Case Report: Three Rare Cases of Ectopic ACTH Syndrome Caused by Adrenal Medullary Hyperplasia

Ectopic ACTH syndrome (EAS) accounts for 10-20% of endogenous Cushing's syndrome (CS). Hardly any cases of adrenal medullary hyperplasia have been reported to ectopically secrete adrenocorticotropic hormone (ACTH). Here we describe a series of three patients with hypercortisolism secondary to ectopic production of ACTH from adrenal medulla. Cushingoid features were absent in case 1 but evident in the other two cases. Marked hypokalemia was found in all three patients, but hyperglycemia and osteoporosis were present only in case 2. All three patients showed significantly elevated serum cortisol and 24-h urinary cortisol levels. The ACTH levels ranged from 19.8 to 103.0pmol/L, favoring ACTH-dependent Cushing's syndrome. Results of bilateral inferior petrosal sinus sampling (BIPSS) for case 1 and case 3 confirmed ectopic origin of ACTH. The extremely high level of ACTH and failure to suppress cortisol with high dose dexamethasone suppression test (HDDST) suggested EAS for patient 2. However, image studies failed to identify the source of ACTH secretion. Bilateral adrenalectomy was performed for rapid control of hypercortisolism. After surgery, cushingoid features gradually disappeared for case 2 and case 3. Blood pressure, blood glucose and potassium levels returned to normal ranges without medication for case 2. The level of serum potassium also normalized without any supplementation for case 1 and case 3. The ACTH levels of all three patients significantly decreased 3-6 months after surgery. Histopathology revealed bilateral adrenal medullary hyperplasia and immunostaining showed positive ACTH staining located in adrenal medulla cells. In summary, our case series reveals the adrenal medulla to be a site of ectopic ACTH secretion. Adrenal medulla-originated EAS makes the differential diagnosis of ACTH-dependent Cushing's syndrome much more difficult. Control of the hypercortisolism is mandatory for such patients.

Chinese massage, Tui Na, combined with herbs improves clinical symptoms and regulates sex hormones in patients with mammary gland hyperplasia

To study the effects of Tui Na therapy on patients with mammary gland hyperplasia.A total of 68 female patients with mammary gland hyperplasia were included in this retrospective study from May 2016 to May 2017 and assigned into control group (N = 34) treated with Rupixiao only (a proprietary Chinese medicine) or Tui Na group (N = 34) treated with Tui Na (Chinese massage) combined with Rupixiao. The pain intensity (visual analogous scale, VAS) and serum levels of luteinizing hormone (LH), estradiol (E2), prolactin (PRL), and progesterone (P) were examined before and after the treatment.The efficacies were 94.1% (32/34) in the Tui Na group and 76.5% (26/34) in the control group (P = .04). After treatment, VAS in Tui Na groups was significantly lower than that in control group (2.1 ± 1.1 vs 3.1 ± 1.1, P < .05). After follow-up for five months, the recurrence rates were 12.5% (4/32) in the Tui Na group and 23.1% (6/26) in the control group (P = .01). The levels of all 4 hormones in the Tui Na group increased significantly after treatment. In control group, only LH and E2 levels were significantly increased after treatment.In patients with mammary gland hyperplasia, Tui Na combined with Rupixiao could improve clinical symptoms, regulate sex hormone levels, and decrease the recurrence rate than Rupixiao alone. Our finding suggests that Tui Na can be potentially used for the treatment of mammary gland hyperplasia.

Increased SLC38A4 Amino Acid Transporter Expression in Human Pancreatic α-Cells After Glucagon Receptor Inhibition

Plasma amino acids and their transporters constitute an important part of the feedback loop between the liver and pancreatic α-cell function, and glucagon regulates hepatic amino acid turnover. Disruption of hepatic glucagon receptor action activates the loop and results in high plasma amino acids and hypersecretion of glucagon associated with α-cell hyperplasia. In the present study, we report a technique to rescue implanted human pancreatic islets from the mouse kidney capsule. Using this model, we have demonstrated that expression of the amino acid transporter SLC38A4 increases in α-cells after administration of a glucagon receptor blocking antibody. The increase in SLC38A4 expression and associated α-cell proliferation was dependent on mechanistic target of rapamycin pathway. We confirmed increased α-cell proliferation and expression of SLC38A4 in pancreas sections from patients with glucagon cell hyperplasia and neoplasia (GCHN) with loss-of-function mutations in the glucagon receptor. Collectively, using a technique to rescue implanted human islets from the kidney capsule in mice and pancreas sections from patients with GCHN, we found that expression of SLC38A4 was increased under conditions of disrupted glucagon receptor signaling. These data provide support for the existence of a liver-human α-cell endocrine feedback loop.

Multiple cytokine profiling in serum for early detection of gastric cancer

AIM

To investigate the value of multiparameter joint analysis in the early diagnosis of gastric cancer (GC) in clinical practice.

METHODS

Concentrations of CEA, CA724 and three kinds of cytokines (TNF-α, IL-6 and IL-8) in 176 GC patients, 117 atypical hyperplasia patients, and 204 healthy control individuals were used for building the diagnostic model, then 58 GC patients, 41 atypical hyperplasia patients, and 66 healthy control individuals were enrolled independently. The joints of the indicators were analyzed by binary logistic regression analysis method.

RESULTS

For discriminating the healthy control group and the GC group, IL-6 had the best diagnostic value, and the area under curve (AUC) of joint analysis was 0.95 (0.93-0.97). For the early stage and advanced stage GC, the AUC were 0.95 (0.92-0.98) and 0.95 (0.92-0.97). For discriminating the atypical hyperplasia group and GC group, CA724 had the best diagnostic value, and the AUC of joint analysis was 0.97 (0.95-0.99). For the early stage and advanced stage GC groups, the AUC were 0.98 (0.96-0.99) and 0.96 (0.94-0.98). After evaluation, for discriminating the GC, early stage GC and advanced cancer group from the healthy control group, the diagnostic sensitivity was 89.66%, 84.21% and 92.31%, respectively, and the specificity was 92.42%, 90.91% and 90.91%. For discriminating the GC, early stage GC and advanced cancer groups from the atypical hyperplasia group, the diagnostic sensitivity was 87.93%, 78.95% and 92.31%, respectively, and the specificity was 87.80%, 85.37% and 90.24%.

CONCLUSION

We have built a diagnostic model including CEA, CA724, IL-6, IL-8, and TNF-α. It may provide potential assistance as a screening method for the early detection of GC.

Are plasma Insulin-Like Growth Factor I (IGF-I) and Igf-Binding Protein 3 (Igfbp-3) Useful Markers of Prostate Cancer?

Increased concentrations of insulin-like growth factor I (IGF-I) and decreased insulin-like growth factor binding protein 3 (IGFBP-3) in serum have been proposed as markers of prostate cancer (CaP). The evidence for this, however, is contradictory. We assayed serum for IGF-I, IGFBP-3 and prostate-specific antigen (PSA) in patients with CaP and benign prostatic hyperplasia (BPH) and in healthy controls (HC). The mean ± SD concentration of IGF-I in CaP (98.3 ± 39.3 ng/mL; n=15) was lower than in BPH (119 ± 31.1 ng/mL; n=24) and HC (119 ± 36.1 ng/mL; n=46), but the differences between the three groups were not statistically significant (p>0.05). The mean IGFBP-3 concentrations in CaP (2691 ± 1105 ng/mL; n=16; p=0.029) and BPH (2618 ± 816 ng/mL; n= 26; p=0.006) patients were significantly lower than that of the HC (3119 ± 618 ng/mL; n=59), but the difference between the two groups of patients was not significant (p>0.05). PSA concentrations in CaP (median=80.8 ng/mL; n=25) were significantly higher than those in BPH (median=8.6 ng/mL; n=39) (p<0.001). Ninety-six percent of CaP and 72% of BPH patients had PSA concentrations >4.0 ng/mL; the proportions of patients with concentrations exceeding 20 ng/mL were 76% and 10%, respectively. We conclude that IGF-I and IGFBP-3 are inferior to PSA for CaP detection.

Early postnatal exposure to endosulfan interferes with the normal development of the male rat mammary gland

Our aim was to evaluate whether postnatal exposure to endosulfan (ENDO) modifies mammary gland (MG) development in pre- and post-pubertal male rats. From postnatal day 1 (PND1) to PND7, male rats were injected subcutaneously every 48h with either corn oil (vehicle) or 600μg ENDO/kg.bw. On PND21 and PND60, MG and blood samples were collected. Estradiol (E2) and testosterone (T) serum levels, MG histology, collagen fiber organization, proliferation index, and estrogen (ESR1) and androgen receptor (AR) expressions were evaluated. On PND21, E2 and T levels were similar between groups, whereas MG area, perimeter, number of terminal end buds and ESR1 expression were increased in ENDO-exposed rats. These changes were associated with alveolar development and increased organized collagen in the stroma. On PND60, a higher proliferation index in ENDO-exposed rats was correlated with a more developed lobuloalveolar structure. Hyperplastic alveoli and, hyperplastic ducts surrounded by a dense stroma were also observed in this group. T levels and ESR1 expression were similar between groups, whereas E2 levels and AR expression were decreased in ENDO-exposed rats. The exposure to ENDO in the first week of life interferes with the normal development of the MG and induces pre-malignant lesions in post-pubertal male rats.

Discriminating between virilizing ovary tumors and ovary hyperthecosis in postmenopausal women: clinical data, hormonal profiles and image studies

BACKGROUND

The presence of virilizing signs associated with high serum androgen levels in postmenopausal women is rare. Virilizing ovarian tumors (VOTs) and ovarian stromal hyperthecosis (OH) are the most common etiologies in virilized postmenopausal women. The differential diagnosis between these two conditions is often difficult.

