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Schöning JV, Flitsch J, Lüdecke DK, Fahlbusch R, Buchfelder M, Buslei R, Knappe UJ, Bergmann M, Schulz-Schaeffer WJ, Herms J, Glatzel M, Saeger W. Multiple tumorous lesions of the pituitary gland. Hormones (Athens) 2022; 21:653-663. [PMID: 35947342 PMCID: PMC9712358 DOI: 10.1007/s42000-022-00392-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 07/19/2022] [Indexed: 12/22/2022]
Abstract
PURPOSE/OBJECTIVE Multiple tumorous lesions in one pituitary gland are rare and mostly described in case reports. Their incidences and combinations are defined in larger collectives. Therefore, we analyzed our large collection for double tumors and combinations of tumors, cysts, and inflammation. METHODS The German Registry of Pituitary Tumors, including cases from 1990 to 2018, served as the database. Our collection comprises a total of 16,283 cases up until the end of 2018. Of these cases, 12,673 originated from surgical and 3,610 from autopsy material. All specimens were fixed in formalin and embedded in paraffin. The sections were stained with hematoxylin-eosin and PAS. Monoclonal (prolactin, TSH, FSH, LH, and α subunit) or polyclonal (GH and ACTH) antibodies were used to detect pituitary hormones in the lesions. Since 2017, antibodies against the transcription factors Pit-1, T-Pit, and SF-1 have been used in difficult cases. The criteria of the 2017 WHO classification have been basic principles for classification since 2018 (Osamura et al. 2017). For differentiation of other sellar tumors, such as meningiomas, chordomas, or metastases, the use of additional antibodies was necessary. For these cases, it was possible to use a broad antibody spectrum. Autopsy pituitaries were generally studied by H&E and PAS sections. If any lesions were demonstrated in these specimens, additional immunostaining was performed. RESULTS Multiple tumorous lesions with more than one pituitary neuroendocrine tumor (PitNET) respectively adenoma make up 1.4% (232 cases) in our collection. Within the selected cases, synchronous multiple pituitary neuroendocrine tumors (PitNETs) account for 17.3%, PANCH cases (pituitary adenoma with neuronal choristoma) for 14.7%, PitNETs and posterior lobe tumors for 2.2%, PitNETs and metastases for 5.2%, PitNETs and mesenchymal tumors for 2.6%, PitNETs and cysts for 52.2%, and PitNETs and primary inflammation for 6.0%. The mean patient age was 53.8 years, with a standard deviation of 18.5 years. A total of 55.3% of the patients were female and 44.7% were male. From 1990 to 2018, there was a continuous increase in the number of multiple tumorous lesions. CONCLUSION From our studies, we conclude that considering possible tumorous double lesions during surgeries and in preoperative X-ray analyses is recommended.
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Affiliation(s)
- Jannik von Schöning
- Institute of Neuropathology, University of Hamburg, UKE, Martinistraße 52, 20246 Hamburg, Germany
| | - Jörg Flitsch
- Clinic of Neurosurgery, University of Hamburg, UKE, 20246 Hamburg, Germany
| | - Dieter K. Lüdecke
- Clinic of Neurosurgery, University of Hamburg, UKE, 20246 Hamburg, Germany
| | - Rudolf Fahlbusch
- International Neuroscience Institute (INI), Rudolf-Pichelmayr-Str. 4, 30625 Hannover, Germany
| | - Michael Buchfelder
- Clinic of Neurosurgery, Friedrich-Alexander University Erlangen-Nürnberg (FAU), 91054 Erlangen, Germany
| | - Rolf Buslei
- Institute of Pathology, SozialStiftung Bamberg, 96049 Bamberg, Germany
| | - Ulrich J. Knappe
- Department of Neurosurgery, Johannes-Wesling-Klinikum Minden, 32429 Minden, Germany
| | - Markus Bergmann
- Institute of Neuropathology, Klinikum Bremen-Mitte, 28205 Bremen, Germany
| | | | - Jochen Herms
- Zentrum für Neuropathologie und Prionforschung, LMU-University of Munich, 81377 Munich, Germany
| | - Markus Glatzel
- Institute of Neuropathology, University of Hamburg, UKE, Martinistraße 52, 20246 Hamburg, Germany
| | - Wolfgang Saeger
- Institute of Neuropathology, University of Hamburg, UKE, Martinistraße 52, 20246 Hamburg, Germany
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Crock PA, Lüdecke DK, Knappe UJ, Saeger W. A personal series of 100 children operated for Cushing's disease (CD): optimizing minimally invasive diagnosis and transnasal surgery to achieve nearly 100% remission including reoperations. J Pediatr Endocrinol Metab 2018; 31:1023-1031. [PMID: 30098286 DOI: 10.1515/jpem-2018-0262] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Accepted: 06/29/2018] [Indexed: 01/01/2023]
Abstract
Background Transnasal surgery (TNS) is the first choice in the treatment of pediatric Cushing's disease. The question is how can high remission rates be achieved with minimally invasive investigations and TNS whilst avoiding radiotherapy or bilateral adrenalectomy in children. Methods Data from a published series 1 (n=55) of surgeon DKL will be compared with his recent series 2 (n=45) until 2009. All patients were operated by direct transnasal microsurgery. Over time, inferior petrosal sinus sampling (IPSS) was replaced by cavernous sinus sampling (CSS), restricted to unclear cases without increase of salivary cortisol in corticotropin-releasing hormone-test, difficult sellar anatomy or negative magnetic resonance imaging (MRI). Multiple direct intra-operative micro-cytology, micro-doppler and adequate visualization techniques are described. Results In series 1, IPSS was performed in 13 (24%) of whom 46% had false adenoma lateralization. All adenomas could be removed with extensive pituitary exploration. Three patients had early successful re-surgery. In series 2, with more refined MRI and endocrinology, CSS was used in only seven patients (15%) and all micro-adenomas were correctly localized. In three of four patients with persistent cortisol excess, repeat-TNS was necessary and successful. Side effects of TNS were minimal. Recurrence rates were 16% and 11% in series 1 and 2, respectively. Only four of 100 children with invasive adenomas were irradiated, significantly less than in other experienced pediatric centers. Conclusions Thus, 98% remission rate could be achieved with fewer invasive pre-surgical investigations, such as central catheter studies, refined TNS and early repeat-TNS. Repeat-TNS in recurrences minimized the need for irradiation.
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Affiliation(s)
- Patricia A Crock
- Department Paediatric Endocrinology and Diabetes, John Hunter Children's Hospital, Locked Bag 1, Hunter Region Mail Centre, Newcastle, NSW 2310, Australia.,PRC GrowUpWell®, Hunter Medical Research Institute and Department Paediatrics, University of Newcastle, Newcastle, NSW, Australia, Phone: +61249855634, Fax: +61249213599
| | - Dieter K Lüdecke
- Retired Emeritus Pituitary Surgeon, Department Neurosurgery, University Hospital Eppendorf, Hamburg, Germany
| | - Ulrich J Knappe
- Department Neurosurgery, Johannes Wesling Klinikum, University Hospital of the Ruhr University Bochum, Minden, Germany
| | - Wolfgang Saeger
- Department of Neuropathology, Pituitary Pathologist, University Hospital Eppendorf, Hamburg, Germany
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Saeger W, Müller M, Buslei R, Flitsch J, Fahlbusch R, Buchfelder M, Knappe UJ, Crock PA, Lüdecke DK. Recurrences of Pituitary Adenomas or Second De Novo Tumors: Comparisons with First Tumors. World Neurosurg 2018; 119:e118-e124. [PMID: 30026158 DOI: 10.1016/j.wneu.2018.07.056] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Revised: 07/05/2018] [Accepted: 07/07/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Recurrences of pituitary adenomas are not so rare. METHODS In the German Registry of Pituitary Tumors, more than 12,000 surgical specimens were collected between 1967 and 2012, of which 312 patients with altogether 334 recurrences (n = 646 specimens) were included in our study. RESULTS The histopathology of 162 recurrent adenomas could be compared with the original tumor and 37 second recurrences could be compared with the first recurrence. Comparing the proliferation index (Ki-67) of the original and the first recurrent tumor (n = 162), we found an unchanged index in 43 cases (26%), whereas in 69 cases (43%) the index increased and in 50 cases (31%) it decreased. Comparing the first with the second recurrence (n = 37), we found an unchanged index in 8 cases (22%), an increased index in 15 cases (40%), and a decreased index in 14 cases (38%). The third recurrence showed an unchanged index in 1 case (20%), an increased index in 2 cases (40%), and a decreased index in 2 cases (40%). p53 was unchanged in recurrences in 44% of cases, increased in 33%, and decreased in 22%. In 4 cases, adenomas developed into adenomas with strongly increased proliferation (formerly atypical adenomas, now aggressive adenomas) for the first recurrence, and 9 recurrences became aggressive adenomas. A change of tumor type without change of the common transcription factor occurred in 82 cases. CONCLUSIONS A second independent de novo adenoma was present in 10 cases, probably due to changes of transcription factors.
