A method for determination of one hundred endogenous steroids in human serum by gas chromatography-tandem mass spectrometry

Steroid profiling helps various pathologies to be rapidly diagnosed. Results from analyses investigating steroidogenic pathways may be used as a tool for uncovering pathology causations and proposals of new therapeutic approaches. The purpose of this study was to address still underutilized application of the advanced GC-MS/MS platform for the multicomponent quantification of endogenous steroids. We developed and validated a GC-MS/MS method for the quantification of 58 unconjugated steroids and 42 polar conjugates of steroids (after hydrolysis) in human blood. The present method was validated not only for blood of men and non-pregnant women but also for blood of pregnant women and for mixed umbilical cord blood. The spectrum of analytes includes common hormones operating via nuclear receptors as well as other bioactive substances like immunomodulatory and neuroactive steroids. Our present results are comparable with those from our previously published GC-MS method as well as the results of others. The present method was extended for corticoids and 17alpha-hydroxylated 5alpha/ß-reduced pregnanes, which are useful for the investigation of alternative "backdoor" pathway. When comparing the analytical characteristics of the present and previous method, the first exhibit by far higher selectivity, and generally higher sensitivity and better precision particularly for 17alpha-hydroxysteroids.

A multivariable prediction model for pegvisomant dosing: monotherapy and in combination with long-acting somatostatin analogues

BACKGROUND

Effective treatment of acromegaly with pegvisomant (PEGV), a growth hormone receptor antagonist, requires an appropriate dose titration. PEGV doses vary widely among individual patients, and various covariates may affect its dosing and pharmacokinetics.

OBJECTIVE

To identify predictors of the PEGV dose required to normalize insulin-like growth factor I (IGF-I) levels during PEGV monotherapy and in combination with long-acting somatostatin analogues (LA-SSAs).

DESIGN

Two retrospective cohorts (Rotterdam + Liège Acromegaly Survey (LAS), total n = 188) were meta-analyzed as a form of external replication to study the predictors of PEGV dosing in addition to LA-SSA, the LAS (n = 83) was used to study the predictors of PEGV monotherapy dosing. Multivariable regression models were used to identify predictors of the PEGV dose required to normalize IGF-I levels.

RESULTS

For PEGV dosing in combination with LA-SSA, IGF-I levels, weight, height and age, were associated with the PEGV normalization dosage (P ≤ 0.001, P ≤ 0.001, P = 0.028 and P = 0.047 respectively). Taken together, these characteristics predicted the PEGV normalization dose correctly in 63.3% of all patients within a range of ±60 mg/week (21.3% within a range of ±20 mg/week). For monotherapy, only weight was associated with the PEGV normalization dose (P ≤ 0.001) and predicted this dosage correctly in 77.1% of all patients within a range of ±60 mg/week (31.3% within a range of ±20 mg/week).

CONCLUSION

In this study, we show that IGF-I levels, weight, height and age can contribute to define the optimal PEGV dose to normalize IGF-I levels in addition to LA-SSA. For PEGV monotherapy, only the patient's weight was associated with the IGF-I normalization PEGV dosage.

Novel Mutation (T273R) in Thyroid Hormone Receptor β Gene Provides Further Insight into Cryptic Negative Regulation by Thyroid Hormone

Production of thyroid hormone is precisely regulated in a negative feed-back mechanism that depends critically on thyroid hormone receptor β (TRβ). This mechanism decreases production of thyrotropin- releasing hormone (TRH) and thyrotropin (TSH) in the hypothalamus and pituitary gland in response to high levels of circulating thyroid hormones (TH). Despite the wealth of accumulated knowledge, it is still not clear how exactly this negative regulation is executed. The syndrome of resistance to thyroid hormone (RTH), in which the levels of TH are not properly sensed, represents naturally occurring situations in which molecular components of this regulation are displayed and may be uncovered. TRβ, which is central to this regulation, is in the majority of RTH cases mutated in a way that preserves some functions of the receptor. Approximately 150 different mutations in TRβ have been identified to date. Here, we hypothesized that additional pathogenic mutations in TRβ are likely to exist in human population and analysed clinical cases with suspected RTH. In keeping with our prediction, analysis of 17 patients from nine families led to identification of four presumed pathogenic mutations of TRβ, including a previously unknown mutation, T273R. This suggests that threonine 273 is likely to be critical for the normal function of TRβ, possibly due to its role in helix 12 mobility and interaction with coactivators, and thus supports the concept that TRβ-dependent trans-activating function is necessary for the inhibition of TRH and TSH expression in response to elevated levels of TH.