OBJECTIVE

To evaluate the contribution of clinical features, hormonal profiles and radiological studies to the differential diagnosis of VOT and OH.

DESIGN

A retrospective study.

SETTING

A tertiary center.

MAIN OUTCOME MEASURES

Clinical data, hormonal status (T, E2, LH and FSH), pelvic images (transvaginal sonography and MRI) and anatomopathology were reviewed.

PATIENTS

Thirty-four postmenopausal women with a diagnosis of VOT (13 women) and OH (21 women) were evaluated retrospectively.

RESULTS

Clinical signs of hyperandrogenism were more prevalent in the VOT group than the OH group. Although the VOT group showed higher T and E2 levels and lower gonadotropin levels than the OH group, a great overlap occurred among the hormone levels. A pelvic MRI provided an accurate differentiation of these two conditions.

CONCLUSION

In this group of patients, the main features contributing to the differential diagnosis of VOT and OH were serum levels of testosterone and gonadotropins and the presence of an ovarian nodule identified on the MRI. Although the association of clinical, hormonal and radiological features contributes to the differential diagnosis of these two conditions, histopathological analysis remains the gold standard for the diagnosis of ovarian hyperandrogenism in postmenopausal women.

Relationship between the Balance of Hypertrophic/Hyperplastic Adipose Tissue Expansion and the Metabolic Profile in a High Glucocorticoids Model

Adipose tissue (AT) expansion is the result of two processes: hyperplasia and hypertrophy; and both, directly or indirectly, depend on the adipogenic potential of adipocyte precursor cells (APCs). Glucocorticoids (GCs) have a potent stimulatory effect on terminal adipogenesis; while their effects on early stages of adipogenesis are largely unknown. In the present work, we study, in a model of high GC levels, the adipogenic potential of APCs from retroperitoneal AT (RPAT) and its relationship with RPAT mass expansion. We employed a model of hyper-adiposity (30- and 60-day-old rats) due to high endogenous GC levels induced by neonatal treatment with l-monosodium glutamate (MSG). We found that the RPAT APCs from 30-day-old MSG rats showed an increased adipogenic capacity, depending on the APCs’ competency, but not in their number. Analyses of RPAT adipocyte diameter revealed an increase in cell size, regardless of the rat age, indicating the prevalence of a hypertrophic process. Moreover, functional RPAT alterations worsened in 60-day-old rats, suggesting that the hyperplastic AT expansion found in 30-day-old animals might have a protective role. We conclude that GCs chronic excess affects APCs’ adipogenic capacity, modifying their competency. This change would modulate the hyperplastic/hypertrophic balance determining healthy or unhealthy RPAT expansion and, therefore, its functionality.

Differential Effects of Peroxisome Proliferator Activator Receptor-α and γ Ligands on Intimal Hyperplasia After Balloon Catheter-Induced Vascular Injury in Zucker Rats

Background: Patients with type 2 diabetes mellitus have a higher rate of restenosis following angioplasty. Peroxisome proliferator activator receptor-x (PPAR) and y ligands such as fenofibrate and rosiglitazone, respectively, have been shown to have protective effects on the vessel wall. We studied the effect of fenofibrate and rosiglitazone on intimal hyperplasia in the Zucker rat, a model for insulin resistance and type 2 diabetes mellitus, following balloon catheter-induced injury.

Methods and Results: Three groups of 13-week-old female fatty Zucker rats were administered an aqueous suspension of either 3 mg/kg/d rosiglitazone (n = 7) or 150 mg/kg/d fenofibrate (n = 6) by gavage, or served as controls (n = 9). In addition, two groups of 13-week-old female lean Zucker rats were either administered 3 mg/kg/d rosiglitazone (n = 6) or served as controls (n = 6). Carotid balloon injury was induced 1 week after the drugs were started. The drug administration was continued for 3 weeks. A 2-mm balloon catheter was introduced through the femoral artery to the left carotid. The balloon was inflated to 4 atmospheres for 20 seconds and then was deflated to 2 atmospheres and dragged down to the aorta. The rats were killed 3 weeks after the injury. The carotid intima/media ratio was calculated. Intimal hyperplasia after carotid balloon-induced injury in the fatty Zucker rats was significantly reduced in the group treated with rosiglitazone (0.18 ± 0.29) compared with the untreated group (0.97 ± 0.13; P < .01). Plasma glucose, triglyceride, and insulin levels were elevated, indicative of the presence of insulin resistance; rosiglitazone treatment significantly reduced insulin and triglyceride levels without decreasing glucose. Rosiglitazone treatment also reduced, but to a lesser extent, the intimal hyperplasia in the lean Zucker rats (0.57 ± 0.10 vs 1.06 ± 0.12 treated and untreated, respectively; P < .01); however, it had no effect on insulin, triglyceride, or glucose levels in this group. The intimal hyperplasia in the fatty Zucker rats treated with fenofibrate was not reduced compared with controls (0.84 ± 0.26 vs 0.97 ± 0.13, respectively); fenofibrate reduced insulin and triglyceride, but not glucose levels, in these animals.

Conclusions: The PPAR-y ligand rosiglitazone, but not the PPAR-x ligand fenofibrate, decreases intimal hyperplasia following balloon injury in both fatty and lean Zucker rats. This effect of the PPAR-y ligand was independent of glycemia, insulin, and lipid levels, and was more pronounced in insulin-resistant rats.

[THE TECHNIQUE OF HIGH-PERFORMANCE LIQUID CHROMATOGRAPHY FOR SIMULTANEOUS DIAGNOSTIC OF INHERENT HYPERPLASIA OF ADRENAL GLANDS TYPE I AND II]

The article considers the technique of high-performance liquid chromatography making it possible simultaneously detect cortisol, cortisone and secondary steroids in serum for consequent analysis of common reversed-phase high-performance liquid chromatography with ultraviolet under 240 nm. The liquid-liquid extraction from alkaline medium in diethyl ether The separation using column of 150x4.6 size ODS 3.5 mkm in isocratic mode. The eluent acetonitrile--0.02 M phosphate buffer pH 8.0--isopropanol (40:60:1). The application of proposed technique managed to separate cortisol, cortisone, dexamethasone, corticosterone, 11-desoxicortisol, testosterone, desoxicorticosterone, 17α-gidroxiprogesterone and androstendion in 20 minutes. The simplicity, reproducibility and sufficient selectivity and sensitivity of technique permit implement it in clinical practice for simultaneous diagnostic of inherent hyperplasia of adrenal glands type I and II.

Ultrasonographic evaluation of parathyroid hyperplasia in multiple endocrine neoplasia type 1: Positive correlation between parathyroid volume and circulating parathyroid hormone concentration

There are few reports on parathyroid ultrasonography of multiple endocrine neoplasia type 1 (MEN1). This study investigated the ultrasonographic features of parathyroid glands in 10 patients with MEN1 who underwent preoperative neck ultrasonography and parathyroidectomy between 2006 and 2010 at Toranomon Hospital. We retrospectively analyzed clinical features, laboratory and ultrasonographic data, and pathological diagnosis. A total of 38 parathyroid glands were surgically removed (three to five glands from each patient). All removed parathyroids were pathologically diagnosed as hyperplasia. Seven cases (70.0 %) had adenomatous thyroid nodules. Twenty-five enlarged parathyroid glands (65.8 %) were detected by preoperative ultrasonography with a detection rate of 81.8 % (9/11) and 59.3 % (16/27) for patients without and with adenomatous nodules, respectively. Total parathyroid gland weight and potentially predictable total parathyroid volume by preoperative ultrasonography were significantly correlated with preoperative serum intact parathyroid hormone (iPTH) concentration (R = 0.97, P < 0.001 and R = 0.96, P < 0.001, respectively). The equation used for prediction of the total volume by ultrasonography was 15 × iPTH (pg/ml) - 1,000 and that for total weight was 20 × iPTH (pg/ml) - 1,400. Although adenomatous nodules often coexisted with MEN1 and made identification of enlarged parathyroid glands by ultrasonography difficult, the positive correlation between the predictable parathyroid volume by ultrasonography and serum iPTH suggests that their measurement is useful in the preoperative detection and localization of enlarged parathyroid glands in patients with MEN1. Furthermore, the presence of parathyroid glands that should be resected can be predicted before surgery using the equation proposed here.

Is adrenal venous sampling mandatory before surgical decision in case of primary hyperaldosteronism?

BACKGROUND

Primary hyperaldosteronism (PHA) is a cause of secondary arterial hypertension potentially curable by laparoscopic unilateral adrenalectomy. We describe the follow-up of these patients according to their medical or surgical treatment.

METHODS

We report a retrospective single-center study of 91 patients with PHA from 1998 to 2012. Treatment was guided by computed tomography (CT) scans. Preoperative adrenal vein sampling (AVS) was performed when the CT scan did not show single solitary unilateral nodules on the adrenal glands. During the follow-up, we considered hypertension to be cured in patients with normal blood pressure without antihypertensive medication (AM), and improvement was defined by a decrease in AM.

RESULTS

A total of 28 patients received only AM. Of the 62 patients who underwent a unilateral adrenalectomy, 46 (74 %) had an adrenal adenoma, 14 (22 %) a hyperplasia, and the adrenal gland was normal in two cases. Hypertension was cured in 24 cases (38 %), and 28 patients (45 %) showed improvement with a reduction in AM. Predictive factors for a cure were gender, age, number of preoperative AMs, preoperative arterial systolic blood pressure, and plasma renin activity. All patients who presented with hypokalemia were cured postoperatively. We performed 38 AVS and nine of these patients were operated on based on the AVS findings, with an improvement of 100 % of arterial blood pressure after surgery.