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Affiliation(s)
- Wolfgang Saeger
- Institute of Neuropathology, University of Hamburg, Hamburg, Germany.
| | - Maximilian Müller
- Institute of Neuropathology, University of Hamburg, Hamburg, Germany
| | - Rolf Buslei
- Institute of Pathology, SozialStiftung Bamberg, Bamberg, Germany
| | - Jörg Flitsch
- Clinic of Neurosurgery, University of Hamburg, Hamburg, Germany
| | | | - Michael Buchfelder
- Clinic of Neurosurgery, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Ulrich J Knappe
- Department of Neurosurgery, Johannes-Wesling-Klinikum Minden, Minden, Germany
| | - Patricia A Crock
- Department of Paediatric Endocrinology, John Hunter Children's Hospital, University of Newcastle, Newcastle, Australia
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Hagel C, Buslei R, Buchfelder M, Fahlbusch R, Bergmann M, Giese A, Flitsch J, Lüdecke DK, Glatzel M, Saeger W. Immunoprofiling of glial tumours of the neurohypophysis suggests a common pituicytic origin of neoplastic cells. Pituitary 2017; 20:211-217. [PMID: 27744503 DOI: 10.1007/s11102-016-0762-x] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE To analyse the antigen expression profiles of 27 cases of pituicytoma, spindle cell oncocytoma, and granular cell tumour of the sellar region concerning a common pituicytic origin of neoplastic cells. METHODS Material from 12 female and 15 male patients (13 granular cell tumours of the sellar region, 10 pituicytomas, four spindle cell oncocytomas) collected in the German Registry of Pituitary Tumours between 1993 and 2015 was re-evaluated according to the current WHO classification of tumours of the central nervous system and supplementary immunohistochemistry including S100-protein, CD56, CD68, thyroid transcription factor-1 (TTF-1), and Ki-67 was performed. RESULTS S100-protein was detected in all 27 tumours and TTF-1 in all 16 tumours that were assessed. Vimentin was expressed in all 13 cases investigated whereas broad spectrum cytokeratin was not detected in any of 14 evaluated cases. GFAP was observed in nine out of 21 cases. 15 out of 17 investigated lesions showed some CD68 expression and five out of 14 cases were labelled with CD56 antibodies. Proliferative activity did not differ significantly between the three tumour subgroups although one primary and one recurrent pituicytoma showed exceptionally high Ki-67-proliferation indices of 15.3 and 12.7 %, respectively (means: granular cell tumour of the sellar region 2.0 %, pituicytoma 2.8 %, spindle cell oncocytoma 2.7 %). CONCLUSIONS The study confirms and expands earlier data and is in line with the notion that the three tumour types are variants of pituicytoma.
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Affiliation(s)
- Christian Hagel
- Institute of Neuropathology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Rolf Buslei
- Department of Neuropathology, Friedrich-Alexander University Erlangen-Nürnberg, Schwabachanlage 6, 91054, Erlangen, Germany
| | - Michael Buchfelder
- Neurochirurgische Klinik, Universitätsklinikum Erlangen, Schwabachanlage 6, 91054, Erlangen, Germany
| | - Rudolf Fahlbusch
- International Neuroscience Institute (INI), Rudolf-Pichelmayr-Str. 4, 30625, Hannover, Germany
| | - Markus Bergmann
- Klinikum Bremen-Mitte, Zentrum für Pathologie, Institut für klinische Neuropathologie, St.-Jürgen-Str. 1, 28177, Bremen, Germany
| | - Armin Giese
- Zentrum für Neuropathologie und Prionforschung, Ludwig-Maximilians-Universität München, Feodor-Lynen-Str. 23, 81377, Munich, Germany
| | - Jörg Flitsch
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Dieter K Lüdecke
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Markus Glatzel
- Institute of Neuropathology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Wolfgang Saeger
- Institute of Neuropathology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.
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Miermeister CP, Petersenn S, Buchfelder M, Fahlbusch R, Lüdecke DK, Hölsken A, Bergmann M, Knappe UJ, Hans VH, Flitsch J, Saeger W, Buslei R. Erratum: Histological criteria for atypical pituitary adenomas--data from the German pituitary adenoma registry suggests modifications. Acta Neuropathol Commun 2016; 4:21. [PMID: 26984397 PMCID: PMC4794839 DOI: 10.1186/s40478-016-0290-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Accepted: 02/15/2016] [Indexed: 11/17/2022] Open
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Miermeister CP, Petersenn S, Buchfelder M, Fahlbusch R, Lüdecke DK, Hölsken A, Bergmann M, Knappe HU, Hans VH, Flitsch J, Saeger W, Buslei R. Histological criteria for atypical pituitary adenomas - data from the German pituitary adenoma registry suggests modifications. Acta Neuropathol Commun 2015; 3:50. [PMID: 26285571 PMCID: PMC4545559 DOI: 10.1186/s40478-015-0229-8] [Citation(s) in RCA: 83] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2015] [Accepted: 08/06/2015] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION The term atypical pituitary adenoma (APA) was revised in the 2004 World Health Organization (WHO) classification of pituitary tumors. However, two of the four parameters required for the diagnosis of APAs were formulated rather vaguely (i.e., "extensive" nuclear staining for p53; "elevated" mitotic index). Based on a case-control study using a representative cohort of typical pituitary adenomas and APAs selected from the German Pituitary Tumor Registry, we aimed to obtain reliable cut-off values for both p53 and the mitotic index. In addition, we analyzed the impact of all four individual parameters (invasiveness, Ki67-index, p53, mitotic index) on the selectivity for differentiating both adenoma subtypes. METHODS Of the 308 patients included in the study, 98 were diagnosed as APAs (incidence 2.9 %) and 10 patients suffered from a pituitary carcinoma (incidence 0.2 %). As a control group, we selected 200 group matched patients with typical pituitary adenomas (TPAs). Cut-off values were attained using ROC analysis. RESULTS We determined significant threshold values for p53 (≥2 %; AUC: 0.94) and the mitotic index (≥2 mitosis within 10 high power fields; AUC: 0.89). The most reliable individual marker for differentiating TPAs and APAs was a Ki-67-labeling index ≥ 4 % (AUC: 0.98). Using logistic regression analysis (LRA) we were able to show that all four criteria (Ki-67 (p < 0.001); OR 5.2// p53 (p < 0.001); OR 3.1// mitotic index (p < 0.001); OR 2.1// invasiveness (p < 0.001); OR 8.2)) were significant for the group of APAs. Furthermore, we describe the presence of nucleoli as a new favorable parameter for TPAs (p = 0.008; OR: 0.4; CI95 %: 0.18; 0.77). CONCLUSIONS Here we present a proposed rectification of the current WHO classification of pituitary tumors describing an additional marker for TPA and specific threshold values for p53 and the mitotic index. This will greatly help in the reliable diagnosis of APAs and facilitate further studies to ascertain the prognostic relevance of this categorization.
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Affiliation(s)
- Christian P Miermeister
- Departments of Neuropathology, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Schwabachanlage 6, 91054, Erlangen, Germany
| | - Stephan Petersenn
- ENDOC Center for Endocrine Tumors, Hamburg & University of Duisburg-Essen, Essen, Germany
| | - Michael Buchfelder
- Departments of Neurosurgery, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Rudolf Fahlbusch
- Department of Neurosurgery, International Neuroscience Institute, Hannover, Germany
| | - Dieter K Lüdecke
- Departments of Neurosurgery, University Clinic Hamburg-Eppendorf, Hamburg, Germany
| | - Annett Hölsken
- Departments of Neuropathology, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Schwabachanlage 6, 91054, Erlangen, Germany
| | - Markus Bergmann
- Department of Neuropathology, Klinikum Bremen Mitte, Bremen, Germany
| | - Hans Ulrich Knappe
- Department of Neurosurgery, Johannes Wesling Hospital Minden, Minden, Germany
| | - Volkmar H Hans
- Department of Pathology, Ruhr University Bochum, Bochum, Germany
| | - Jörg Flitsch
- Departments of Neurosurgery, University Clinic Hamburg-Eppendorf, Hamburg, Germany
| | - Wolfgang Saeger
- Departments of Neuropathology, University Clinic Hamburg-Eppendorf, Hamburg, Germany
| | - Rolf Buslei
- Departments of Neuropathology, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Schwabachanlage 6, 91054, Erlangen, Germany.
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Lüdecke DK, Herrmann HD, Schulte FJ. Special problems with neurosurgical treatments of hormone-secreting pituitary adenomas in children. Prog Exp Tumor Res 2015; 30:362-70. [PMID: 3628819 DOI: 10.1159/000413695] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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Abstract
OBJECT
Correct diagnosis and precise localization of adenomas in patients with Cushing's disease are essential for avoiding unsuccessful transsphenoidal pituitary exploration. In addition to the well-established inferior petrosal sinus sampling, preoperative cavernous sinus sampling (CSS) was introduced as a potentially improved way to predict adenoma lateralization. The authors present their results with CSS in a consecutive series of patients with Cushing's disease.