Prediction of adrenocortical insufficiency after pituitary adenoma surgery using postoperative basal cortisol levels

Our aim was to analyze the correlation of early postoperative cortisol levels in patients after transsphenoidal pituitary adenoma surgery compared to the standard dose ACTH test and Insulin tolerance test (ITT) several months later. We retrospectively reviewed data from 94 patients operated for pituitary adenoma in years 2009-2012. The comparison of day 7 (median) postoperative basal cortisol levels and 3.6 months (median) after pituitary adenoma surgery stimulation test - standard dose 250 microg 1-24ACTH test in 83 patients or ITT in 11 patients were performed. All 16 patients with early postoperative cortisol levels >500 nmol/l proved a sufficient response in the stimulation tests. At basal cortisol levels of 370-500 nmol/l the sufficient response was found in 96 % (27/28) of patients. In the postoperative basal cortisol levels 200-370 nmol/l we found a preserved corticotroph axis later on in 88 % (28/32) of cases. Patients with basal cortisol levels 100-200 nmol/l had a maintained corticotroph axis function in 8/11 cases - 73 %. All patients with an early postoperative basal cortisol level above 500 nmol/l proved in the stimulation tests a preserved corticotroph axis function. The interval 370-500 nmol/l showed a minimal risk of postoperative adrenal insufficiency.

Serum cortisol seems to be a more appropriate marker for adrenocortical reserve evaluation in ACTH test in comparison to salivary cortisol

Salivary cortisol reflects the free fraction of serum cortisol. Monitoring salivary cortisol may be a promising alternative method for assessing serum cortisol in some clinical situations. We aimed to compare the reliability of salivary vs. serum cortisol during ACTH test. 84 subjects (mean age 63.2; 24-89 years; n=66 males) suspected for adrenocortical insufficiency underwent an ACTH test. Patients were divided based on peak serum cortisol into hypocortical group with cortisol <500 nmol/l and to reference group cortisol >500 nmol/l. Median serum cortisol levels in reference group were 445, 766, and 902 nmol/l at 0, 30, and 60 minutes, respectively, and in hypocortical group were 256, 394, and 453 nmol/l. Median salivary cortisol levels were 19.02, 40.02, and 62.1 nmol/l in reference group, and 9.60, 14.08, and 13.28 nmol/l in hypocortical group. Obtained values showed good correlation between serum and salivary cortisol (p<0.0001). The percentage of explained variability R(2) (coefficient of determination for linear model) representing a measure of agreement between experimental values and predictions for repeated measures ANOVA, was significantly higher (p=0.021) for serum cortisol (R2=93.4 %) when compared to the salivary cortisol (R2=89.3 %). A stronger discriminating power of serum versus salivary cortisol suggests that it seems to be slightly, but statistically significantly more appropriate marker of adrenocortical reserve in ACTH test.

[Recommendation of the Czech Society of Endocrinology for the treatment of Cushing's syndrome in adults]

Cushing's syndrome is a rare disorder with variable aetiology which is connected with significantly increased morbidity and mortality. Therefore, early determination of correct aetiology and early treatment are essential for a decrease of morbidity and mortality of patients. Present article introduces review and current recommendation of Czech Society of Endocrinology for the treatment of Cushings syndrome.

Plasma concentrations of adipocyte fatty acid binding protein in patients with Cushing's syndrome

Serum adipocyte fatty acid-binding protein (FABP-4) concentrations are linked to human obesity and other features of metabolic syndrome. Patients with Cushing´s syndrome (CS) develop numerous features of metabolic syndrome due to chronic cortisol excess. Here we tested the hypothesis that chronically increased cortisol levels in CS patients may alter circulating levels of FABP-4. Fourteen patients with CS, 19 patients with simple obesity (OB) and 36 healthy control subjects (C) were included in the study. Serum FABP-4 concentrations were significantly higher in both CS and OB patients relative to C group, but they did not differ between CS and OB groups. In a combined population of all groups, serum FABP-4 levels correlated positively with BMI, body fat content, serum glucose, triglycerides, HbA1c and HOMA index and were inversely related to HDL-cholesterol, resting energy expenditure and freeT3 levels. We conclude that FABP-4 levels are significantly increased in both patients with simple obesity and obese patients with Cushing´s syndrome. We suggest that increased FABP-4 concentrations in CS patients are rather due to their excessive fat accumulation and related metabolic abnormalities than due to a direct effect of cortisol on FABP-4 production.

Plasma concentrations of fibroblast growth factors 21 and 19 in patients with Cushing's syndrome

The objective of this study was to measure plasma fibroblast growth factor 21 and 19 (FGF21 and FGF19) levels in patients with Cushing's syndrome (CS) and to compare it with those of lean control subjects (C) and patients with obesity (OB). Fourteen untreated patients with CS, 19 patients with OB and 36 controls were included in the study. Plasma FGF21 and FGF19 levels were measured by ELISA kits, other hormonal and biochemical parameters were measured by standard laboratory methods. Plasma FGF19 did not significantly differ among the studied groups. Plasma FGF21 levels were significantly higher in both CS and OB groups relative to C group but they did not differ between CS and OB groups. In a combined population of all three groups FGF21 levels positively correlated with BMI, waist circumference and percentage of total and truncal fat mass. Less prominent inverse relationship with these parameters was found for FGF19. Neither FGF21 nor FGF19 were significantly related to cortisol concentrations. Increased FGF21 concentrations in both patients with CS and OB relative to lean subjects suggest that excessive body fat and/or related metabolic abnormalities rather than direct effects of cortisol are responsible. In contrast neither obesity nor hypercortisolism significantly affected FGF19 concentrations.