CONCLUSION

Laparoscopic unilateral adrenalectomy for PHA cured or improved hypertension in 84 % of patients. Preoperative AVS is mandatory for surgical decision making if the CT scan shows bilateral or no lesions associated with PHA.

Outcomes after subtotal parathyroidectomy for primary hyperparathyroidism due to hyperplasia: significance of whole vs. partial gland remnant

INTRODUCTION

Primary hyperparathyroidism (PHPT) due to multigland hyperplasia is managed by subtotal parathyroidectomy (sPTX), with a partial gland left in situ. However, smaller, hyperplastic glands may be encountered intraoperatively, and it is unclear if leaving an intact gland is an equivalent alternative. This study evaluates the rates of permanent hypoparathyroidism and cure of PHPT patients with four-gland hyperplasia that were left with either a whole gland remnant (WGR) or a partial gland remnant (PGR) after sPTX.

METHODS

We reviewed the outcomes of PHPT patients with hyperplasia who underwent sPTX at an academic institution. Surgeon intraoperative judgment determined remnant size (a WGR vs. a PGR).

RESULTS

Between 2002 and 2013, 172 patients underwent sPTX for PHPT. There were 108 patients (62.8%) who had a WGR. Another 64 patients (37.2%) had a PGR. Mean age was 60 ± 14 years. There were 82.6% female patients. Cases with positive family history for PHPT were more likely to have a PGR (12.5 vs. 3.7%; p = 0.03). Patients had similar preoperative and postoperative laboratories. Individuals with a PGR tended to have larger glands encountered by surgeons intraoperatively (525 ± 1,308 vs. 280 ± 341 mg; p = 0.02). One patient with a WGR developed permanent hypocalcemia. Overall, the cure rate was 97.1%. A mean of 29 ± 28.7 months follow-up revealed a recurrence rate of 5.2%. Disease persistence and recurrence rates were similar in patients.

CONCLUSION

PHPT due to hyperplasia is managed by sPTX, leaving WGR without increased rates of disease persistence/recurrence. Patients without family history for hyperparathyroidism and those with smaller glands may be the best candidates for this approach.

Incidence of multiglandular disease in sporadic primary hyperparathyroidism

OBJECTIVES

Multiple, minimally invasive surgical techniques have been developed over the last few decades for the management of sporadic primary hyperparathyroidism (PHTP). However, in cases with multiglandular disease, bilateral cervical exploration remains the gold standard. Therefore, it is important to have an accurate estimation of the incidence of multiglandular disease in sporadic PHTP.

METHODOLOGY

698 patients were treated for PHTP between 1993 and 2010 at the University Hospitals Leuven, using the bilateral cervical exploration method. After excluding cases of multiple endocrine carcinoma syndrome, the incidences of double adenoma and multiple gland hyperplasia were investigated in these patients. Age, gender, imaging results, serum calcium and parathyroid hormone concentrations were analyzed and compared to the data of 50 randomly-selected, PHTP patients with solitary adenomas.

RESULTS

6.6% and 2.4% of the patients with sporadic PHTP had double adenomas and multiple gland hyperplasia, respectively. The female/male ratio was 4.8 (38/8) and 1.8 (11/6), and the average age was 63 and 52 yrs for patients with double adenomas and multiple gland hyperplasia, respectively. The patients with solitary adenomas had a female/male ratio of 3.5, and an average age of 60 yrs. There were no significant differences in serum calcium or parathyroid hormone concentrations between patients with multiglandular disease and those with solitary adenomas.

CONCLUSIONS

Multiglandular disease occurs in 9% of patients with sporadic PHTP, and cannot be excluded before surgery. This incidence must be considered when using minimally invasive techniques for treatment of sporadic PHTP. In cases of multiglandular disease, bilateral cervical exploration is indicated.

Predictive value of gastrin levels for the diagnosis of gastric enterochromaffin-like cell hyperplasia in patients with Hashimoto's thyroiditis

AIM

Gastrin and chromogranin A (CgA) levels have been tested for the diagnosis of enterochromaffin-like cell hyperplasia (ECLH) in patients with type 1 diabetes and autoimmune atrophic gastritis but not for patients with Hashimoto's thyroiditis (HT). The aim of the study was to develop receiver operating characteristic (ROC) curves for gastrin and CgA levels and other clinical and biochemical parameters, as means for pretest probability of gastric ECLH in patients with HT.

METHODS

A total of 115 patients with HT were prospectively studied for a median period of 4 (2-7) years. Gastrin, CgA, vitamin B12, anti-parietal cell antibodies, free thyroxine, thyrotropin, and neuron-specific enolase levels were measured. Their predictive values were calculated according to the histological findings for ECLH diagnosis from esophagogastroduodenoscopy-obtained biopsies.

RESULTS

Thirteen patients (11.3%) had ECLH. The areas under the curve for gastrin and CgA level were 0.898 (p < 0.001) and 0.853 (p < 0.001), respectively. The product sensitivity × specificity was 0.803 and 0.653 for gastrin and CgA levels >89.5 and >89.1 ng/ml, respectively. Two and 4 patients with ECLH had normal gastrin and CgA levels, respectively. The most specific combined parameters predicting ECLH were gastrin >89.5 ng/ml with concomitant low B12 levels (96.1% specificity).

CONCLUSION

Gastrin levels have high diagnostic accuracy for ECLH identification in patients with HT, and are highly specific when combined with low B12 levels. However, they should be interpreted with caution, as some patients may harbor gastric ECLH even if gastrin levels are not increased, necessitating further follow-up.

Colonic delivery of docosahexaenoic acid improves impaired glucose tolerance via GLP-1 secretion and suppresses pancreatic islet hyperplasia in diabetic KK-A(y) mice

Glucagon-like peptide-1 (GLP-1) is an incretin hormone that regulates the insulin secretion depending on blood glucose level. Recent studies show that the unsaturated fatty acids can promote GLP-1 secretion from intestinal L-cells. We have shown previously that docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA) administered into a mouse closed intestinal loop, especially into the colonic segment, stimulate GLP-1 and insulin secretion and have a hypoglycemic effect, suggesting that DHA and EPA have potential as antidiabetic agents. The present study examined the antidiabetic effect of DHA following long-term in vivo delivery to the colon using normal ddY and diabetic KK-A(y) mice. The plasma GLP-1 concentration of KK-A(y) mice increased after long-term DHA administration, and this had a significant hypoglycemic effect. In contrast, although GLP-1 secretion in ddY mice tended to increase after DHA administration, blood glucose concentration did not differ between vehicle- and DHA-treated ddY mice. Immunostaining of the pancreas after long-term DHA administration showed that continuous DHA treatment stimulated β-cell apoptosis and accordingly suppressed islet cell growth in KK-A(y) mice. Colon targeting of DHA may provide a new strategy for improving impaired glucose tolerance in type 2 diabetes mellitus by stimulating GLP-1 secretion, which may subsequently suppress the compensatory hyperplasia of pancreatic islets.

Impact of JAK2 V617F mutation on hemogram variation in patients with non-reactive elevated platelet counts

BACKGROUND

Non-reactive platelet counts elevation occurs mainly in myeloproliferative disorders (MPDs), which have been reported to be closely associated with JAK2 V617F mutation. Complete blood cell count (CBC) is essential in diagnosis of MPDs, however, the impact of JAK2 V617F mutation on the patients' hemogram variation remains not clear.

METHODS

JAK2 V617F mutation was detected by allele specific real-time quantitative fluorescence PCR (AS-qPCR).

RESULTS

Of the 402 non-reactive platelet elevating patients, JAK2 V617F mutation was detected in 222 (55.2%) patients. RBC counts, WBC counts, platelet-large contrast ratio (P-LCR), platelet distribution width (PDW) and mean platelet volume (MPV) were much higher in JAK2 V617F mutated patients, except platelet counts. In addition, when the patients were classified into subgroups by blood cell counts, it was found that JAK2 V617F mutation rate increased progressively with the increase of RBC counts and WBC counts, other than platelet counts. Furthermore, trilineage hyperplasia group showed highest JAK2 V617F mutation rate (93.26%), followed by the bilineage hyperplasia groups. Lastly, JAK2 V617F mutant allele burden was found much higher in polycythemia vera (PV) patients [median(P25-P75): 45.02%(35.12%-54.22%)] than in essential thrombocythemia (ET) patients [median(P25-P75): 28.23%(17.77%-41.66%)], and that it increased with WBC counts (r = 0.393, p = 0.000) and RBC counts(r = 0.215, p = 0.001), other than platelet counts (r = -0.051, p = 0.452). Further analysis revealed that in ET patients, JAK2 V617F mutant allele burden correlated with WBC counts and platelet counts positively, other than RBC counts, while in PV patients, it correlated with WBC counts and RBC counts positively, but not platelet counts.

CONCLUSIONS

JAK2 V617F mutation occurs frequently in patients with non-reactive elevated platelet counts. The presence of JAK2 V617F mutation has great impact on hemogram variation, including RBC counts, WBC counts, platelet parameters and lineage hyperplasia, but not on platelet counts. Besides, JAK2 V617F mutant allele burden affects the blood cell proliferation pattern.