METHODS
During 1999–2014, transsphenoidal surgeries were consecutively performed in 510 patients with Cushing's disease. For most patients, suppression of cortisol in high-dose dexamethasone tests and stimulation of adrenocorticotropic hormone and cortisol after administration of corticotropin-releasing hormone were sufficient to prove the diagnosis of adrenocorticotropic hormone–dependent hypercortisolism. Of the 510 patients, 67 (13%) were referred to the department of neuroradiology for CSS according to the technique of Teramoto. The indications for CSS were unclear endocrine test results or negative MRI results. Data for all patients were retrospectively analyzed.
RESULTS
A central/peripheral gradient was found in 59 patients; lateralization to the left or right side was found in 51. For 8 patients with a central/peripheral gradient, no left/right gradient could be determined. For another 8 patients with equivocal test results, no central/peripheral gradient was found. No severe CSS-associated complications were encountered. Of the 51 patients who underwent transsphenoidal surgery, the predicted lateralization was proven correct for 42 (82%).
CONCLUSIONS
As MRI techniques have improved, the number of potential candidates for this invasive method has decreased in the past decade. However, because detecting minute adenomas remains problematic, CSS remains a useful diagnostic tool for patients with Cushing's disease.
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Affiliation(s)
| | | | | | - Nina Sauer
- 3Department of Endocrinology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Jens Aberle
- 3Department of Endocrinology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
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Maltby VE, Crock PA, Lüdecke DK. A rare case of pituitary infarction leading to spontaneous tumour resolution and CSF-sella syndrome in an 11-year-old girl and a review of the paediatric literature. J Pediatr Endocrinol Metab 2014; 27:939-46. [PMID: 24859515 DOI: 10.1515/jpem-2014-0143] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2014] [Accepted: 04/16/2014] [Indexed: 11/15/2022]
Abstract
Pituitary infarction or apoplexy with spontaneous cure of the underlying pituitary adenoma is rare. In the paediatric population, we found only a few reported cases. We report a rare case of pituitary infarction progressing to CSF-sella syndrome (or empty sella) in an 11-year-old girl. She presented with sudden onset vomiting, moderate headaches, lethargy, weight loss, and tall stature above her mid-parental height. She did not have any severe symptoms of apoplexy. Her clinical and radiological findings suggested infarction of a pituitary lesion, such as a pituitary adenoma or infarction of a cystic lesion, such as a Rathke's cleft cyst. In this report, we discuss her case of probable infarction of a growth hormone secreting adenoma with a phase of accelerated growth ending up with total anterior pituitary insufficiency. The differential diagnosis and review of the rare cases of paediatric pituitary infarction in the literature will be discussed.
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Lüdecke DK, Crock PA, Bidlingmaier M, Schuppert F. Novel use of endogenous GH-measurement directly after transsphenoidal microsurgery in acromegaly treated with pegvisomant. Exp Clin Endocrinol Diabetes 2013; 121:509-12. [PMID: 23765756 DOI: 10.1055/s-0033-1347253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVE The GH receptor antagonist pegvisomant is increasingly used as therapy in acromegaly. Pituitary surgery might be indicated on pegvisomant treatment, due to side effects, adenoma growth or intention to cure after primary treatment. This study was initiated to clarify if, and when, GH measurement could be useful postoperatively with an assay specific for endogenous GH that does not cross-react with pegvisomant. METHODS This study was designed as a prospective study in 2006 with the German Pituitary Working Group. Only 2 cases with potentially resectable adenomas from the German Pegvisomant Observational Study (GPOS) had been operated. Now with a post-operative follow-up of more than 5 years in these 2 cases, the usefulness of immediate pre-operative GH measurement shortly after pegvisomant treatment was evaluated. RESULTS In both patients a steep decline of endogenous GH after transnasal microsurgery could be proven by using the special GH assay after near radical or radical removal, of the GH secreting adenomas respectively. Conventional GH assays showed no effect. GH half-life was more than 20 min in the patient with a small invasive residual adenoma and less than 20 min in the cured patient. Endogenous GH-levels declined to less than 1 ng/ml in the days after surgery in the patient with long-term cure. CONCLUSION Measurement of endogenous GH in this special subgroup of patients under pegvisomant therapy can be used to decide upon early reoperation. Thus the beneficial effect of pegvisomant on acromegalic symptoms can be kept without interfering with post-operative monitoring of GH levels.
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Affiliation(s)
- D K Lüdecke
- Department of Neurosurgery, University Hospital Hamburg, Germany
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Haase M, Schott M, Kaminsky E, Lüdecke DK, Saeger W, Fritzen R, Schinner S, Scherbaum WA, Willenberg HS. Cushing's disease in a patient with steroid 21-hydroxylase deficiency. Endocr J 2011; 58:699-706. [PMID: 21646730 DOI: 10.1507/endocrj.k11e-097] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Cushing's disease rarely appears as a consequence of hereditary disease. However, familial diseases with diminished glucocorticoid feedback are associated with secondary hypercorticotropinism and have been shown to give rise to pituitary adenomas. We here describe the rare case of a 30-year old female patient with congenital adrenal hyperplasia who also showed clinical signs and a typical history of hypercortisolism that was specified as Cushing's disease. After removal of a pituitary microadenoma, serum-cortisol levels fell below normal and the symptoms improved. However, after four years the menstrual cycle was irregular again and ACTH levels were in the upper range of normal. A corticotropin challenge showed a minor cortisol response but a marked increase in 17-hydroxyprogesterone serum concentrations. Genetic analysis revealed a homozygous mutation in exon 7 of the CYP21A2 gene (CTG>TTG, p.V281L). We conclude that a marked ACTH drive was able to override insufficient 21-hydroxylation and even to cause hypercortisolism. Although we describe a rare case, the impairment of the glucocorticoid feedback system in the context of congenital adrenal hyperplasia and other diseases may contribute to the development of secondary hypercorticotropinism as well as corticotropin producing adenomas.
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Affiliation(s)
- Matthias Haase
- Department of Endocrinology, Diabetes and Rheumatology, University Hospital Duesseldorf, Germany.
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Sokolova I, Lüdecke DK, Flitsch J. Long-term follow-up after transsphenoidal surgery for acromegaly. Exp Clin Endocrinol Diabetes 2010. [DOI: 10.1055/s-0030-1267022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Abstract
Acromegaly is a rare disease caused by a growth-hormone-secreting pituitary adenoma. Symptoms include enlargement of the hands, feet, and jaw with growing dental interspaces, as well as hypertrophy of the tongue and nasal and sinusoidal mucosa. The two latter symptoms are mostly responsible for the accompanying obstructive sleep apnea syndrome. Besides these "cosmetic" symptoms, the disease is associated with hypertension and diabetes mellitus, as well as with an increased risk for adenomas and carcinomas of the colon. The average time span from first symptom to diagnosis is well over 6 years; a single determination of insulin-like growth factor 1 in serum can confirm the disease. The treatment of choice remains surgical resection of the adenoma in suitable patients, whereas in extensive disease with invasion of surrounding tissue, drug therapy and/or radiotherapy may be necessary.
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Affiliation(s)
- J Flitsch
- Bereich Hypophysenchirurgie, Neurochirurgische Klinik, Universitätskrankenhaus Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg.
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Betzold JM, Saeger W, Lüdecke DK. Ultrastructural-morphometric effects of radiotherapy on pituitary adenomas in acromegaly. Exp Clin Endocrinol 2009; 100:106-11. [PMID: 1305059 DOI: 10.1055/s-0029-1211187] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Within a series of 22 irradiated GH-producing adenomas we studied by light microscopical and morphometrical means the grading of nuclear pleomorphism, the proportion of densely granulated cells, the number of mitoses, multinuclear cells, necrotic or necrobiotic cells, and the degree of fibrosis in comparison to non-irradiated tumours. By electronmicroscopical morphometry we investigated the changes in area, circumference, area percentage, and number of intracellular structures. The rate of necrobiotic cells and the grade of nuclear pleomorphism were significantly higher in the irradiated tumours. The fibrotic areas were larger. No differences were observed in the degree of granulation and the rate of multinuclear cells. Mitoses were found in only one tumour. Within the group of the well-differentiated adenomas the areas and circumferences of the nuclei, nucleoli, mitochondria, immature secretory granules, and secretory granules increased significantly. The area percentages of the nuclei, mitochondria, immature secretory granules, and secretory granules increased as well. The mitochondria, Golgi-fields, and the rough endoplasmatic reticulum decreased in number. The undifferentiated adenomas changed almost in the same significant way. To us most of these changes are a sign of irradiation damage. The enlargement of intracellular structures could be a sign of an increased rate of secretory activity.