[120 laparoscopic adrenalectomies with a harmonic scalpel]

BACKGROUND

Presently the laparoscopic adrenalectomy (LA) becomes most popular since 1992 when it was performed for the first time by laparoscopic method by Gagner. Typical indication for LA is the aldosteron-secreting adenoma, Cushing's syndrome, feochromocytoma or scarcity tumors such as adrenal cyst or myelolipomas.

AIM

The evaluation of the laparoscopic adrenalectomy as safe method for adrenals tumout's extirpation to the sizes 10 cm.

METHODS

LA is provided with transperitoneal lateral approach most frequently then in back side position. Retroperitoneal approach is used less commonly.

RESULTS

Since 2006, firstly at the 1st Surgical department of 1st Medical School of Charles University and General Faculty Hospital and lastly at the Surgical department 2nd Medical School of Charles University and Central Military Hospital, has been performed on the whole 120 LA in 114 patients. The bilateral LA was performed in 6 patients. The conversion from the laparoscopic to open adrenalectomy was necessary by reason of the king size of the tumor (13/14 cm) in two cases. The lateral position and transperitoneal approach was used in all cases. The harmonie scalpel was used with advantage. Average length of the operation was 82 minutes (40-154 min), respective 180 minutes (130-270 min) in the case of the bilateral LA. The median size of the adrenal tumor was 4.9 cm (1.5-12.5 cm) with average weight 44 g (18-421 g). All of the patients after LA were monitored for 24 hours in the Intensive care units. The average time of the hospitalization was 3.7 days (2-6 days).

CONCLUSION

Laparoscopic adrenalectomy presently becomes as the "gold standard" for the treatment of adrenal tumors to the size 10 cm namely and in the event of malignancy. The harmonie scalpel is useful and sparing advice for the LA.

[Randomly discovered enlargement in the region of sella turcica]

Computer tomography (CT) and magnetic resonance imaging (MRI) quite often detect unexpected cases of enlargement in the hypothalamus-hypophysial region, without the above methods being indicated for clinical manifested symptomatology provoked by the tumour. This is not surprising if we consider that autopsies show the presence of hypophysial adenomas of 10-15% of population on an average. X ray, CT or MRI are indicated in the case of head traumas, lateral nasal cavity inflammations, headaches, strokes, neurological diseases and other disorders. A number of tumours of diverse etiology occur in the hypothalamus-hypophysial region, but hypophysial adenomas are by far the most frequent among all (above 90 %). Among other primary enlargements, the most frequent are craniopharyngeomas and meningeomas, while other enlargements are by fare less common. Such randomly detected tumours are mostly asymptomatic, but targeted anamnesis may show some of the symptoms quite clearly. The symptomatology can be linked with possible slight hormonal overproduction of hypophysial adenomas, a deficit of hypophysial hormones or local manifestations of expansion. Exact assessment of MRI results, of hormonal activity of the enlargement, of the relation to surrounding structures, especially the optic nerves, and the assessment of hypophysial functions are important for the therapeutic decision. Depending on the type and extension of the tumour the options considered are pharmacotherapy (the treatment of choice in the case of prolactinomas), surgery, radiotherapy (today prevailingly using the gamma knife), and if no intervention is necessary, follow up with regular MRI examinations. Tumorous growth is more often observed in "macroadenomas" than in "microadenomas" (up to 10 mm).

[How corticoids, growth hormone and oestrogens influence lipids and atherosclerosis]

The hormones with a strong influence on the lipid spectrum and the development of atherosclerosis include cortisol, growth hormone and oestrogens. Cortisol accelerates atherosclerosis both through dyslipidemia and through an increase in visceral fat, hypertension, increased insulin resistance and the development of reduced glucose tolerance which may result in diabetes mellitus. Even when a cortisol excess disappears, as is the case of patients cured of Cushing syndrome, arterial walls remain permanently vulnerable to the atherosclerotic process. In conditions involving a lack of growth hormone, dyslipidemia develops and increases the burden on the cardiovascular system if not treated in a timely manner by the substitution of growth hormone. Oestrogens have a double effect: they have an anti-atherogenic effect on artery walls that are not yet damaged by an atherosclerotic process, but where atherosclerosis has already developed they have a prothrombotic effect and destabilise the atheromatous plaques. If oestrogen is to be used as protection against the onset of atherogenesis, it is necessary to start in a period when the atherosclerotic process has not yet begun to damage the woman's arterial walls and it is best to use natural hormones (estradiol) and to prevent endometriosis it should be combined with crystalline progesterone applied locally--inravaginally. Oestrogens should be given in small doses, preferably parenterally. Even this will not prevent genetic oestrogen effects though.