[Effects of encircled needling plus electroacupuncture on hyperplastic mammary glands and serum sex hormones in the rat]

OBJECTIVE

To observe the effect of encircled needling plus electroacupuncture (EA) of the second pair of nipples on hyperplastic mammary glands, serum estradiol (E2), progesterone (P), prolactin (PRL) and testosterone (T) contents, estrogen receptor (ER) expression of the mammary glands in mammary hyperplasia rats.

METHODS

Forty Wistar rats were equally randomized into normal control, model, acupuncture and medication groups. Mammary gland hyperplasia model was established by intramuscular injection of diethylstilbestrol (0.5 mg/kg, once daily for 25 days) and progesterone (4 mg/kg, once daily for 5 days). For rats of the acupuncture group, 4 filiform needles were inserted into the surrounding tissues of the second pair of breasts, respectively, followed by giving the animal with EA stimulation for 30 min. Another one acupuncture needle was inserted into "Danzhong" (CV 17) and retained for 30 min. For rats of the medication group, tamoxifen solution (1.8 mg/kg) was given by gavage. Both medication and EA intervention were given once daily for 30 days. The diameter and height of the second pair of nipples were measured before and on the 10th, 20th and 30th days of the treatment. Serum E2, P, PRL and T levels were assayed by radioimmunoassay, and the tissues of the second pair of nipples were stained with H. E. method. Estrogen receptor immunoactivity of the breast tissue was detected by immunohistochemistry.

RESULTS

The diameter and height of the second pair of nipples, serum E2, PRL and T contents, and breast ER protein expression level were significantly higher in the model group than in the normal control group (P<0.05), while serum P content was remarkably lower in the model group than in the normal control group (P<0.05). In comparison with the model group, the diameter and height of the second pair of nipples, serum E2, PRL and T contents, and breast ER protein expression level were considerably lower in both acupuncture and medication groups (P<0.05), and serum P contents were significantly higher in the latter two groups (P<0.05). In addition, H.E. staining showed that the numbers of the lobule, alveolus and ducts of mammary glands were significantly increased, and the expansion of the acinar lumina and ducts was found in the model group. These pathological changes were relatively milder in both acupuncture and medication groups.

CONCLUSION

Encircled needling plus EA stimulation of the surrounding tissues of the nipples can improve the hyperplasic nipples and pathological changes of the breast tissue in mammary gland hyperplasia rats, which is closely associated with its functions in lowering serum estradiol, prolactin, testosterone contents and estrogen receptor protein expression of the breast, and in increasing serum progesterone level.

Serum levels of HSP90 in the continuum of breast ductal and lobular lesions

BACKGROUND

Heat-shock protein 90 (HSP90) is an abundant protein in mammalian cells. It interacts with a variety of proteins that play key roles in breast neoplasia. This is the first study to assess serum levels of HSP90 in atypical ductal hyperplasia (ADH), lobular neoplasia (LN), ductal carcinoma in situ (DCIS), invasive ductal carcinoma (IDC) and infiltrative lobular carcinoma (ILC).

PATIENTS AND METHODS

Serum concentrations of HSP90 in women with benign (n=34), ADH (n=26), DCIS (n=30), IDC (n=29), LN (n=20) and ILC (n=9) lesions were determined with immunoenzymatic assays. For the evaluation of serum concentrations along the transition from benign through precursor and preinvasive to invasive lesion, the severity of diagnosis was treated as an ordinal variable.

RESULTS

No significant association was demonstrated between serum HSP90 levels and the severity of the lesion in ductal and lobular series. The post hoc comparison between the lobular and ductal precursor lesions (i.e. ADH vs. LN) did not yield a statistically significant difference. Similarly, the post hoc comparison between the lobular and ductal invasive carcinomas (i.e. IDC vs. ILC) did not point to a statistically significant difference.

CONCLUSION

This is the first study evaluating HSP90 serum levels in both lobular and ductal lesions of the breast. Contrary to published pathological findings according to which HSP90 exhibits significant variability along both series, such a finding was not replicated for the level of serum HSP90 concentrations.

[Magnetic resonance imaging and hormonal profile of the pituitary gland in patients with primary congenital hypothyroidism]

The aim of our study was an estimation of the size and structure of the pituitary gland using MRI and the estimation of hormonal profile of the pituitary anterior lobe (except for ACTH) in 21 adult patients with congenital primary hypothyroidism.

MATERIAL AND METHODS

The studied group was divided into 2 subgroups: A--with normal level of serum TSH and B--with its elevated. The MRI showed pituitary hyperplasia or tumor in 28.5% of patients, partially empty sella in 14.3% and hypoplasia in 9.5%. In subgroup B there were mostly hyperplasia or tumor (35.7%), while in subgroup A there were no domination of any abnormalities.

RESULTS

Serum mean TSH level was 49.8+/-86.2 mU/l with an increase in 67%. The mean prolactin was 11.2+/-7.5 mg/ml with an increase in 19%. Serum LH and FSH concentrations were normal in the whole group. The mean alpha subunit level was elevated in 52%. In 42.8% somatotropic hypopituitarism was recognised due to GH stimulation tests.

CONCLUSIONS

The TRH hyperstimulation in patients with congenital primary hypothyroidism may lead to pituitary hyperplasia or tumor visible on MRI and to pituitary hormonal abnormalities.

Elevated serum thymidine kinase 1 predicts risk of pre/early cancerous progression

BACKGROUND

Serological thymidine kinase 1 (STK1) is a reliable proliferation marker for prognosis, monitoring tumour therapy, relapse and detection of malignancies. In this study we investigate the use of STK1 in health screening.

METHODS

The concentration of STK1 was determined by a sensitive dot blot ECL assay in 8,135 persons participating in a health screening program.

RESULTS

The frequency of persons with elevated STK1 (<2.0 pM) was 1.1%, representing diseases linked to pre/early cancerous progression. One person with malignancy (gastric carcinoma) was found among persons with elevated STK1, but none of persons with normal STK1 values. There was a significantly higher frequency of persons with moderate/severe type of hyperplasia of breast and prostate expressing elevated STK1, compared to persons with normal STK1 values. No significant difference was found concerning mild hyperplasia. Of persons with elevated STK1, 89.2% had diseases linked to risk for pre/early cancerous progression, compared to 41.2% of persons with normal STK1 values. Among the persons with elevated STK1 values, one developed liver carcinoma after 13 months and five persons showed progression in their disease within 19 months (breast and prostate hyperplasia, HBV infection).

CONCLUSION

Serological TK1 may be a reliable marker for risk assessment of pre/early cancerous progression.

Aberrant cortisol regulations in bilateral macronodular adrenal hyperplasia: a frequent finding in a prospective study of 32 patients with overt or subclinical Cushing's syndrome

CONTEXT

ACTH-independent macronodular adrenal hyperplasia (AIMAH) is a rare and heterogeneous condition characterized by abnormal steroid production. Cortisol secretion can be regulated by aberrant hormone receptors.

OBJECTIVE

A large series of patients with AIMAH were evaluated to provide information on the prevalence and profile of aberrant regulations, in relation with the functional status.

DESIGN AND PATIENTS

Thirty-two consecutive patients with AIMAH were prospectively studied: 10 had a Cushing's syndrome (CS), and 22 had a subclinical CS (SCS).

METHODS

A baseline endocrine evaluation was followed by an in vivo protocol in search of aberrant cortisol responses (seven provocative tests). An acute inhibition test with the somatostatin analog octreotide was also performed.

RESULTS

At least one aberrant cortisol response was identified in 28 of 32 (87%) patients. The overall prevalence of aberrant responses was independent of the functional status. Responses to the upright posture and to metoclopramide were frequently observed (67 and 56% respectively). A glucagon response was frequently observed in the SCS group (58%). A cortisol inhibition by octreotide was specifically found in the three CS patients who positively responded to the mixed meal, and was observed also in 12 of 13 (92%) patients with SCS.

CONCLUSIONS

Cortisol responses indicative of aberrant receptor expression were highly prevalent in AIMAH. Thorough phenotyping of AIMAH may help uncover the underlying pathophysiology.

A meal test improves the specificity of chromogranin A as a marker of neuroendocrine neoplasia

Chromogranin A (CgA) is a neuroendocrine tumor (NET) marker. Modest CgA elevation is found in subjects with enterochromaffin-like (ECL) cell hyperplasia due to hypergastrinemia. Somatostatin analogs reduce CgA levels in patients with NET. Meals may affect serum CgA levels. The aims of the study were to investigate meal-induced CgA release and the short-term effect of octreotide on serum CgA levels. Four groups were studied: group A, seven patients with ECL cell hyperplasia secondary to use of proton pump inhibitors (PPIs); group B, six patients with gastric carcinoid type 1/ECL hyperplasia due to chronic atrophic gastritis (CAG); group C, six patients with nongastric NETs; group D, seven controls. The subjects were studied on three separate days with the use of three exposures: a test meal, pentagastrin subcutaneously (not group C), and octreotide intravenously. Serum CgA and gastrin were analyzed. A test meal induced a significant CgA increase in long-term PPI users and in healthy controls. The meal did not affect CgA levels in patients with gastric carcinoid type 1 or patients with NETs. The test meal increased gastrin levels in all groups except in those with CAG. Pentagastrin increased CgA levels in all groups tested except in those with CAG, while octreotide, reduced CgA and gastrin levels in all groups. Serum CgA should be determined in fasting individuals. A test meal may distinguish between increased CgA levels in PPI users from nongastric NET patients. Concomitant gastrin determination may help to discriminate between nongastric NETs and CAG. Intravenous octreotide rapidly reduces serum CgA.

Subclinical hyperthyroidism in cats: a spontaneous model of subclinical toxic nodular goiter in humans?