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Affiliation(s)
- J M Betzold
- Department of Pathology, Marienkrankenhaus Hamburg, F.R.G
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Abstract
Gangliocytomas are benign, slow growing neuronal tumors and are found for the most part in children and young adults. They are most often localized in either the spinal cord or the cerebral hemispheres. Gangliocytomas in the sellar region are extremely rare and only 43 such tumors (including 4 own cases) have ever been described in the literature. Although these tumors are genuine rarities without any epidemiological importance, they do provide some interesting information on tumorigenesis of pituitary adenomas: 65% of the sellar gangliocytomas are associated with a pituitary adenoma. 74% of patients with these tumors suffered hormonal oversecretion of at least one of the pituitary hormones (mostly growth hormone). With only one exception, the hypothalamic releasing hormone corresponding to the hormonal oversecretion syndrome could be demonstrated in the gangliocytoma immunohistochemically. Ultrastructural studies could demonstrate close cell to cell contacts between adenoma and gangliocytome cells. All these data support the hypothesis that chronic overstimulation by hypothalamic releasing hormones play a role in the development of hormone secreting pituitary adenomas. However, in contrast to sellar gangliocytemas, extrahypothalamic tumors secreting excessive hypothalamic hypophysiotropic hormones have never been associated with a pituitary adenoma. They have only been associated with pituitary cell hyperplasia. Therefore, the hypothesis can be made that hypothalamic releasing hormones only promote but do not initiate tumorigenesis of pituitary adenomas.
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Affiliation(s)
- M J Puchner
- Department of Neurosurgery, University Hospital Eppendorf, Hamburg, Germany
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16
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Abstract
In the sellar region most tumors of our collection (n = 1937) are pituitary adenomas, followed by craniopharyngiomas, chordomas and meningiomas. Difficulties in morphological differential diagnosis by light microscopy may occur in meningiomas, plasmacytomas, chordomas and germinomas. In these cases, immunohistological investigations and sometimes even electron microscopy are helpful in solving the problems. Meningiomas can sometimes resemble pituitary adenomas. Of diagnostic value in these cases is the expression of vimentin and S-100-protein in the meningioma cells. Plasmacytomas may also mimic pituitary adenomas. In these cases, the positive reaction with antibodies against LCA and immunoglobulins or against kappa-light-chains and lambda-light-chains leads to the diagnosis. Chordomas, too, can sometimes be hardly distinguished from pituitary adenomas. In these cases, the expression of S-100-protein, vimentin and CEA by the chordoma cells and the typical electron microscopic features of chordomas are helpful for the differential diagnosis. Germinomas may sometimes be indistinguishable from lymphocytic hypophysitis. Of diagnostic importance are here the expression of HCG and placental alkaline phosphatase by germinoma cells. In the above mentioned cases, it is also important to perform immunohistochemical examinations for pituitary hormones including alpha-subunit. All these tumors do not express these hormones.
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Affiliation(s)
- D Sautner
- Department of Pathology of the Marienkrankenhaus, Hamburg, Germany
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Kurosaki M, Saegert W, Abe T, Lüdecke DK. Expression of vascular endothelial growth factor in growth hormone-secreting pituitary adenomas: special reference to the octreotide treatment. Neurol Res 2009; 30:518-22. [PMID: 18953743 DOI: 10.1179/174313208x289499] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
OBJECTIVE The present study was designed to investigate the localization of VEGF in GH-secreting pituitary adenomas and to evaluate the characteristic differences of VEGF expression in relation to the clinical effect of preoperative treatment with octreotide. METHODS Fifty-six cases of GH-secreting adenomas, which were divided into three groups and three normal pituitary glands, were studied using immunohistochemistry for expression of VEGF. The octreotide group consisted of 33 patients who received the octreotide before the surgery. The bromocriptine group consisted of 11 patients who received bromocriptine orally. The control groups consisted of 12 patients who were not treated with octreotide or bromocriptine pre-operatively. VEGF staining patterns for each specimen were examined under light microscopy and graded in a scale. These findings were correlated with clinical characteristics. RESULTS VEGF was displayed in a diffuse cytoplasmic pattern in all cases. VEGF staining was strongly seen in the cytoplasm in normal pituitary glands. Moderately positive staining with VEGF appeared in six of 33 (18%) cases of the octreotide group, and in eight of 12 (67%) cases of the control group. In contrast, weakly positive staining was observed in 25 of 33 (76%) cases of the octreotide group, and in three of 12 (25%) cases of the control group. The staining pattern differs statistically between the octreotide and control group, typically in densely granulated GH cell adenomas. Weak staining with VEGF appeared in all ten cases in which the tumor had shrunk. Age, gender, tumor size, tumor invasiveness and adenoma type did not influence VEGF expression. CONCLUSION We conclude that octreotide may inhibit the angiogenesis through down-regulation of VEGF.
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Affiliation(s)
- Masamichi Kurosaki
- Department of Neurosurgery, Institute of Neurological Sciences, Tottori University Faculty of Medicine, Yonago, Japan.
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18
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Abstract
The growth of prostate cancer is controlled by several hormones and growth factors. In cases of metastasized prostate cancer, antigonadotropic therapy is currently considered state-of-the-art treatment. Surgical therapies such as adrenalectomy and hypophysectomy are no longer in use. Nevertheless, hypophysectomy has proven efficacy for palliative pain treatment as well as increasing duration of survival. The authors present the case of a 63-year-old man with metastatic prostate cancer who presented with high serum prostate-specific antigen levels (1216 microg/L) and cavernous sinus syndrome. His disease was progressing despite leuprorelin and docetaxel therapy, and he had severe bone pain despite high-dose pain therapy. He was also anemic. Contrast-enhanced MR imaging showed a pituitary lesion as well as metastatic infiltration of the skull base including the cavernous sinus. The patient's serum level of prolactin was mildly elevated, testosterone was below the detection limit, and insulin-like growth factor-I (IGF-I) was in the upper range for a patient of his age (233 microg/L). Because of the elevated prolactin and high-normal IGF-I levels he was offered a hypophysectomy in addition to pituitary tumor removal. Histological examination of the resected lesion confirmed a nonsecreting pituitary adenoma with infiltration of prostate cancer cells. Postoperatively the patient's prostate-specific antigen levels dropped to 876 microg/L, his bone pain resolved, and the cavernous sinus syndrome improved. Nevertheless, he died of septicemia 4 months after surgery. Older publications as well as this case have shown the benefit of hypophysectomy for pain treatment. A reduction of IGF-I levels even in the final stage metastasized prostate cancer may play a major role. Respectively, clinical studies with somatostatin analogs are currently in progress, which may lead to a "new" way of treatment in these otherwise hopeless patients. On the basis of the pain relief seen after hypophysectomy in this case and similar benefits reported in older publications, the authors raise the question whether this treatment should be offered more frequently, and whether additional medical options of hormone treatment may be beneficial in similar cases.
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Affiliation(s)
- Jörg Flitsch
- Pituitary Unit, Department of Neurosurgery, Institute of Neuropathology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
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Abstract
The case of a 61-year-old man presenting with dizziness, nausea, vomiting, reduced serum osmolality, and hyponatremia is reported. Endocrinologically, low levels for ADH, cortisol and testosterone as well as low-normal values for ACTH, LH and FSH were detected. Cranial computed tomography and MRI scans revealed an intra- and suprasellar tumor of adenoma-like appearance with elevation of the optic chiasm. No infiltration of the cavernous sinus was seen. After transsphenoidal resection of the tumor, no additional anterior lobe insufficiencies or diabetes insipidus occurred. Histological examination revealed a tumor consisting of spindle-shaped cells of uniformly high cellularity with no evidence of hypocellular areas. A cellular schwannoma was diagnosed. An intrasellar cellular schwannoma clinically and radiologically mimicking a non-secreting pituitary adenoma is uncommon. However, rare entities like schwannomas, melanocytomas or pituicytomas have to be considered in addition to the more common tumors like pituitary adenomas and meningiomas.
