lipoprotein cholesterol (P less than .0029). There was no significant difference in the response of the blood lipids to the three hormone groups. Therefore, preference would depend on the combination that caused the least bleeding or amenorrhea.
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Affiliation(s)
- W T Kable
- Department of Obstetrics and Gynecology, Creighton University School of Medicine, Omaha, NE 68131
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Abstract
Ham's F-10 medium (Gibco, Grand Island, NY) and medium T6 with and without 15% fetal calf serum (FCS) were compared for their ability to support development of murine blastocysts with the capacity to implant and produce normal fetuses when transferred to pseudopregnant females. All media supported equal rates of blastocyst development from 2-cell embryos. In addition, there were no differences in the rates of blastocyst implantation. However, once implanted, blastocysts grown in T6 produced a significantly higher proportion of normal fetuses (58.5% to 65.9%) than blastocysts grown in either Ham's F-10 (2.4%) or T6 with FCS (27.6%). These results demonstrate that the rate of murine blastocyst development from 2-cell embryos in vitro is not a good criterion of healthy embryos. Murine blastocysts transferred in medium with 0% versus 50% FCS implanted and developed into normal fetuses at equal rates.
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Affiliation(s)
- M Arny
- Department of Obstetrics and Gynecology, New York University Medical Center, New York 10016
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Beller FK, Nachtigall L, Rosenberg M. Coagulation studies of menopausal women taking estrogen replacement. Obstet Gynecol 1972; 39:775-8. [PMID: 4260072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Nachtigall L, Bassett M, Hogsander U, Levitz M. Plasma estriol levels in normal and abnormal pregnancies: An index of fetal welfare. Am J Obstet Gynecol 1968. [DOI: 10.1016/0002-9378(68)90301-3] [Citation(s) in RCA: 50] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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