INTRODUCTION AND OBJECTIVES

Hyperthyroidism in cats, caused by nodular hyperplasia or adenomas, is clinically and histologically similar to toxic nodular goiter in humans. Subclinical hyperthyroidism in humans is defined as low thyrotropin (TSH) in conjunction with within-reference-range thyroid hormone concentrations, but has not previously been defined in cats. The objective of this study was to test the hypothesis that euthyroid senior cats with low TSH have histological evidence of thyroid nodular hyperplasia and/or adenoma.

DESIGN

Thyroid glands removed postmortem from four groups of cats (n = 73) were examined histologically and scored in a blinded fashion. Clinically euthyroid senior (>7 years) cats were divided into two groups dependent on their TSH concentration--TSH below the limit of quantification (LOQ) of the assay (<0.03 ng/mL; n = 15; UndetectableTSH group) and TSH above the LOQ (>or=0.03 ng/mL; n = 31; DetectableTSH group)--using archived plasma samples, collected 0-6 months antemortem. Thyroids were also scored for two control groups: Young group (cats <6 years old; n = 13) and Hyperthyroid group (clinically and biochemically hyperthyroid cats; n = 14).

MAIN OUTCOME

Cats in the UndetectableTSH group had a higher frequency of nodules, a greater percentage of abnormal thyroid tissue, and a higher overall histopathological grade than cats with detectable TSH had.

CONCLUSION

Euthyroid (as defined by total thyroxine) senior cats with low TSH are likely to have histological evidence of nodular thyroid disease, and such cats could be considered to be subclinically hyperthyroid.

Muscle-specific knockout of PKC-lambda impairs glucose transport and induces metabolic and diabetic syndromes

Obesity, the metabolic syndrome, and type 2 diabetes mellitus (T2DM) are major global health problems. Insulin resistance is frequently present in these disorders, but the causes and effects of such resistance are unknown. Here, we generated mice with muscle-specific knockout of the major murine atypical PKC (aPKC), PKC-lambda, a postulated mediator for insulin-stimulated glucose transport. Glucose transport and translocation of glucose transporter 4 (GLUT4) to the plasma membrane were diminished in muscles of both homozygous and heterozygous PKC-lambda knockout mice and were accompanied by systemic insulin resistance; impaired glucose tolerance or diabetes; islet beta cell hyperplasia; abdominal adiposity; hepatosteatosis; elevated serum triglycerides, FFAs, and LDL-cholesterol; and diminished HDL-cholesterol. In contrast to the defective activation of muscle aPKC, insulin signaling and actions were intact in muscle, liver, and adipocytes. These findings demonstrate the importance of aPKC in insulin-stimulated glucose transport in muscles of intact mice and show that insulin resistance and resultant hyperinsulinemia owing to a specific defect in muscle aPKC is sufficient to induce abdominal obesity and other lipid abnormalities of the metabolic syndrome and T2DM. These findings are particularly relevant because humans who have obesity, impaired glucose tolerance, and T2DM reportedly have defective activation and/or diminished levels of muscle aPKC.

[Experimental study on Ruxian Pill I in treating mammary gland hyperplasia rabbits]

OBJECTIVE

To observe the effect of Ruxian Pill I (RXP I) on mammary gland hyperplasia (MGH) in rabbits and to explore its mechanism.

METHODS

Sixty rabbits were divided into the high, medium and low dose of RXP I groups, the Xiaoyao Pill (XYP) group, the model group and the normal control group with 10 in each group. The former 5 groups were injected with diethylstilbestrol and progesterone intramuscularly for one month to induce the MGH model and then given respective medicines via gastrogavage for 3 months. The changes in morphology of mammary gland were observed using light and electronic microscope, the levels of estradiol (E2) and progestogen (P) were measured by radioimmunoassay, and the expression of estradiol receptor (ER) and progestogen receptor (PR) were detected with immunohistochemistry before, at the end of and 3 months after the treatment.

RESULTS

Compared with those before treatment and those in the model group, in the high and midium dose of RXP I groups after treatment, obvious decrease of acini number in hyper-plastic lobuli mammae, connective tissues and blood capillaries, layers of glandular epithelium cells and organellers were seen with partial of hyperplastic cell apoptosis in them. Besides, the serum E2 level decreased obviously (P < 0.05), while the serum P level increased, and the ER expression down-regulated significantly (P < 0.05), but no obvious changes of PR expression was found. Three months later, all the above indexes maintained stable without rebound.

CONCLUSION

RXP I treatment could alleviate the hyperplasia of mammary glands, reduce E2 level, and down-regulate ER expression in rabbits with MGH, showing a significant therapeutical effect.

Adrenocorticotropin concentration following administration of thyrotropin-releasing hormone in healthy horses and those with pituitary pars intermedia dysfunction and pituitary gland hyperplasia

OBJECTIVE

To compare the effect of thyrotropin-releasing hormone (TRH) administration on endogenous ACTH concentrations in healthy horses and those with pituitary pars inter-media hyperplasia and compare the test with the dexamethasone suppression test (DST).

DESIGN

Prospective case series.

ANIMALS

15 horses with clinical signs of pituitary pars intermedia dysfunction (PPID), 4 horses with equivocal signs of PPID, and 29 horses without signs of PPID.

PROCEDURES

ACTH concentrations prior to and after administration of TRH were measured 61 times in 48 horses. Results of the DST (cortisol response) were compared with those of the TRH test in 29 horses. Thirty-three horses (24 with no clinical signs of PPID, 5 with clinical signs of PPID, and 4 with equivocal clinical signs of PPID) were euthanized and necropsied and their pituitary glands evaluated.

RESULTS

ACTH concentrations increased in all horses, but magnitude and duration of increase were significantly higher in horses with PPID. Endogenous ACTH concentrations were influenced by season. The ACTH baseline concentrations and response to TRH were not correlated with results of the DST. Results of DST were abnormal only in clinically abnormal horses or those with pars intermedia hyperplasia, but were within reference range in 17 of 26 tests in these horses.

CONCLUSIONS AND CLINICAL RELEVANCE

The ACTH response to TRH is a useful test for diagnosis of pituitary gland hyperplasia, particularly in horses in which baseline ACTH concentrations are within reference range. The DST was specific but not sensitive and was inconsistent for individuals, and results often did not agree with the TRH test response.

Male gonadal function, prolactin secretion and lactotroph population in an experimental model of cirrhosis

Liver cirrhosis, a highly prevalent chronic disease, is frequently associated with endocrine dysfunctions, notably in the gonadal axis. We evaluated lactotroph population by immunohistochemistry, gonadotropins and prolactin by immunoradiometric assay and testosterone and estradiol by radioimmunoassay in adult male Wistar rats with cirrhosis induced by carbon tetrachloride. No significant difference in mean +/- SEM percentages of lactotrophs was found between cirrhotic animals and controls (N = 12, mean 18.95 +/- 1.29%). Although there was no significant difference between groups in mean serum levels of prolactin (control: 19.2 +/- 4 ng/mL), luteinizing hormone (control: 1.58 +/- 0.43 ng/mL), follicle-stimulating hormone (control: 19.11 +/- 2.28 ng/mL), estradiol (control: 14.65 +/- 3.22 pg/mL), and total testosterone (control: 138.41 +/- 20.07 ng/dL), 5 of the cirrhotic animals presented a hormonal profile consistent with hypogonadism, all of them pointing to a central origin of this dysfunction. Four of these animals presented high levels of estradiol and/or prolactin, with a significant correlation between these two hormones in both groups (r = 0.54; P = 0.013). It was possible to detect the presence of central hypogonadism in this model of cirrhotic animals. The hyperestrogenemia and hyperprolactinemia found in some hypogonadal animals suggest a role in the genesis of hypogonadism, and in the present study they were not associated with lactotroph hyperplasia.

Effectiveness of parathyroid-hormone measurement in detecting patients with multiple gland disease causing primary hyperparathyroidism

BACKGROUND AND AIM

Intraoperative parathyroid hormone measurement (iPTH) has strengthened the successful use of minimal-invasive approaches in surgery of primary hyperparathyroidism (pHPT). The aim of the study was to evaluate the efficacy of iPTH monitoring in treating pHPT resulting from multiple gland disease.

MATERIALS AND METHODS

In this retrospective study, 58 patients with pHPT underwent surgery (minimally invasive or open exploration) between January 2003 and July 2005. iPTH levels were routinely measured at the start of anesthesia, in any case before skin incision, and 10 as well as 15 min after removal of abnormal gland(s). A drop in iPTH >50% after 10 min and >60% after 15 min was considered adequate to prove the success of the removal of the abnormal gland(s). The removed tissue was examined histologically by immediate frozen section.

RESULTS

A single gland disease was found in 51 (88%) cases, a multiple gland disease (double adenoma or hyperplasia) in 7 (12%) cases. In all cases of single adenoma, an adequate drop of iPTH was seen after removal of the pathologic gland. In contrast, in all cases with a second adenoma, an adequate drop in iPTH was detected only after removal of both adenoma/hyperplasia. Immediate sectioning was only helpful for identification of removed tissue, but was no help in deciding whether to search for an additional gland. The follow-up showed no late disease recurrence.

CONCLUSION

The measurement of iPTH is an effective and safe means in treating single gland disease as well as multiple gland disease (adenoma/hyperplasia) causing pHPT and also allows a successful limited dissection via minimally invasive parathyroidectomy.