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Flitsch J, Bernreuther C, Lüdecke DK. Intra- and suprasellar schwannomas with hypopituitarism – report of 2 cases. Exp Clin Endocrinol Diabetes 2007. [DOI: 10.1055/s-2007-972498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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21
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Saeger W, Lüdecke DK, Buchfelder M. The lymphocytic hypophysitis: Report of 19 cases from the German Registry of Pituitary Tumors. Exp Clin Endocrinol Diabetes 2007. [DOI: 10.1055/s-2007-972340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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22
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Neverla I, Brichta M, Kamm HC, Lüdecke DK. Information patterns of patients with surgically treated acromegaly. Exp Clin Endocrinol Diabetes 2007. [DOI: 10.1055/s-2007-972500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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23
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Saeger W, Buchfelder M, Lüdecke DK. Atypical pituitary adenomas: A new entity in the WHO classification of 2004. Exp Clin Endocrinol Diabetes 2007. [DOI: 10.1055/s-2007-972493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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24
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Flitsch J, Lüdecke DK, Matschke J. Hypophysectomy for prostate cancer – a revival of old knowledge? Exp Clin Endocrinol Diabetes 2007. [DOI: 10.1055/s-2007-972508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Saeger W, Lüdecke DK, Buchfelder M, Fahlbusch R, Quabbe HJ, Petersenn S. Pathohistological classification of pituitary tumors: 10 years of experience with the German Pituitary Tumor Registry. Eur J Endocrinol 2007; 156:203-16. [PMID: 17287410 DOI: 10.1530/eje.1.02326] [Citation(s) in RCA: 339] [Impact Index Per Article: 19.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
In 1996, the German Registry of Pituitary Tumors was founded by the Pituitary Section of the German Society of Endocrinology as a reference center for collection and consultant pathohistological studies of pituitary tumors. The experiences of the first 10 years of this registry based on 4122 cases will herein be reported. The data supplement former collections of the years 1970-1995 with 3480 surgically removed tumors or lesions of the pituitary region. The cases were studied using histology, immunostainings and in some cases also molecular pathology or electron microscopy. The adenomas were classified according to the current World Health Organization classification in the version of 2004. From 1996 on 3489 adenomas (84.6%), 5 pituitary carcinomas (0.12%), 133 craniopharyngiomas (3.2%), 39 meningiomas (0.94%), 25 metastases (0.6%), 22 chordomas (0.5%), 115 cystic non-neoplastic lesions (2.8%), and 46 inflammatory lesions (1.1%, 248 other lesions or normal tissue (6.0%)) were collected by us. The adenomas (100%) were classified into densely granulated GH cell adenomas (9.2%), sparsely granulated GH cell adenomas (6.3%), sparsely granulated prolactin (PRL) cell adenomas (8.9%), densely granulated PRL cell adenomas (0.3%), mixed GH/PRL cell adenomas (5.2%), mammosomatotropic adenomas (1.1%), acidophilic stem cell adenomas (0.2%), densely granulated ACTH cell adenomas (7.2%), sparsely granulated ACTH cell adenomas (7.9%), Crooke cell adenomas (0.03%), TSH cell adenomas (1.5%), FSH/LH cell adenomas (24.8%), null cell adenomas (19.3%), null cell adenoma, oncocytic variant (5.8%), and plurihormonal adenomas (1.3%). Following the WHO classification of 2004, the new entity 'atypical adenoma' was found in 12 cases in 2005. Various prognostic parameters and clinical implications are discussed.
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Affiliation(s)
- Wolfgang Saeger
- Institute of Pathology, Marienkrakenhaus, Alfredstrasse 9, D-22087 Hamburg, Germany.
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Redmann A, Mann K, Lüdecke DK, Petersenn S. Treatment of acromegaly with somatostatin analogues: correlation between somatostatin receptor subtype expression levels and clinical response. Exp Clin Endocrinol Diabetes 2006. [DOI: 10.1055/s-2006-932872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Abstract
The measurement of cortisol in saliva is becoming more widely accepted as a screening test for the diagnosis of hypercortisolism. Since 1986, cortisol measurement in saliva has been continuously used in our department. In this study we compared salivary cortisol profiles from proven Cushing's disease patients with profiles from healthy subjects and obese children. The purpose was to evaluate the predictive value of the method for the diagnosis of hypercortisolism and to define cut-off levels to exclude or identify hypercortisolism. Cortisol in saliva was measured in 150 Cushing's disease patients (30 children, 120 adults, ranging from age 4-70), 100 healthy subjects (55 children, 45 adults, ranging from age 6-60), and 31 children (age 7-15) with an age-related body-mass-index above the 90th percentile. Generally, five saliva samples were taken over the day at 6:00-8:00 a.m., 11:00-12:00 a.m., 4:00-6:00 p.m., 7:00-8:00 p.m., and 10:00 p.m. The samples were measured using a radioimmuno-assay (INCSTAR Corporation, Stillwater, Minnesota, USA). For healthy subjects, morning levels of cortisol in saliva between 3-19 microg/l were found. These levels dropped to levels in between <1-11 microg/l at 11:00-12:00 a.m., <1-6 microg/l at 4:00-6:00 p.m., <1-4.5 microg/l at 7:00-8:00 p.m., and <1-2.9 microg/l at 10:00 p.m. The measured values showed a correlation with age, height, and weight. In Cushing's disease patients, the circadian salivary cortisol rhythm was missing, compared to healthy subjects. There was no significant difference in salivary cortisol levels or circadian rhythm between healthy or obese children. We found a high sensitivity for the detection of hypercortisolism at the 10:00 p.m. salivary cortisol measurement. The following, age dependent cut-off levels for salivary cortisol at 10:00 p.m. were calculated for the exclusion of hypercortisolism. Age 6-10: 1.0 microg/l (specificity 100%, sensitivity 87.5%); age 11-15: 1.7 microg/l (specificity 100%, sensitivity 100%); age 16-20: 1.6 microg/l (specificity 100%, sensitivity 76.2%); age 21-60: 1.6 microg/l (specificity 100%, sensitivity 90.9%) [corrected] For the proof of Cushing's syndrome, the following age-dependent cut-off levels at 10:00 p.m. were found: age 6-10: 1.9 microg/l (specificity 100%, sensitivity 80%); age 11-15: 1.7 microg/l (specificity 100%, sensitivity 100%); age 16-20: 2.5 microg/l (specificity 100%, sensitivity 84.2%); age 21-60: 1.9 microg/l (specificity 100%, sensitivity 97.6 %) [corrected] The cortisol assessment in saliva is a sensitive and reliable method to discriminate normocortisolemic from hypercortisolemic patients. From our view, the major advantages of this method are the reliability, non-invasiveness, and use in ambulatory patients.
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Affiliation(s)
- M Trilck
- Pituitary Unit, Department of Neurosurgery, University Hospital Hamburg-Eppendorf, Hamburg, Germany
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Schoof E, Dörr HG, Kiess W, Lüdecke DK, Freitag E, Zindel V, Rascher W, Dötsch J. Five-Year Follow-Up of a 13-Year-Old Boy with a Pituitary Adenoma Causing Gigantism – Effect of Octreotide Therapy. Horm Res Paediatr 2004; 61:184-9. [PMID: 14739526 DOI: 10.1159/000076386] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2003] [Accepted: 11/19/2003] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND/AIM In children, there is little experience with octreotide therapy for pituitary tumors, especially growth hormone (GH) producing adenomas. We report on a 13-year-old boy with gigantism due to a GH-producing pituitary adenoma caused by a Gsalpha mutation on the basis of McCune-Albright syndrome. METHODS At the age of 6.5 years a GH- and prolactin-producing pituitary adenoma was diagnosed. The adenoma was surgically removed. Immediately thereafter, the small adenoma residuum was treated with octreotide (2 x 100 microg/day s.c.). RESULTS During therapy with octreotide, the growth rate dropped to normal values; however, rose again after 2 years of treatment. The insulin-like growth factor I (IGF-I) levels remained above the 95th percentile, the GH level mostly >2 microg/l. After 5 years of octreotide therapy, GH (6.9 microg/l), IGF-I (620 microg/l), IGF-binding protein 3 (5.4 mg/l), and prolactin (17.0 ng/ml) levels were still elevated. The growth velocity was +2.4 SDS (standard deviation score), the pubertal status was mature, and the bone age was 14.3 years (prospective final height 208 cm). A magnetic resonance imaging scan showed an unchanged residual 4-mm rim of adenoma at the pituitary site. Side effects from octreotide therapy were not reported by the patient or his family. The therapy was changed to the long-acting release octreotide analog octreotide-LAR. After 1 year of treatment with octreotide-LAR, the GH level was 1.0 microg/l, and the prospective final height dropped by 10 cm. CONCLUSIONS This case demonstrates that combined surgical and medical treatment can influence the prognosis of childhood gigantism; however, the prognosis of this rare condition remains uncertain.