Impaired microvascular reactivity and endothelial function in patients with Cushing's syndrome: influence of arterial hypertension

The aim of the study was to evaluate skin microvascular reactivity (MVR) and possible influencing factors (fibrinolysis, oxidative stress, and endothelial function) in patients with Cushing's syndrome. Twenty-nine patients with active Cushing's syndrome (ten of them also examined after a successful operation) and 16 control subjects were studied. Skin MVR was measured by laser Doppler flowmetry during post-occlusive (PORH) and thermal hyperemia (TH). Malondialdehyde and Cu,Zn-superoxide dismutase were used as markers of oxidative stress. Fibrinolysis was estimated by tissue plasminogen activator (tPA) and its inhibitor (PAI-1). N-acetyl-beta-glucosaminidase, E-selectin, P-selectin, and ICAM-1 were used as markers of endothelial function. Oxidative stress and endothelial dysfunction was present in patients with hypercortisolism, however, increased concentration of ICAM-1 was also found in patients after the operation as compared to controls (290.8+/-74.2 vs. 210.9+/-56.3 ng.ml(-1), p<0.05). Maximal perfusion was significantly lower in patients with arterial hypertension during PORH and TH (36.3+/-13.0 vs. 63.3+/-32.4 PU, p<0.01, and 90.4+/-36.6 vs. 159.2+/-95.3 PU, p<0.05, respectively) and similarly the velocity of perfusion increase during PORH and TH was lower (3.2+/-1.5 vs. 5.2+/-3.4 PU.s(-1), p<0.05, and 0.95+/-0.6 vs. 1.8+/-1.1 PU.s(-1), p<0.05, respectively). The most pronounced impairment of microvascular reactivity was present in patients with combination of arterial hypertension and diabetes mellitus.

Increased lipolysis of subcutaneous abdominal adipose tissue and altered noradrenergic activity in patients with Cushing's syndrome: an in-vivo microdialysis study

Cushing's syndrome is associated with typical central redistribution of adipose tissue. The aim of the study was to assess lipolysis and catecholamines and their metabolites in subcutaneous abdominal adipose tissue using an in-vivo microdialysis technique. Nine patients with Cushing's syndrome and nine age-, gender- and body mass index (BMI)-matched control subjects were included in the study. Local glycerol concentrations were significantly increased in subcutaneous adipose tissue of patients with Cushing's syndrome (p<0.001). Plasma noradrenaline, dihydroxyphenylglycol and dihydroxyphenylalanine were decreased in patients with Cushing's syndrome (p<0.02, p<0.05, and p<0.02, respectively). Adrenaline, noradrenaline, dihydroxyphenylglycol and dihydroxyphenylalanine concentrations in subcutaneous abdominal adipose were non-significantly higher in patients with Cushing's syndrome. In conclusion, we showed that lipolysis in subcutaneous adipose tissue of patients with Cushing's syndrome is significantly increased as compared to healthy subjects. This finding together with non-significantly increased local catecholamine concentrations in these patients suggests a possible link between increased lipolysis and catecholaminergic activity in subcutaneous adipose tissue.

Plasma levels of total and active ghrelin in acromegaly and growth hormone deficiency

Ghrelin is an endogenous growth hormone (GH) secretagogue recently isolated from the stomach. Although it possesses a strong GH releasing activity in vitro and in vivo, its physiological significance in endogenous GH secretion remains unclear. The aim of this study was to characterize plasma ghrelin levels in acromegaly and growth hormone deficiency (GHD). We investigated plasma total and active ghrelin in 21 patients with acromegaly, 9 patients with GHD and 24 age-, sex- and BMI-matched controls. In all subjects, we further assessed the concentrations of leptin, soluble leptin receptor, insulin, IGF-I, free IGF-I and IGFBP-1, 2, 3 and 6. Patients with acromegaly and GHD as well as control subjects showed similar levels of total ghrelin (controls 2.004+/-0.18 ng/ml, acromegalics 1.755+/-0.16 ng/ml, p=0.31, GHD patients 1.704+/-0.17 ng/ml, p=0.35) and active ghrelin (controls 0.057+/-0.01 ng/ml, acromegalics 0.047+/-0.01 ng/ml, p=0.29, GHD patients 0.062+/-0.01 ng/ml, p=0.73). In acromegalic patients plasma total ghrelin values correlated negatively with IGF-I (p<0.05), in GHD patients active ghrelin correlated with IGF-I positively (p<0.05). In the control group, total ghrelin correlated positively with IGFBP-2 (p<0.05) and negatively with active ghrelin (p=0.05), BMI (p<0.05), WHR (p<0.05), insulin (p=0.01) and IGF-I (p=0.05). Plasma active ghrelin correlated positively with IGFBP-3 (p=0.005) but negatively with total ghrelin and free IGF-I (p=0.01). In conclusion, all groups of the tested subjects showed similar plasma levels of total and active ghrelin. In acromegaly and growth hormone deficiency plasma ghrelin does not seem to be significantly affected by changes in GH secretion.