Basic and clinical aspects of parathyroid hyperplasia in chronic kidney disease

Marked parathyroid hyperplasia develops in patients with chronic kidney disease, especially those with long dialysis vintage. Although progression of hyperplasia is associated with downregulation of vitamin D receptor and calcium-sensing receptor, initial abnormality that triggers and maintains parathyroid cell proliferation, as well the critical abnormality for the progression of diffuse hyperplasia to nodular hyperplasia, still remains to be elucidated. It is quite important for the optimal management of renal osteodystrophy to recognize the development of nodular hyperplasia, because the cells in nodular hyperplasia are usually resistant to medical therapy and further treatment of such patients often leads to vascular calcification. For this purpose, size and blood supply of enlarged parathyroid glands have been used as good clinical markers. Furthermore, we have recently shown that the serum fibroblast growth factor 23 level can be used for predicting refractory hyperparathyroidism. Once nodular hyperplasia develops in any of the enlarged parathyroid glands, such patients need to be treated by parathyroid intervention including percutaneous ethanol injection therapy. In addition, as direct vitamin D injection therapy has been shown to induce regression of hyperplasia, it may become possible to reverse or normalize established nodular hyperplasia if we can develop new agents with such effects in the near future.

A case of ACTH-independent bilateral macronodular adrenal hyperplasia and severe congestive heart failure

Cortisol secretion in ACTH independent bilateral macronodular adrenal hyperplasia (AIMAH) can be regulated by aberrant adrenal receptors. We describe a patient with Cushing's syndrome (CS) due to AIMAH and concomitant Class IV congestive heart failure (CHF). Clinical testing for the presence of aberrant receptors revealed a pronounced serum cortisol (257%) and aldosterone response (212%) to the administration of ACTH and a partial serum cortisol (35%) and aldosterone (106%) response to upright posture. This suggested the possible presence of aberrant hormone receptors for ACTH [melanocortin 2 receptor (MC2-R)], vasopressin, catecholamines or angiotensin II (AT-II) on the patient's adrenal glands. Adrenal tissue from the patient demonstrated an eight-fold increased expression of MC2-R compared to normal adrenal tissue. This increased expression was consistent with the increase in cortisol and aldosterone seen in response to exogenous ACTH. We propose that the severe CHF resulted in activation of the renin-angiotensin system, with an increased production of AT-II. The elevated circulating levels of AT-II may have led to increased expression of MC2-R on the patient's adrenal glands and increased responsiveness to ACTH. This unusual case of CS may elucidate a heretofore unknown mechanism for the development of AIMAH.

Direct injection of calcitriol or its analog into hyperplastic parathyroid glands induces apoptosis of parathyroid cells

Hyperplasia of the parathyroid gland (PTG) is associated not only with excessive secretion of parathyroid hormone (PTH) but also with changes in the parathyroid cell (PTC) characteristics (i.e. hyperproliferative activity, and low contents of vitamin D and calcium-sensing receptors). Control of PTG hyperplasia is most important in the management of secondary hyperparathyroidism, but the advanced stage of hyperplasia is considered irreversible. In the present study, dialysis patients with PTG hyperplasia underwent direct injection of calcitriol or maxacalcitol (OCT) into the PTG. Ultrasonography showed that this treatment had significantly reduced PTG volume and tissue analysis using the terminal deoxynucleotidyl transferase-mediated dUTP nick end-labeling (TUNEL) method and DNA electrophoresis indicated that cellular apoptosis had been induced. The mechanism of apoptosis was evaluated in detail in uremic rats fed a high-phosphate diet. OCT or its vehicle was directly injected into the rats' PTGs. In the PTGs treated by OCT, there was a significantly increased number of TUNEL-positive PTCs and DNA electrophoresis revealed the characteristic ladder pattern of DNA fragmentation, both findings indicative of apoptosis. There was also a significant upregulation of both vitamin D and Ca-sensing receptors in the PTCs and a clear shift of the Ca-PTH response curve to the left and downward. None of these findings was observed in the PTGs treated by vehicle. This novel treatment is successful in causing regression of PTG hyperplasia. Thus, it is expected to significantly reduce the PTH level and ameliorate the abnormal bone turnover and mineral metabolism.

Insulin stimulates arterial neointima formation in normal rats after balloon injury

AIM

Insulin resistance in patients is associated with increased atherosclerosis and arterial restenosis. It is thought that the concomitant hyperinsulinaemia exacerbates vascular disease because resistance to insulin-induced glucose disposal is associated with resistance to certain effects of insulin which inhibit, but with no resistance to other effects which promote, neointimal hyperplasia. We sought to determine the net effect of hyperinsulinaemia on neointimal hyperplasia in normal animals.

METHODS

Rats were infused with or without insulin for 16 days and the carotid artery injured by balloon catheter on day 2.

RESULTS

Steady-state serum insulin concentrations were 0.56 +/- 0.04 and 1.25 +/- 0.05 nm for control and hyperinsulinaemic rats respectively (p < 0.01). Systolic blood pressures, weights and serum glucose levels were not affected by hyperinsulinaemia. Fourteen days after injury, the neointima-to-media area ratio was 0.72 +/- 0.07 and 1.39 +/- 0.15 for control and hyperinsulinaemic rats respectively (p < 0.05). Media area was unaffected by hyperinsulinaemia.

CONCLUSIONS

The effects of hyperinsulinaemia which promote neointimal hyperplasia after balloon injury of rat carotid artery predominate over the effects which inhibit it even in normal animals.

Rat thymectomy effects on leptin receptor and T-bet: erythroid hyperplasia with maturation arrest and suppressed T-cell-mediated hepatotoxicity

Thymectomy is an inevitable therapy for thymoma. Therefore, determining hemato-immune changes post-thymectomy is important. Twenty-six normal LEW/Sea rats thymectomized (Tx) at the ages of 38 +/- 5 days were followed without any treatment for 4 months (experiments [Exp] A and B). In addition, 16 LEW/Sea rats Tx at the age of 42 days (Exp C and D) and 10 non-Tx control LEW/Sea rats (Exp E) were immunized with syngeneic male liver cells 2 to 3 times and followed 2.7 months after the first immunization. Flow cytometric (FCM) analysis of mesenteric lymph nodes (MLN) and peripheral blood (PB) showed as follows: among the 26 Tx rats (Exp A and B), MLN lymphocyte population at 4 months postthymectomy was characterized by decreased numbers of CD4+ cells (22%-36%) or alphabeta T-cell receptor (TCR)-positive cells (16%-54%) and increased numbers of interleukin 2 receptors (IL-2R) (>90%). In the 16 Tx-immunized rats (Exp C and D), both alphabeta TCR (MLN) and CD45R (PB) expression on lymphocytes was suppressed with rather high numbers of CD4. Bone marrow (BM) and PB hematological studies of the partially and totally Tx rats indicated the following: 8 BM of the 10 totally Tx males (Exp A) and the 7/10 male spleen showed erythroid hyperplasia with maturation arrest at the stage of basophilic erythroblasts and reticulocytopenia in the PB. One of the 10 males, which had both BM myeloid to erythroid (M/E) ratio of 4.3 and spleen myeopoiesis, was in a more advanced stage, a prestage of pure red cell aplasia (PRCA) with 22% of CD4+ MLN cells. Syngeneic liver cell immunization resulted in the Tx rats as follows: hepatotoxicity based on the immunization was weaker in the 16 Tx rats (Exp C and D) than in the 10 non-Tx rats (Exp E). Polymerase chain reaction (PCR) of PB and MLN showed compensatory activated leptin receptor (LR) and T-bet DNA in 19 Tx rats (Exp A and B) with abnormal FCM findings. The ineffective erythropoiesis at 4 months after thymectomy was explained by the erythroblast LR/erythropoietin receptor (EPOR) dysfunction. The low grade hepatotoxicity in the Tx rats (Exp C and D) was explained by the disturbed Th1 reactions (or the disturbed T-bet gene transcription) at postthymectomy.

Role of FNA in the medical management of minimally enlarged thyroid

Fine-needle aspiration (FNA) of thyroid is a cost-effective and simple diagnostic tool in the initial screening of patients with thyroid nodules. But, its role in a clinically normal thyroid or a minimally enlarged thyroid in a symptomatic patient suspected of having thyroid dysfunction is unknown. With our 2-yr experience in a setup of a tertiary health care hospital in a developing country, we have aimed to implement a management protocol using FNA thyroid done without ultrasound guidance and TSH estimation done during the same visit in symptomatic patients suspected of having thyroid pathology but presenting with no goiter or having minimally enlarged thyroid with no palpable nodules. The thyroid enlargement in 172 cases were graded with the criteria endorsed by WHO, Pan American Health Organization, and International Council for Control of Iodine Deficiency Disorders into grade 0, 1, and 2. The cases were evaluated cytologically and correlated with TSH values according to the algorithm formulated by the authors. FNA was diagnostic in 86.6, 98, and 100% in grade 0, 1, and 2 goiters, respectively. 52.3% (n = 90), 19.8% (n = 34), 16.9% (n = 29) of cases were diagnosed as Hashimoto's thyroiditis (HT), colloid goiter (CG), and lymphocytic thyroiditis (LT). Sixteen had a combination of LT and CG (n = 6), HT and CG (n = 6), papillary carcinoma (n = 2), and diffuse hyperplasia (n = 2). No statistically significant difference (P = 0.4586) was noted between the groups of patients with grade 0 and grade 1-2 goiter, who underwent FNAC. 38.95% of patients (n = 67) with TSH values greater than 10 microIU/ml and considered hypothyroid showed features of HT/LT at FNA. 23.83% (n = 41) having TSH values between 5 and 10 microIU/ml (subclinical hypothyroidism) also showed features of HT/LT at FNA. Both groups were treated with thyroxine. 35.46% (n = 61) of cases with TSH values within normal range (0.5-5.1 microIU/ml) and considered euthyroid showed a spectrum of lesions at cytology other than HT and LT. They are being followed up to detect them at an early stage of subclinical hypothyroidism. Only 13 cases (7.5%) who were serologically euthyroid showed HT/LT and are being followed-up. Thus, the authors advocate FNA of the thyroid as a single simple cost-effective office procedure in the medical management of all nonpalpable/minimally enlarged thyroid in patients suspected of having thyroid pathology and/or in combination with TSH values. FNA helps in early detection of subclinical hypothyroidism, which is of utmost importance in pregnant women and further makes possible availability of baseline values for future reference. With the implementation of this protocol of FNA thyroid without imaging, we affirm that the practice of cytology which differs in different geographic areas and from country to country depending on economy and availability of infrastructure can be made more user-friendly.