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Affiliation(s)
- Ellen Schoof
- Department of Pediatrics, University of Erlangen-Nürnberg, Loschgestrasse 15, D-91054 Erlangen, Germany
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Flitsch J, Lüdecke DK. Early repeat surgery for persistent Cushing’s disease: indication, approach and results. Exp Clin Endocrinol Diabetes 2004. [DOI: 10.1055/s-2004-819165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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30
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Redmann A, Ueberberg B, Unger N, Broecker-Preuss M, Wiedemayer H, Stolke D, Lüdecke DK, Mann K, Petersenn S. Comparative quantitative analysis of somatostatin receptor expression in pituitary tumors. Exp Clin Endocrinol Diabetes 2004. [DOI: 10.1055/s-2004-819168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Lüdecke DK. [Management of patients with non-functioning pituitary adenomas. Summary of results of an expert conference of the Hypophysis Work Group of the German Society of Endocrinology, Friedewald, 15-17 February 2002]. ACTA ACUST UNITED AC 2003; 98:616-27. [PMID: 14631537 DOI: 10.1007/s00063-003-1307-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2003] [Accepted: 06/30/2003] [Indexed: 11/24/2022]
Abstract
BACKGROUND Pituitary adenomas without clinically active hypersecretion are summarized under the term non-functioning pituitary adenomas (NFPA). Since there are no specific serum markers, the differential diagnosis and treatment imply special difficulties. Therefore, an expert group of the German Society of Endocrinology met in February 2002 and worked out concise practical management solutions. DIAGNOSIS The diagnosis is initiated by magnetic resonance imaging (MRI) as in pituitary incidentalomas, or by mass effects with loss of pituitary function, mild hyperprolactinemia, or by neurologic and/or ophthalmologic symptoms. Except for null-cell adenomas and oncocytomas, different hormones, mainly gonadotropins, are found by immunohistology. TREATMENT No reliable medical tumor therapy of NFPA could be established. Small tumors need yearly follow-up by MRI, endocrine, and ophthalmologic assessment. The effectiveness of transnasal selective microsurgery in > 90% has been proven. With improvements of surgical facilities like better visualization, transcranial surgeries are rarely necessary. Surgery and endocrine management have to be under control of experienced specialists, and will be described in detail within the direct perioperative period and the necessary long-term followup. Large immediate or later mostly slowly regrowing tumor rests may be treated again by surgery or special radiotherapy.
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Affiliation(s)
- Dieter K Lüdecke
- Hypophysenchirurgie, Neurochirurgische Klinik, Universitäts-Krankenhaus Eppendorf, Hamburg.
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Knappe UJ, Hagel C, Lisboa BW, Wilczak W, Lüdecke DK, Saeger W. Expression of serine proteases and metalloproteinases in human pituitary adenomas and anterior pituitary lobe tissue. Acta Neuropathol 2003; 106:471-8. [PMID: 12904990 DOI: 10.1007/s00401-003-0747-5] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2002] [Revised: 05/27/2003] [Accepted: 06/28/2003] [Indexed: 01/22/2023]
Abstract
Data on the dural invasiveness of pituitary adenomas have been correlated to the expression of matrix metalloproteinases (e.g. MMP-9). Serine proteases have not yet been investigated in human pituitary adenomas. In this study, paraffin-embedded material from 84 human pituitary adenomas (acromegaly n=18, Cushing's disease n=21, prolactinoma n=18, thyroid-stimulating hormone-secreting adenoma n=1, nonsecreting adenoma n=26) and 9 nontumourous anterior pituitary lobes (obtained from patients with prostate cancer) was immunohistochemically analysed for expression of MMP-2, MMP-9, tissue inhibitor of metalloproteinases-2 (TIMP-2), urokinase-type plasminogen activator (uPA), uPA receptor (uPAR), tissue-type plasminogen activator (tPA), plasminogen activator inhibitor-1 (PAI-1), and interleukin-6 (IL-6). Cavernous sinus invasion was determined by assessment of preoperative magnetic resonance imaging and intraoperative inspection (invasive n=50, noninvasive n=34). In pituitary adenomas, reactions were positive (diffuse expression) to MMP-2 (74% of cases), MMP-9 (49%), TIMP-2 (88%), uPA (89%), uPAR (90%), tPA (69%), and PAI-1 (87%). A weak expression of IL-6 was found in 12% of the adenomas. All reactions were positive (focal expression) in every sample of anterior lobe tissue, except for uPA (negative in 3 out of 9 cases), and IL-6 (faintly positive in 5 out of 8 cases). Adenomas showed remarkably greater expression of uPA than anterior lobe tissue (Chi-square P<0.05). Nonsecreting adenomas exhibited a stronger tendency towards overexpression of uPA in invasive tumours when compared to noninvasive adenomas (Chi-square P=0.053). We found no correlation of MMP-9 expression and tumour invasion. TIMP-2 was overexpressed in noninvasive as compared to invasive adenomas (Chi-square P<0.05). The interrelationship between MMPs and serine proteinases in pituitary adenomas remains to be elucidated. From our data, a correlation between IL-6 and an activation of MMP-9 cannot be proven. The uPA-system may, however, play a role in dural invasion of pituitary adenomas.
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Affiliation(s)
- Ulrich J Knappe
- Department of Neurosurgery, Dr.-Horst-Schmidt-Kliniken, Ludwig-Erhard-Strasse 100, 65199, Wiesbaden, Germany.
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Lüdecke DK, Flitsch J, Grzyska U. Sinus cavernosus versus sinus petrosus catheterization in Cushing's diagnosis. Exp Clin Endocrinol Diabetes 2003. [DOI: 10.1055/s-2003-817540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Abstract
The present study was designed to investigate the immunohistochemical characteristics of gangliocytomas associated with growth hormone (GH)-secreting pituitary adenomas. In our surgical collection of 476 GH-secreting adenoma cases, we examined tumor tissue from 6 patients (1.3%). All 6 patients were women, ranging from 29 to 52 years (mean, 40.3 +/- 9.5 SD) of age. Among 470 patients with GH-secreting adenomas without gangliocytoma, there were 255 female and 215 male patients. The preponderance of female patients with gangliocytomas was striking. Histological examination of the resected specimens showed areas of ganglion cells and adenomatous cells. Ganglion cell lesions were stained positively for synaptophysin (4 of 4; 100%) and neurofilament (4 of 4; 100%) as well as GH-releasing hormone (5 of 6; 83.3%). Subtypes of GH cell adenomas included 4 cases of sparsely granulated type and 2 cases of mixed GH and prolactin (PRL) cell adenomas. Based on these findings, we hypothesized that the intrasellar gangliocytoma promoted the growth of the pituitary adenoma by chronic overstimulation from excess GH-releasing hormone.
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Flitsch J, Knappe UJ, Lüdecke DK. The use of postoperative ACTH levels as a marker for successful transsphenoidal microsurgery in Cushing's disease. Zentralbl Neurochir 2003; 64:6-11. [PMID: 12582940 DOI: 10.1055/s-2003-37145] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
OBJECTIVES The declines of ACTH and other POMC metabolites immediately after tumor extirpation do not predict the complete tumor removal of an ACTH-secreting pituitary adenoma in Cushing's disease. However, the pituitary surgeon should be in a position to evaluate the surgical result as soon as possible for the eventual planning of early repeat surgery. So far, subnormal serum cortisol levels after surgery are widely accepted as the criterion for cure. We investigated whether the early postoperative ACTH concentration is a reliable marker for the initial surgical outcome as well as the long-term remission. METHODS In a prospective study, 147 patients undergoing primary transsphenoidal microsurgery for Cushing's disease between 1990 and 1996 were investigated. The early postoperative ACTH courses were reviewed and compared with the long-term outcome. ACTH measurements were performed immediately after tumor excision, 1, 2, 4, 8, and 12 hours later, and the following morning. Further ACTH levels were determined on various days of the hospital stay. Glucocorticoids were not given until hypocortisolism was proven. RESULTS Ninety-five patients (65 %) presented with subnormal ACTH levels (< 10 ng/l) during their postoperative stay, of whom two patients (2 %) experienced recurrence of disease after 66 and 100 months. Of 29 procedures with early postoperative ACTH levels ranging from 10-20 ng/l (20 %), one patient received further treatment for persistent (3.5 %) and one patient for recurrent Cushing's disease (3.5 %). Of 12 patients (8 %) with early postoperative ACTH levels in between 20 to 30 ng/l, one patient received further treatment for persistent (8 %) and four patients for recurrent disease (33 %). ACTH levels of more than 30 ng/l, found in 11 patients (7 %), were accompanied by persistent (8 patients, 73 %) or recurrent (2 patients, 18 %) Cushing's disease. CONCLUSION Subnormal (< 10 ng/l) or low normal (< 20 ng/l) postoperative ACTH levels within the first 7 days after surgery can be regarded as early markers for complete removal of an ACTH adenoma as well as indicators for long-term outcome in Cushing's disease. The risks of persistence or recurrence of Cushing's disease rise with the level of early postoperative ACTH values. Normal ACTH levels should result into further evaluation of the ACTH-cortisol secretion, for example by stimulation- or suppression tests.
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Affiliation(s)
- J Flitsch
- Arbeitsbereich Hypophysenchirurgie, Klinik für Neurochirurgie, Universitätsklinikum Hamburg-Eppendorf, Hamburg.