Reduced microvascular perfusion and reactivity in adult GH deficient patients is restored by GH replacement

BACKGROUND

An increased cardiovascular risk and mortality in hypopituitary patients receiving conventional hormonal treatment without GH replacement have been shown in several studies. Various atherogenic risk factors including endothelial dysfunction - an early event in the atherogenesis - are more expressed in adults with GH-deficiency (GHD). Changes in microcirculation and vascular reactivity could represent an early marker of developing vascular changes.

OBJECTIVE

To evaluate the microcirculation and vascular reactivity in a GHD state before and during GH replacement. SUBJECTS, METHODS AND DESIGN: Thirteen adult patients (ten men, mean age 40+/-9 years) with severe GHD were studied. The skin microvascular perfusion and reactivity were measured by laser-Doppler flowmetry on the forearm. Two dynamic tests for vascular perfusion and reactivity were used - postocclusive reactive hyperemia (PORH) and thermal hyperemia (TH) at 44 degrees C. Measurements were performed before and after 6 and 12 months on GH replacement with a dose of GH that normalized IGF-I serum levels. The parameters of tissue perfusion and vascular reactivity measured in GHD were compared with values during GH treatment and with the results of the control group.

RESULTS

Peak flow during TH in GHD patients was significantly reduced before GH treatment when compared with healthy subjects (means+/-s.e.m., 68+/-6.6 vs 111+/-8.3 perfusion units (PU), P<0.001) and normalized on GH treatment (109+/-12.7 PU). The velocity of perfusion increase during TH before treatment was significantly reduced in GHD as well (0.84+/-0.07 vs 1.53+/-0.19 PU/s, P<0.03) and normalized on GH treatment (1.38+/-0.24 PU/s). The PORH was also significantly reduced in GHD compared with controls (PORH(max) 414+/-63 vs 528+/-58%, P<0.05) and during GH treatment was restored to values not different from controls (642+/-86%, P=NS).

CONCLUSIONS

Skin microcirculation and vascular reactivity measured by laser-Doppler flowmetry is significantly reduced in GHD adults and is restored during GH replacement therapy. Reduced tissue perfusion and reactivity probably reflect the endothelial dysfunction in the GHD state. Reduced nitric oxide production and bioavailability and also other factors like increased sympathetic activity and reduced conversion of thyroxine to triiodothyronine in the GHD state can contribute to changes in microcirculation. Restoration of vascular reactivity by GH replacement might have favorable clinical consequences on the increased vascular morbidity of GHD patients. Reduced skin microvascular perfusion and reactivity in GHD probably contribute to the impaired thermoregulation - a clinical symptom of GHD.

Recurrent ACTH-independent Cushing's syndrome in multiple pregnancies and its treatment with metyrapone

A 17-year-old primigravid woman presented with Cushing's syndrome. Typical clinical symptoms and signs developed at the beginning of pregnancy. By week 17 of gestation, plasma cortisol diurnal rhythm was absent and there was a paradoxical increase in plasma cortisol after a 1-mg dexamethasone overnight suppression test. Basal urinary free cortisol was 10 times above the upper limit (in pregnancy) and ACTH levels were suppressed. The diagnosis of ACTH--independent Cushing's syndrome was established. MRI scans revealed normal adrenal and pituitary glands. To control hypercortisolism, the patient was treated with metyrapone. At 34 weeks of gestation, the patient developed preeclampsia and underwent caesarean section. A female infant weighing 1070 g was delivered. No apparent metyrapone-induced teratogenic effects were observed. Cushing's syndrome in the patient resolved within three weeks of delivery. No corticosteroid replacement therapy either for child or mother was needed. Eight months after delivery the patient became pregnant again and rapidly developed Cushing's syndrome with typical clinical symptoms and signs and laboratory results (urinary free cortisol 6464 nmol/24 h). This second pregnancy was unwanted and terminated by artificial abortion that was followed by rapid resolution of hypercortisolism. A third pregnancy, 12 months after delivery was also accompanied by the rapid development of hypercortisolism which recovered after artificial termination. The mechanisms by which pregnancy-induced Cushing's syndrome occurred in this patient are unclear. Aberrant responsiveness or hyperresponsiveness of adrenocortical cells to a non-ACTH and non-CRH substance produced in excess in pregnancy should be considered. Metyrapone suppression of hypercortisolism currently represents the best treatment for these rare cases.

[Radiosurgical treatment of hypophyseal adenomas with the gamma knife: results in a group of 163 patients during a 5-year period]

BACKGROUND

Gamma knife radiosurgery of pituitary adenomas is considered to be very perspective. It can be a very useful complement of traditional microsurgery, pharmacotherapy or fractionated radiotherapy which are seldom a sufficient treatment on their own. The modern radiosurgery does not offer the experience representative enough in this indication. We can offer results of medium long follow-up for tumor growth and hormonal hypersecretion of pituitary adenomas in a relatively large series of patients.