Serum Concentrations of Estrogens, Sex Hormone Binding Globulin, and Androgens and Risk of Breast Hyperplasia in Postmenopausal Women

OBJECTIVE

We sought to determine whether serum concentrations of estrogens, androgens, and sex hormone binding globulin in postmenopausal women were related to the presence of mammary hyperplasia, an established breast cancer risk factor.

METHODS

Study participants provided serum before breast biopsy or mastectomy in three hospitals in Grand Rapids, Michigan, between 1977 and 1987. A total of 179 subjects with breast hyperplasia were compared with 152 subjects with nonproliferative breast changes that are not associated with increased breast cancer risk.

RESULTS

The odds ratios (OR) associated with the three upper quartiles of estradiol in comparison with the lowest quartile were 2.2 [95% confidence interval (95% CI) 1.1-4.6], 2.5 (95% CI, 1.1-5.3), and 4.1 (95% CI, 2.0-8.5; Ptrend = 0.007). The corresponding ORs for bioavailable estradiol, estrone, and estrone sulfate were of generally similar magnitude (Ptrend = 0.003 for bioavailable estradiol, 0.0004 for estrone, and 0.0009 for estrone sulfate). Relative to women concurrently in the lowest tertile for serum estradiol, estrone, and estrone sulfate, women concurrently in the highest tertile for all three hormones had an OR of 5.8 (95% CI, 2.2-15.2). Serum concentrations of sex hormone binding globulin, testosterone, dehydroepiandrosterone, androstenedione, and androstenediol were not associated with risk of hyperplasia.

CONCLUSIONS

Serum concentrations of estrogens, but not of androgens or sex hormone binding globulin, were strongly and significantly associated with risk of breast hyperplasia in postmenopausal women, suggesting that estrogens are important early in the pathologic process towards breast cancer.

Effects of 5 years of treatment with rabeprazole or omeprazole on the gastric mucosa

BACKGROUND

Prolonged gastric acid suppression leads to hypergastrinaemia, which promotes hyperplasia of the enterochromaffin-like (ECL) cells of the oxyntic mucosa. The objective was to determine the effects of 5 years of treatment with rabeprazole or omeprazole on the gastric mucosa.

METHODS

Two hundred and forty-three patients received rabeprazole (20 mg or 10 mg) or omeprazole (20 mg) once daily for up to 5 years, for gastro-oesophageal reflux disease and 51% completed the whole 5 year period. Gastric biopsy specimens were taken and examined for gastritis, Helicobacter pylori infection, and ECL cell status.

FINDINGS

H. pylori infection in the gastric corpus was more common than in the antrum, and remained constant, whereas antral H. pylori infection became less common as the study progressed. H. pylori infection was a highly significant predictor of higher gastritis scores, which were similar among the three treatment groups. ECL cell hyperplasia occurred in a minority of patients, and was associated with serum gastrin concentrations. No ECL cell dysplasia or tumours were observed. There were no significant differences among the treatment groups in gastritis or ECL cell hyperplasia grades.

INTERPRETATION

This study has confirmed the link between ECL cell hyperplasia and elevated serum gastrin concentrations, but has found no evidence that this progresses to high grades of hyperplasia during 5 years of treatment with rabeprazole or omeprazole.

Selective arterial calcium stimulation and hepatic venous sampling in the evaluation of hyperinsulinemic hypoglycemia: potential and limitations

PURPOSE

To describe the potential and limitations of selective arterial calcium stimulation and hepatic venous sampling (ASVS) in the evaluation of patients with hyperinsulinemic hypoglycemia.

MATERIALS AND METHODS

Twenty-seven consecutive adult patients with documented hyperinsulinemic hypoglycemia undergoing an ASVS test and histologically confirmed diagnosis were included.

RESULTS

By histology, 24 patients were found to have an insulinoma, two had islet cell hyperplasia, and one had insulin-secreting neuroendocrine carcinoma of the liver. ASVS correctly predicted the source of excessive insulin secretion in 26 of 27 (sensitivity, 96%) patients. In two patients with an insulinoma, ASVS had to be repeated for correct diagnosis; in one patient with a glucose-sensitive insulinoma, ASVS was falsely negative. In one patient, a falsely negative ASVS test was caused by diazoxide treatment; in another patient a falsely negative ASVS test occurred because of extraordinarily high baseline insulin levels when the calcium stimulation was performed. CT and/or MR imaging correctly predicted the source of excessive insulin secretion in 59% of patients, the sensitivity of the intraoperative exploration was 88%.

CONCLUSIONS

In the authors' experience, the ASVS test is superior to CT/MR imaging and even the intraoperative exploration in identifying the source of excessive insulin secretion in patients with hyperinsulinemic hypoglycemia. To prevent false negative ASVS tests, medications with an influence on insulin secretion have to be discontinued prior to ASVS and two baseline blood samples should be obtained before the calcium stimulation is performed.

Essential Role of Vascular Endothelial Growth Factor and Flt-1 Signals in Neointimal Formation After Periadventitial Injury

Objective— Vascular endothelial growth factor (VEGF) is upregulated after arterial injury. Its role in the pathogenesis of neointimal formation after periadventitial injury, however, has not been addressed.

Methods and Results— Expression of VEGF and its receptors but not that of placental growth factor markedly increased with the development of neointimal formation in hypercholesterolemic mice after cuff-induced periarterial injury. Transfection with the murine soluble Flt-1 (sFlt-1) gene to block VEGF in vivo in mice inhibited early inflammation and later neointimal formation. The sFlt-1 gene transfer did not affect plasma lipid levels but attenuated increased expression of VEGF, Flt-1, Flk-1, monocyte chemoattractant protein-1, and other inflammation-promoting factors. Mice with Flt-1 kinase deficiency also displayed reduced neointimal formation.

Conclusions— Inflammatory changes mediated by VEGF and Flt-1 signals play an important role in the pathogenesis of neointimal formation after cuff-induced periadventitial injury. VEGF might promote neointimal formation by acting as a proinflammatory cytokine.

Comparison of Sequential versus Simultaneous Methods of Adrenal Venous Sampling

PURPOSE

To compare two methods of adrenal venous sampling (AVS) in preoperative localization of adrenal lesions in primary hyperaldosteronism.

MATERIALS AND METHODS

Twenty-one patients (13 men, eight women) underwent selective adrenal venous sampling between July 2001 and May 2003. One of the 21 patients underwent repeat AVS, for a total of 22 procedures. In half the procedures (n = 11), simultaneous bilateral adrenal venous catheterization and sampling was performed before and after intraprocedural adrenocorticotropic hormone (ACTH) administration; in the remaining half (n = 11), sequential catheterization of the left and right adrenal veins was performed during continuous ACTH infusion 1 hour before and throughout AVS. Chart review provided procedural data, including sampling intervals and aldosterone/cortisol ratios. Patient records provided clinical data, including blood pressure, serum aldosterone levels, and computed tomography and magnetic resonance imaging findings. Surgical pathology reports confirmed unilateral disease but were not applicable to bilateral disease.

RESULTS

Selective AVS was completed successfully in 21 of 22 procedures (95%); the unsuccessful sampling was repeated successfully. Disease lateralized in 13 of 22 cases. Simultaneous bilateral AVS localized unilateral disease in seven of eight cases (88%) and was nondiagnostic in one case (13%), with cases confirmed by surgical pathology reports. Sequential bilateral AVS localized unilateral disease in four of four cases (100%) confirmed by surgical pathology reports, with one lost to follow-up. Bilateral disease was diagnosed in six of 22 cases: two of 11 by simultaneous AVS and four of 11 by sequential AVS. Three of 22 cases demonstrated borderline hormone levels that failed to meet the diagnostic threshold for recommended adrenalectomy. Mean elapsed time between acquisition of right and left samples did not differ between simultaneous and sequential AVS (P = .09). Baseline (prestimulation) sampling did not contribute unique diagnostic information in any case and provided contradictory or confounding information in three of 11 simultaneous AVS procedures (27%).

CONCLUSIONS

Sequential bilateral catheterization does not compromise the reliability of time-sensitive AVS. Both simultaneous and sequential AVS are adequate studies; however, obtaining baseline prestimulation samples during simultaneous AVS is unnecessary and increases the cost of the procedure.

Elevated soluble epidermal growth factor receptor level in pituitary adenoma and carcinoma

OBJECTIVE

To investigate effect of the soluble epidermal growth factor receptor (sEGFR/sErbB1) level in the peripheral blood in development, invasiveness, apoplexy of each type of pituitary tumor.

METHODS

The sEGFR level was determined in peripheral serum from 190 patients with pituitary diseases by enzyme linked immunosorbent assay. The sEGFR levels were measured in 10 pituitary Rathke's pouch, 18 pituitary hyperplasia, 161 pituitary adenomas including 30 microadenomas, 83 large adenomas, 48 giant adenomas, 1 pituitary carcinoma, and 28 healthy controls.