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Bauer CK, Wulfsen I, Schäfer R, Glassmeier G, Wimmers S, Flitsch J, Lüdecke DK, Schwarz JR. HERG K(+) currents in human prolactin-secreting adenoma cells. Pflugers Arch 2003; 445:589-600. [PMID: 12634931 DOI: 10.1007/s00424-002-0980-0] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2001] [Revised: 09/24/2002] [Accepted: 10/22/2002] [Indexed: 11/28/2022]
Abstract
To investigate the presence and possible function of ether-à-go-go-related gene (erg) K(+) channels in human lactotroph cells (HERG channels), primary cultures were prepared from human prolactinoma tissue. In almost all primary cultures, HERG currents could be recorded in identified prolactin cells using an external high-K(+) solution. The antiarrhythmic agent E-4031, a specific blocker of erg channels, served to isolate HERG currents as the drug-sensitive currents. In cells of two tumours tested, thyrotropin-releasing hormone significantly reduced the amplitude of the HERG currents. The potential dependence of HERG current availability and the deactivation kinetics differed significantly even between prolactin cells derived from one adenoma. For comparison, corresponding values were obtained for heterologously expressed rat erg1, erg2 and erg3 channels. The expression of the three HERG channel subunits was investigated in nine human adenomas using RT-PCR. Transcripts for HERG1 were present in all adenomas and although transcripts for HERG2 and HERG3 were also detected, their expression level was more variable. The results demonstrate the functional expression of HERG channels in human prolactin-secreting tumours and are compatible with a physiological role for these channels in the control of prolactin secretion, as has been shown in normal rat lactotroph cells.
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Affiliation(s)
- C K Bauer
- Institut für Angewandte Physiologie, Universitätsklinikum Hamburg-Eppendorf, Martinistrasse 52, Universität Hamburg, 20246 Hamburg, Germany.
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37
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Saeger W, Wilczak W, Lüdecke DK, Buchfelder M, Fahlbusch R. Hormone markers in pituitary adenomas: changes within last decade resulting from improved method. Endocr Pathol 2003; 14:49-54. [PMID: 12746562 DOI: 10.1385/ep:14:1:49] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The significance of polyclonal antibodies for demonstration of hormone expression in pituitary adenomas was compared with the significance of monoclonal antibodies (MAbs). Adenomas were classified by light microscopic structures in paraffin- and epon-embedded sections, by immunostaining for all pituitary hormones, and in part by electron microscopy. In the first series, 166 adenomas were studied with polyclonal antibodies during 1990 and 1991. In the second series, 572 adenomas were immunostained with MAbs during 1999 and 2000. In the first series, a very typical type-specific hormone expression was demonstrable in 63.2% of adenomas in contrast to 91.1% in the second series. Consequently, in the first series 36.7% of adenomas expressed additional or atypical hormones in >10% of adenoma cells, whereas in the second series only 8.9% contained additional hormones. We conclude that MAbs show a clearer cutoff in immunostainings of pituitary hormones and therefore should be preferred for adenoma classification.
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Affiliation(s)
- Wolfgang Saeger
- Institute of Pathology of the Marienkrankenhaus Hamburg, Hamburg, Germany.
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38
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Abstract
The classical trias in Cushing's disease, normal or moderately elevated plasma ACTH, significant suppression of cortisol in the high-dose dexamethasone test, and stimulation of ACTH and cortisol in the CRH test, confirms the diagnosis in most cases. However, as a referral centre for complex Cushing's disease cases, we are confronted with problems in the differentiation of pituitary and ectopic Cushing's syndrome and with problems in the localisation of minute ACTH-secreting pituitary adenomas. In this study, cavernous sinus sampling (CSS) was evaluated as a diagnostic tool in complex Cushing's disease cases. Thirty-five patients were transferred to our unit for the treatment of Cushing's disease between January 1999 and August 2000. Of those, 17 patients (including five children) had the combination of equivocal results in endocrinological testing and negative MRI prior to admission. In these cases, CSS was performed preoperatively to confirm the diagnosis and to obtain further information about the localisation of pituitary microadenomas. Twelve of these 17 patients showed the classical trias for Cushing's disease after equivocal tests were repeated. A central-peripheral gradient was also found using CSS. In ten of the 11 patients, where CSS could be successfully performed, the lateralisation of the ACTH-adenoma was correctly predicted (91%). In the eleventh case, a right ACTH-gradient was found in a stalk tumour. In one patient (a child), the catheterisation of the cavernous sinus failed due to anatomical reasons. Eleven of these 12 patients successfully underwent transnasal adenomectomy. In two of the 17 patients, active Cushing's syndrome was excluded. In the remaining three cases, ectopic Cushing's syndrome was suspected based on CSS results. Therefore, these patients did not undergo pituitary exploration. In complex cases, we recommend CSS for diagnostic purposes, especially for the localisation of ACTH-secreting microadenomas within the pituitary. In our experience, CSS has a higher accuracy than inferior petrosal sinus sampling (IPSS) in the localisation of ACTH-adenomas.
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Affiliation(s)
- J Flitsch
- Department of Neurosurgery, University Hospital Hamburg-Eppendorf, Hamburg, Germany.
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39
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Abstract
BACKGROUND Prolactin (PRL)-secreting pituitary adenomas (prolactinomas) are rare in childhood and adolescence; there are only a few published series of patients who were surgically treated. We discuss the gender-dependent differences, and the surgical indications and results for 14 patients with prolactinomas under 18 years of age at surgery. METHODS We reviewed the data for 14 patients (10 girls and 4 boys) treated surgically for prolactinomas between 1980 and 1996. Surgery was chosen because of intolerance and/or resistance to dopamine agonist (DA) in 9 patients, the patient's decision in 3, rhinorrhea in 1, and pituitary apoplexy in 1 during DA therapy. All patients underwent direct transnasal explorations. Since 1988, intraoperative PRL measurements were performed. The follow-up period was at least 6 years. RESULTS Nine of the 10 girls had primary or secondary amenorrhea, and 3 of the 4 boys had visual field defects. The boys and girls were the same age at the onset of symptoms and had the same preoperative duration of symptoms. Boys had larger, more invasive tumors and higher preoperative and postoperative plasma PRL levels than girls. Two boys demonstrated significant extrasellar extension at the time of diagnosis. Two patients required drilling of the incompletely pneumatized sphenoid sinus to reach the sella. Radical tumor resection was achieved in seven girls and in none of the four boys. In 12 of the 14 patients, normal pituitary function was preserved by transnasal surgery. There was no severe surgical morbidity or mortality. Endocrinological remission by surgery alone was achieved for seven girls, and was achieved in 4 of the 5 patients (80%) with microadenomas. In patients with preoperative mean PRL levels of less than 200 microg/L, the surgical cure rate was 75%. CONCLUSIONS Prolactinomas in childhood and adolescence differ in their biology in boys and girls. Transnasal surgery is as safe in childhood patients as it is in adult patients, and it may be an effective alternative to long-term medical therapy for selected patients with prolactinomas. Successful surgical outcomes were achieved in patients with microadenomas and preoperative serum PRL levels of less than 200 microg/L.
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Affiliation(s)
- Takumi Abe
- Department of Neurosurgery, Showa University School of Medicine, Tokyo, Japan
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40
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Schmid M, Münscher A, Saeger W, Schreiber S, Lüdecke DK. Pituitary hormone mRNA in null cell adenomas and oncocytomas by in situ hybridization comparison with immunohistochemical and clinical data. Pathol Res Pract 2002; 197:663-9. [PMID: 11700887 DOI: 10.1078/0344-0338-00143] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Null cell adenomas and oncocytomas are clinically inactive adenomas of the pituitary gland. They do not show any significant hormone content detectable by immunohistochemistry. This study aimed at demonstrating mRNAs for all main pituitary hormones in 32 null cell adenomas and 31 oncocytomas by non-isotopic in situ hybridization using digoxigenin-labeled oligonucleotide probes. The results were compared with immunohistochemical and clinical data. Immunohistochemistry (ABC method) was done with monoclonal antibodies against PRL, GH, FSH, LH, TSH, ACTH, alpha-subunit, and Ki-67 (mib-1). The signals for hormone production were detected in both adenoma types in a range from 42% for GH in oncocytomas to 78% for beta-FSH in null cell adenomas. However, these signals are apparently not effective on hormone production, as was shown by almost negative immunostaining. Owing to the simultaneous detection of at least two mRNAs in 78% of null cell adenomas and in 94% of oncocytomas, we assume that both tumor types originate from pluripotential precursor cells that are capable of producing various hormones. According to our data, it is unlikely that the signals influence the clinical behavior.
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Affiliation(s)
- M Schmid
- Institute of Pathology, Marienkrankenhaus, Hamburg, Germany
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41
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Abstract
The present study was designed to investigate the incidence and immunohistochemical characteristics of pituitary tumors in the elderly. In our surgical collection of 1925 cases, we examined tumor tissue from 15 patients over 80 years of age. Pituitaries obtained at routine autopsies from 692 subjects over 80 years of age were also investigated. Of the 15 surgical cases studied, the majority of patients presented with chiasmatic syndromes, likely caused by macroadenomas. Gonadotroph adenomas were the most frequently diagnosed tumor type, followed by null-cell adenomas and oncocytomas. There is only one case with GH cell adenoma. Among 692 autopsy cases, 79 (11.4%) pituitaries were found to contain adenomas in the anterior lobe. In one pituitary, two separate adenomas were detected, hence the number of adenomas in our material was 80. All autopsy cases were microadenomas except one. The mean diameter of adenomas was 2.2 mm. ACTH cell adenomas were the most frequently diagnosed tumor type, followed by PRL cell adenomas and null cell adenomas. The occurrence of pituitary adenomas discovered after routine autopsy in the elderly was common, although these tumors were not found frequently in surgical cases over 80 years of age. Our immunohistochemical study revealed that many tumors contained one or more than one anterior pituitary hormone, although almost all pituitary adenomas were considered to be clinically inactive in surgical and autopsy cases.