METHODS AND RESULTS

We have analyzed a group of 163 patients with pituitary adenoma treated with gamma knife during 5 years and followed 12-60 months, median 24 months after irradiation. An antiproliferative effect has been achieved in 1-2 years using the minimal dose to the margin 16-35 Gy, median 20 Gy in all our patients who were controlled by MRI (n = 126 patients). One half of these adenomas evidently decreased their size. Our effective antiproliferative dose was safe for the surrounding structures. The hormonal normalization has been achieved at 50.4% from 133 hypersecreting adenomas (39/91 = 43% of acromegalics, 11/13 = 85% of patients with Cushing's disease, 2/9 = 22% of patients with Nelson's syndrome, 11/18 = 61% of prolactinomas). The median latency was 12 months. The minimal dose to the margin was 10-45 Gy, median 35 Gy. Rare side effects were provoked only by increasing the dose to influence the hypersecretion-the development of partial hypopituitarism in 3.1% of patients, the panhypopituitarism in 0.6% of patient and there was 1 hemianopic visual field defect (0.6%).

CONCLUSIONS

Radiosurgery by gamma knife has a similar value for pituitary adenomas as microsurgery has with different distribution of advantages and drawbacks. This makes it suitable for the combined treatment where pharmacotherapy has its place under special conditions. Fractionated radiotherapy has now a marginal importance.

[Combined therapy of acromegaly with a combination of lanreotide and terguride]

BACKGROUND

The aim of the treatment of acromegaly is to normalise the hormonal activity. Besides the surgical and radiation treatment, medical therapy can be used. The project was set to determine the value of combined therapy with lanreotide and terguride in patients with active acromegaly.

METHODS AND RESULTS

Nine patients previously treated with lanreotide for at least one year without normalisation of hormonal activity were included in the study. Terguride was added to lanreotide for one month. The combined treatment brought about reduction of growth hormone (GH) levels, however, with marginal significance only. GH-BP, IGF-I and IGFBP-3 serum levels were not changed significantly. Considering the individual cases, the combined treatment resulted in normalisation of GH levels in one patient and that of IGF-I in another one. Substantial decrease of GH levels (> 50%) was found in three patients and that of IGF-I (> 20%) in another one patient.

CONCLUSIONS

The combined treatment of acromegaly appears to be more effective than monotherapy with lanreotide only in a subset of acromegalic patients.

[Sleep apnea syndrome in acromegaly. Treatment and development-- retrospective analysis]

In total 56 subjects with acromegaly (37 men and 19 females) were examined in attempt to find sleep apnoea syndrome (SAS). The examination consisted of clinical examination and of all-night monitoring MESAM4 or polyMESAM. The diagnosis of SAS was established in 76.4% of subjects: 31 men and 11 females, average age 51.8 (SD +/- 9.6) years. The average ODI (oxygen desaturation index--number of oxygen saturation drops per 1 hour of sleep) of SAS patients was 29.2 (+/- 20.7). The therapy of SAS was recommended to 27 patients: sleeping position on the side (3 patients), reduction of the weight (8 patients), change of hypnotic drug (1 patient) and CPAP--continuous positive airway pressure (24 patients). CPAP titration was performed in 18 patients (in one subject the titration was repeated 4 years later). CPAP was titrated within all-night polysomnography in 10 subjects and in 9 subjects using self adjusting CPAP. Primary acceptance of CPAP was 94.4%. The average CPAP pressure was 7.8 (+/- 2.1) mbar. The theoretical duration of CPAP use was 546.6 (+/- 533.7) days. Long term compliance was considered as sufficient (weekly 25 hours or more) in 66.7% of patients. Ten patients underwent important acromegaly therapy or its change during the follow up and the improvement or the disappearance of SAS symptoms occurred in 6 of them.

MRI--diagnostic and follow-up tool for microprolactinomas

Magnetic resonance imaging is a method of choice for the diagnosis of microprolactinomas. Using a Phillips Gyroscan NT 15 (1.5 T), 42 patients whose clinical history and serum prolactin levels were compatible with the diagnosis of prolactinomas were examined. Four patients (3 male and 1 female) with macroadenoma were investigated and excluded, while microprolactinoma was found in the other 38 (32 female and 6 male) patients. Imaging features were similar in all microprolactinomas--hypointensity up to 10 mm in size in T1 weighted images, only sometimes, in the case of a cystic or a hemorrhagic component, also registered in T2 weighted images. Deviation of the pituitary stalk was present in 19 of the 38 patients (16 with microprolactinoma, 3 without any detectable lesion). Convex upper limit of the gland was demonstrated in 17 subjects (16 microprolactinomas, 1 without detectable lesion). Pituitary adenoma is not the only cause of raised serum prolactin level. This can be a consequence of medication, spinal cord tumor, compression of the pituitary stalk, hypothyroidism or a lesion in dermatomes T3 to T5 (mammary gland level). Results from imaging must always be assessed in the light of the patient's clinical history and biochemical parameters.