RESULTS

In the patients with pituitary hyperplasia, microadenoma, large adenoma, giant adenoma, and pituitary carcinoma, the sEGFR level was 188.92 +/- 32.62, 209.83 +/- 19.01, 333.20 +/- 69.33, 405.85 +/- 37.38, and 617.45 fmol/mL independently. They were all significantly higher than patients with pituitary Rathke's pouch (156.78 +/- 18.24 fmol/mL, P < 0.001) and healthy control group (159.11 +/- 40.50 fmol/mL, P < 0.05). The sEGFR level in pituitary carcinoma was higher than pituitary adenoma. In patients with pituitary adenoma, the sEGFR level was positive correlated to the size of pituitary adenomas (r=0.998), the significant difference was observed for the sEGFR level in each group of the patients with pituitary adenomas (P < 0.001). Furthermore, in patients with pituitary ACTH-secreting microadenomas, the serum sEGFR levels in invasiveness (295.00 +/- 77.80 fmol/mL) was higher than that in non-invasiveness (210.60 +/- 16.4 fmol/mL, P < 0.05). In patients with pituitary ACTH-secreting, PRL-secreting, GH-secreting, and non-functioning large adenomas, the serum sEGFR levels in invasiveness (407.86 +/- 28.50, 399.25 +/- 30.10, 386.00 +/- 13.08, and 369.25 +/- 36.70 fmol/mL) was higher than that in non-invasiveness (335.25 +/- 63.49, 300.64 +/- 47.57, 297.00 +/- 61.93, and 269.30 +/- 25.68 fmol/mL) respectively (P < 0.05). In patients with invasive pituitary PRL-secreting, GH-secreting, and non-functioning giant adenomas, the serum sEGFR levels not significantly different in between invasiveness (417.50 +/- 35.94, 409.50 +/- 69.14, and 417.50 +/- 44.13 fmol/mL) and non-invasiveness (386.00 +/- 49.64, 417.50 +/- 44.03, and 409.51 +/- 35.17 fmol/mL) (P > 0.05). In patients with pituitary large adenomas, the sEGFR levels in pituitary apoplexy (377.48 +/- 39.18 fmol/mL) was higher than that in non-pituitary apoplexy (343.18 +/- 68.17 fmol/mL, P > 0.05).

CONCLUSIONS

The increased level of peripheral serum sEGFR is concomitant with development, proliferous size of the adenomas in patients with pituitary adenomas. In addition, the elevated levels of serum sEGFR occur in pituitary apoplexy as clinical active tumors, and the non-invasive ACTH secreting adenomas. The sEGFR levels could be differentiated helpfully between pituitary adenomas and non-pituitary adenomas. These data suggest that serum sEGFR could be as a referable marker of the size and activation of proliferation in pituitary adenoma.

Effects of Preinjury Administration of Corticosteroids on Pseudointimal Hyperplasia and Cytokine Response in a Rat Model of Balloon Aortic Injury

Restenosis occurs in approximately one-third of patients with coronary or peripheral vascular disease who undergo balloon angioplasty or a surgical bypass procedure primarily because of the development of pseudointimal hyperplasia (PIH). Corticosteroids were effective in suppressing PIH in several experimental studies, but no clinical studies have been reported. To resolve this discrepancy, we studied the effects of preinjury administration of several doses of methylprednisolone (MP) at targeted times in a rat model of balloon aortic injury. Rats were given either no treatment or an intravenous injection of MP (0.5, 5.0, 50, or 500 mg/kg) 2 hours before aortic injury. Four hours later interleukin-6 (IL-6), IL-10, and macrophage migration inhibitory factor (MIF) concentrations in serum and tissue of injured aortas were assessed. Two weeks after injury, damaged aortas were harvested and studied histopathologically. Compared with results in controls, MP at a dose of 5 mg/kg significantly inhibited increases in plasma and tissue levels of IL-6 and significantly reduced the pseudointimal area, pseudointimal/medial area ratio, and proliferating cell nuclear antigen index in injured vessels. Administration of MP had no significant effect on the IL-10 or MIF level. Thus in a rat model of balloon aortic injury, preinjury administration of MP 5 mg/kg mitigated the development of PIH and cell proliferation and suppressed the postinjury increase in serum and tissue IL-6 concentrations. These results suggest that there is an appropriate dosage as well as appropriate timing for MP administration to suppress PIH.

[Expressive level of vascular endothelial growth factor in peripheral blood in patients with pituitary adenomas]

OBJECTIVE

To discuss whether vascular endothelial growth factor (VEGF) in the peripheral blood can reflect the biological activities of pituitary adenomas.

METHODS

The concentrations of VEGF in peripheral blood were measured with ELISA in 203 patients with pituitary adenomas, 22 patients with pituitary hyperplasia, 7 patients with pituitary Rathke' pouch and 3 patients with pituitary abscess.

RESULTS

The serum VEGF levels were (366.8 +/- 211.1) pg/ml and (286.8 +/- 107.6) pg/ml in patients with pituitary adenomas and pituitary hyperhasia, respectively, which were higher than those in patients with pituitary Rathke' pouch [(180.5 +/- 61.7) pg/ml], patients with pituitary abscess [(147.5 +/- 46.3) pg/ml] and the health control [(180.8 +/- 56.2) pg/ml] (P < 0.05). In patients with pituitary adenomas, the VEGF levels were (380.0 +/- 234.5) pg/ml in macroadenomas and (380.1 +/- 2870.3) pg/ml in giant adenomas, higher than those in microadenomas [(294.6 +/- 111.6) pg/ml] and in pituitary hyperhasia respectively (P < 0.05). The serum VEGF levels were not significantly different in pituitary adenoma in terms of invasive growth, apoplexy, cyst and hormone secretory functions (P > 0.05).

CONCLUSIONS

The upregulation of serum VEGF expression may reflect the biological activities of pituitary adenoma. However, it may not be associated with pituitary Rathke' pouch, pituitary abscess, adenoma with invasiveness, apoplexy, cyst and hormone secretory function. The serum VEGF levels could be helpful in differentiating pituitary adenoma from pituitary Rathke' pouch and pituitary abscess.

Ovarian stromal hyperplasia and ovarian vein steroid levels in relation to endometrioid endometrial cancer

OBJECTIVE

To study the relationship between the presence of endometrioid endometrial cancer, the degree of ovarian stromal hyperplasia and ovarian steroid production in postmenopausal women.

DESIGN

Retrospective and prospective study, respectively.

SETTING

Medical Centre Leeuwarden and the University Hospital Groningen, The Netherlands. Postmenopausal women with or without endometrial cancer, undergoing a hysterectomy with bilateral salpingo-oophorectomy.

METHODS

In 112 women with endometrioid endometrial cancer, 47 women with a benign gynaecological condition and 10 women with non-endometrioid endometrial cancer, the degree of ovarian stromal hyperplasia was scored retrospectively on a semi-quantitative scale (atrophy, slight, marked). All women were postmenopausal and had undergone a hysterectomy with bilateral salpingo-oophorectomy. Prospectively, blood sampling from the ovarian veins was performed in a further 60 women. Steroid levels (oestrone, oestradiol, androstenedione, testosterone) were determined and related to the degree of ovarian stromal hyperplasia and the presence (n = 52) or absence (n = 8) of endometrioid endometrial cancer.

MAIN OUTCOME MEASURES

Degree of ovarian stromal hyperplasia and steroid levels in the utero-ovarian circulation.

RESULTS

In the retrospective study, the degree of ovarian stromal hyperplasia was higher in the presence of endometrioid endometrial cancer (P = 0.0001). The prospective study showed that an increasing degree of ovarian stromal hyperplasia was related to higher ovarian levels of both testosterone and androstenedione (P < 0.05 and P < 0.005, respectively), but not to oestrone or oestradiol. A non-significant increase in mean ovarian vein levels of both testosterone and androstenedione was seen in patients with endometrial cancer as compared with patients with benign conditions.

CONCLUSION

In endometrioid endometrial cancer, higher degrees of ovarian stromal hyperplasia were found and with increasing degrees of ovarian stromal hyperplasia, levels of ovarian vein androgens were higher. A causal relationship in the origin of hormone-dependent endometrial pathology may exist between ovarian stromal hyperplasia, ovarian vein androgen levels and endometrioid endometrial carcinoma.

Intraoperative parathormone measurement in patients with primary hyperparathyroidism: a prospective clinical study

BACKGROUND

The objective of this pilot study was to evaluate the use of intraoperative iPTH measurement in combination with bilateral neck exploration in patients with primary hyperparathyroidism.

METHODS

A prospective study was conducted in a single centre university hospital in Switzerland comprising 33 patients with primary hyperparathyroidism undergoing neck surgery. No routine preoperative localisation studies were conducted. Intraoperative iPTH measurement was performed at defined times. Exploration was discontinued when iPTH fell below 15% of baseline.

RESULTS

For all patients with adenoma the median serum iPTH decreased to 11.9% (standard deviation 5.5%) of baseline concentrations. All patients with hyperplasia achieved normocalcaemia. At median follow-up of 17.7 weeks neither recurrent nor persistent hypercalcaemia was observed. Eleven patients were explored unilaterally.

CONCLUSION

Measurement of intraoperative serum iPTH is a helpful tool in the differentiation of single adenoma from hyperplastic glands. When we call for a strict 78% decrease in serum iPTH from base levels after 10 minutes, measurement of this marker protein even allows differentiation of single- from multi-glandular disease.