[Molecular cytogenetic diagnosis of Klinefelter's syndrome in men more frequently detects sex chromosome mosaicism than classical cytogenetic methods]

BACKGROUND

It was found by classical cytogenetic methods that approximately 80% of X-chromatin positive mates have karyotype 47,XXY and the rest have mosaicism of sex chromosomes. More sensitive molecular-cytogenetic studies allow to evaluate even non-dividing cells of different tissues and therefore they suggest that there could be more frequent occurrence of patients with numerical changes of gonosomes than quoted in the literature. The aim of this study was to detect numerical changes of sex chromosomes by means of double-colour fluorescence in situ hybridisation (FISH) in dividing and non-dividing nuclei of peripheral lymphocytes of males with Klinefelter's syndrome, to compare clinical findings with cytogenetic results, to determine differences in sensitivity of classical and molecular-cytogenetic methods and estimatere the values obtained with controls (healthy males).

METHODS AND RESULTS

26 males with previously diagnosed Klinefelter's sy were examined. Classical cytogenetic studies consisted of evaluation of at least 20 G-banded mitoses of 72 h cultivated peripheral blood. The results we obtained: 19 patients with 47,XXY, 5 mosaics 47,XXY/46,XY, 1 patient mosaic 46,XX/47,XXY and 1 patient 48,XXYY karyotype. The results of double colour FISH and classical cytogenetics were compared and mosaics of cells with normal karyotype 46,XY was found. As a control 10 healthy males were examined and mosaics of gonosomes were not detected.

CONCLUSIONS

FISH method has a higher sensitivity for detection of sex chromosomes mosaics than classical cytogenetics. The existence of small cellular side clones with 46,XY karyotype or numerical sex chromosomes changes which were not determined previously can be proved by FISH in patients with Klinefelter's sy.

Independence of estrogen-induced pituitary proliferation on local IGF-I mRNA and EGF mRNA expression. Modifying effects of tamoxifen and terguride

Pituitary hyperplasia as well as proliferation of the endometrium are typical responses to estrogen administration in rodents. Both insulin-like growth factor-I (IGF-I) and epidermal growth factor (EGF) have been implicated as paracrine mediators and amplifiers of estrogen action in the rodent uterus. The auto/paracrine role of IGF-I, EGF, their receptors and IGF binding proteins in pituitary proliferation has not yet been solved. Here we have used a semi-quantitative reverse transcription polymerase chain reaction (RT PCR) assay to demonstrate the changes in IGF-I mRNA and EGF mRNA abundance in the proliferating male rat pituitary in response to estradiol benzoate (EB; 1 mg/kg b.w. twice weekly i.m. for 3 weeks) and modifying effect of drugs antagonizing the pituitary enlargement - antiestrogen tamoxifen (TAM, 5 mg/kg b.w. daily) and also the dopaminergic agonist terguride (TER, 0.66 mg/kg b.w. daily, routinely used for the treatment of prolactinomas). In three separate experiments, EB induced a 2.2-2.5 fold increase in pituitary weight. The abundance of IGF-I and EGF mRNAs in pituitaries of EB-treated animals did not differ from the controls in two experiments and in the third series with the most marked pituitary hyperplasia mRNAs of both growth factors were even significantly decreased. Antiestrogen TAM administered with EB partially blocked the EB-induced proliferation and significantly stimulated IGF-I mRNA (p=0.003) and EGF mRNA (p=0.023) expression, while EB or TAM alone did not stimulate mRNAs of the studied growth factors. Significant antiproliferative effect of dopaminergic agonist TER on EB-induced pituitary proliferation (p=0.006) was accompanied with decreased IGF-I mRNA (p=0.025), but not EGF mRNA abundance. Our results suggest that the estrogen-induced pituitary proliferation is independent of the local expression of IGF-I and EGF mRNAs.

[Spontaneous remission of corticosteroid osteopenia after successful surgical treatment of Cushing's syndrome. A cross-sectional study]

BACKGROUND

Osteoporosis is one of the most serious consequences of Cushing's syndrome. Only a small number of longitudinal observations on bone mineral density (BMD) in patients with treated Cushing's syndrome have been reported so far. To evaluate changes in bone mass in patients with Cushing's syndrome after surgical cure of the disease, BMD was evaluated cross-sectionally.

METHODS AND RESULTS

BMD (DPX-L, Lunar) was measured in the lumbar spine and femoral neck (i.e. in skeletal areas with high proportion of trabecular and cortical bone, respectively) in 72 patients after successful surgical cure of Cushing's syndrome (8 men, 34 women before menopause and 30 women after menopause who were not on hormone replacement therapy). No other drug's interfering with skeletal metabolism were used. The reference group consisted of young healthy Czech women and/or men. The mean lumbar spine and femoral neck BMD increased to normal values within 3 and 5 years after surgery, respectively. In women after menopause, however, the significant positive relationship between BMD and time after surgery was negatively influenced by time after menopause. It is likely that several other factors contributed to the increase in bone mass in the patients (cure of hypercortisolism, recovery from hypogonadism and restoration of muscle strength).

CONCLUSIONS

After surgical cure of Cushing's syndrome in premenopausal women and in men, BMD rapidly and substantially increases. The recovery is negatively affected by estrogen deficiency in postmenopause.

[Determination of ACTH in the inferior petrosal sinuses in the examination of patients with hypercortisolism]

BACKGROUND

Differential diagnosis of the etiology of ACTH-dependent hypercortisolism is very difficult in some cases. The uncertainty, whether there is a central or ectopic etiology, is also strengthened by the fact that even nuclear magnetic resonance (MR) sometimes does not prove the pituitary adenoma. A more precise differential diagnosis under these conditions has been made, over the last years, by selective determination of ACTH levels bilaterally in sinus petrosi inferiores (SPI) and by their comparison with the level in peripheral blood. The confirmation of central etiology makes a decision about neurosurgical intervention easier. This intervention, due to the present microsurgery technique, makes it possible to detect otherwise undetectable microadenoma and enables its selective excision with maintaining healthy hypophysis tissue and all its functions.

METHODS AND RESULTS

In the last two years the authors indicated 11 patients (10 women, one man at the age of 17-54 years, mean age 33.5 year) with proved ACTH-dependent hypercortisolism to the determination of ACTH in SPI. Their CT or NMR examination did not prove a hypophysis tumour unequivocally. Only in one female patient the catheterization was not possible for anomalous vascular bed with aplasia of internal jugular vein on the left and hypoplasia of internal jugular vein on the right. In 8 patients the determination of the ratio of ACTH levels between SPI and periphery (7.78 +/- 1.54, mean +/- S.E.) has shown that even the basal levels indicated central etiology of hypercortisolism. This has been confirmed by the ratio of the values of ACTH after stimulation with corticotrophin releasing hormone (CRH). The diagnosis was confirmed in all patients by surgery, by histology and post-operation course. In two female patients the ratio of basal levels of ACTH, SPI/periphery did not prove useful for the diagnosis of the Cushing's disease. In the first patient the CRH stimulation was not yet performed routinely and the ratio of basal levels of ACTH, SPI/periphery gave a false negative result, as shown by the finding of adenoma of hypophysis during the operation. The operation was indicated on the basis of hormonal examinations and repeated MR with a finding of suspected microadenoma and the diagnosis was then confirmed by further clinical development. The determination of the levels of ACTH after CRH stimulation would give more precision in this case, as shown by analysis of the results of large cohorts in literature, which we perform at present as well. In the other patient the CRH stimulation test was done, changing the ratio from 1.1 to 5.7 and thus confirmed central etiology of the Cushing's syndrome. In agreement with literature this method did not contribute to lateral localization of the tumour.

CONCLUSIONS

The determination of basal levels of ACTH in SPI and levels after CRH stimulation enables to differentiate between central and ectopic overproduction of ACTH in the ACTH-dependent Cushing's syndrome.

Long-term treatment of acromegaly with the slow-release somatostatin analogue lanreotide

Thirteen patients with active acromegaly despite previous surgery were treated with 30 mg lanreotide im twice a month for 9 months. In 10 subjects the treatment continued to 19 months. GH serum levels of all patients decreased significantly from an initial value of 32.0 (29.4) micrograms/l [median (standard error of median)] to 10.0 (3.6) and 19.1 (5.7) after 3 and 9 months of treatment, respectively. In the 10 patients with the treatment longer than one year the decrease in GH was from 46.8 (29.4) micrograms/l to 12.5 (5.0) and 16.1 (5.3) after 13 and 19 months, respectively. IGF-I serum levels decreased significantly from 1193 (73) micrograms/l to 782 (99) and 621 (103) after 3 and 9 months, respectively, and were normalized in 3 patients. In the 10 patients treated for longer than one year, levels decreased significantly from 1318 (74) micrograms/l to 653 (170) and 742 (180) after 13 and 19 months, respectively. IGF BP-3 levels were reduced to the normal range in 6 patients and decreased from 8.7 (1.5) mg/l to 6.4 (0.8) and to 5.4 (1.0) after 3 and 9 months, respectively. In the patients with the 19 months treatment the decrease was from 9.3 (1.6 mg/l to 3.9 (0.9) and 4.8 (0.9) after 13 and 19 months, respectively. The IGF BP-3 to IFG I ratio increased in 7 patients. This elevation significantly correlated with the decrease in bioassayable somatomedin. Prolactin serum levels fell in all patients with increased prolactin secretion.(ABSTRACT TRUNCATED AT 250 WORDS)

[Comparison of the excretion of 3 androgens registered in Czechoslovakia]

Hypogonadal men of different aetiology were administered testesterone undecanoate (Andriol, Organon) and methyltestosterone (Agovirin coated tablets, Spofa) for three months alternatively. By means of specific radioimmunoassays excretion of testosterone and methyltestosterone respectively in the urine was observed in 20 and 5 patients respectively. The course of excretion of both the preparations is possible to illustrate by decreasing curves with apparent half-lives 1.74 and 3.90 day respectively. Analogous observation of testosterone excretion after three-month administration of testosterone isobutyrate (Agovirin depot) to five female-to-male transsexual patients was observed. Excretion course shows the maximum on 27th day after the treatment was discontinued and it is not possible to illustrate it by a monotonous curve.