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Affiliation(s)
- M Kurosaki
- Institute of Pathology, Marienkrankenhaus, Hamburg, Germany
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42
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Abstract
BACKGROUND Although craniopharyngiomas have been examined in several microscopical studies to date, immunohistochemical analysis has not been sufficient. METHOD In addition to the routine haematoxylin and eosin staining, 38 cases of intra- and/or supra-sellar craniopharyngioma, including 34 adamatinomatous and 4 squamous papillary types, were studied using immunohistochemistry for expression of four types of cytokeratin. FINDINGS Histological examination found epithelial cells in 26 of 38 (68.40%) cases. However, cytokeratins were demonstrated in 35 of 38 (92.1%) cases. The remaining 3 cases without demonstration of epithelial cell nests were supposed to be adamantinomatous craniopharyngiomas based on the findings in the stroma. In 31 of 34 adamantinomatous craniopharyngioma cases, the epithelium was detected by immunostaining for cytokeratins. The epithlieum expressed 56 kDa (KL-1) and 40 kDa (cytokeratin 19) cytokeratins with similar staining patterns and intensities. The staining intensity of 54 kDa cytokeratin (cytokeratin 7) was similar to that of the high molecular weight cytokeratin (keratin M-903). However, in many cases (15 of 27), immunoreactivity of cytokeratin 7 was not demonstrated in an outer palisaded basal layer. In all 4 squamous papillary craniopharyngiomas, moderate staining with cytokeratin 7 appeared in the superficial layer, whereas basal or mid-zone epithelial cells were negative for cytokeratin 7. The basal layer stained negatively for KL-1, as well as cytokeratin 7. INTERPRETATION Immunostaining for cytokeratin is valuable in the investigation of craniopharyngioma, especially when specimens contain only a small or questionable part of epithelium. Most notably, KL-1 or cytokeratin 7 stainings are suitable for analyzing these tumours, with special reference to histological subtypes.
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Affiliation(s)
- M Kurosaki
- Division of Neurosurgery, Institute of Neurological Sciences, Tottori University School of Medicine, Yonago, Japan
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43
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Abstract
The management of adrenocorticotropic hormone (ACTH)-dependent Cushing's disease implies difficulties in the differential diagnosis, in the detection of minute pituitary adenomas, as well as in the radical removal of invasive adenomas. Magnetic resonance imaging (MRI) is unspecific and often negative in minute adenomas of three or less millimeters diameter. The trias of detectable ACTH, suppression of cortisol in the high-dose dexamethasone test, and stimulation in the corticotropin-releasing-hormone (CRH)-test has a high accuracy to prove pituitary dependency. In unclear cases, the use of inferior petrosal sinus sampling (IPSS) or cavernous sinus sampling (CSS) for the exclusion of ectopic ACTH-syndrome is currently advised especially in cases where cranial MRI is negative. The reliability of these methods to localize the mostly lateralized microadenomas is still discussed. Transsphenoidal microsurgical adenomectomy, the accepted primary therapy of Cushing's disease, has been published from experienced pituitary centers with remission rates ranging from 70% to 98% in the last decade. False diagnosis (pseudo-Cushing, ectopic ACTH-syndrome), incorrect adenoma localization by IPSS or CSS, and the rate of minute or non-resectable invasive tumors influence the results. The handling of minute specimen implies problems for surgeon and pathologist. Intraoperative tumor localization was improved by ACTH measurement from the cavernous sinus and the adenoma itself, by cytology, and frozen sections. The histology of the anterior lobe (rate of Crooke's cells) bears information of clinical relevance. Invasive macroadenomas may deserve repeat microsurgery, medical treatment, and radiosurgery.
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Affiliation(s)
- D K Lüdecke
- Department of Neurosurgery, University Hospital Hamburg-Eppendorf, Germany
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44
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Abe T, Lüdecke DK. Effects of preoperative octreotide treatment on different subtypes of 90 GH-secreting pituitary adenomas and outcome in one surgical centre. Eur J Endocrinol 2001; 145:137-45. [PMID: 11454508 DOI: 10.1530/eje.0.1450137] [Citation(s) in RCA: 109] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To investigate the possible impact of pretreatment with octreotide on different subtypes of GH-secreting pituitary adenomas and on the outcome of transnasal surgery. METHODS We reviewed a consecutive series of 90 acromegalic patients treated with octreotide alone before transnasal surgery. On the basis of magnetic resonance imaging, the tumours were classified into four groups: group A, microadenoma (n=7); group B, transnasally resectable macroadenoma (n=21); group C, invasive, potentially transnasally resectable macroadenoma (n=43); group D, non-resectable grossly invasive macroadenoma (n=19). All patients were treated for at least 3 months before surgery, with a mean daily dose of 221+/-31 microg octreotide. The mean follow-up was 51.7+/-1.4 months. The comparative group included 57 acromegalic patients who were not receiving octreotide treatment. RESULTS After pretreatment with octreotide, tumour shrinkage was clearly observed in 28 of the 90 patients (31%). At surgery, the tumours after octreotide treatment were more often white or grey in colour (91% compared with 75%) and were observed to be slightly more often fluid or soft in texture (86% compared with 79%) than those in the comparative series. Endocrinological remission was achieved in all patients in group A, 95.2% in group B, and 81.4% in group C. In only 10 of the 14 patients with tumour shrinkage in group C, endocrinological remission was also achieved (71.4%). In the comparative series, endocrinological remission was achieved in 92.9% of group A, 87.5% of group B, and 73.9% of group C. CONCLUSIONS Octreotide treatment slightly improved the already relatively high rate of endocrinological remission in invasive, potentially transnasally resectable macroadenomas. The rate of tumour shrinkage was found to decrease with extrasellar size. With the exception of tumour growth in approximately 7% of invasive adenomas and pituitary apoplexy in one patient, there was no disadvantage associated with the octreotide pretreatment.
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Affiliation(s)
- T Abe
- Department of Neurosurgery, Showa University School of Medicine, Tokyo, Japan.
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45
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Flitsch J, Spitzner S, Lüdecke DK. Emotional disorders in patients with different types of pituitary adenomas and factors affecting the diagnostic process. Exp Clin Endocrinol Diabetes 2001; 108:480-5. [PMID: 11083069 DOI: 10.1055/s-2000-8144] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
A prospective study of 48 patients with pituitary adenomas, 19 adenomas causing Cushing's disease, 18 adenomas causing acromegaly, and 11 clinically hormone-inactive adenomas (inactive adenomas), was performed to study emotional disorders occurring before and after transsphenoidal microsurgery. Factors which led to an obvious delay in the diagnostic process were identified. - The tools utilised were an interview and repeated personality assessments. The personality assessments were begun preoperatively and continued for about half a year postoperatively. The interview data, including retrospective statements regarding somatic difficulties, was analysed. - The thesis of a uniform psychopathology due to the influence of elevated hormone levels, and a lack in patients' sensitivity towards their changed appearance in acromegaly could not be confirmed. A high variability of reported emotional problems was found. The most common psychopathological signs for Cushing's disease were excitability and depression, for acromegaly fatigue/loss of energy was the most frequent complaint. Six to eight months postoperatively, a majority of patients noticed an increase of physical well-being. In acromegaly, the time span between first consultation and diagnosis averaged 6.2 years, in Cushing's disease it was 4.3 years, and in inactive adenomas it was 3.9 years. Only a small part of the delay in diagnosis, less than two years, could be attributed to the patients' hesitation to consult a physician.
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Affiliation(s)
- J Flitsch
- Clinic of Neurosurgery, University Hospital Eppendorf, Hamburg, Germany.
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46
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Abstract
Although androgen receptors have been identified in normal gonadotroph and somatotroph cells of the pituitary, immunohistochemical studies have failed to reveal these receptors in pituitary adenomas so far. Using a monoclonal antibody to androgen receptor in our series of 60 adenomas of the gonadotroph cell complex (20 FSH/LH cell adenomas, 20 null cell adenomas, 20 oncocytic adenomas), only one null cell adenoma showed strong nuclear immunostaining. All the other antibodies were completely negative. The significance of this finding in correlation with clinical data is still unclear, although it may be associated with more rapid tumor growth. In paraadenomous tissue, some normal gonadotrophs expressed the androgen receptor.
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MESH Headings
- Adenoma, Oxyphilic/chemistry
- Adenoma, Oxyphilic/metabolism
- Adenoma, Oxyphilic/pathology
- Adenoma, Oxyphilic/surgery
- Biomarkers, Tumor/analysis
- Humans
- Immunohistochemistry
- Neoplasm Proteins/analysis
- Pituitary Gland, Anterior/chemistry
- Pituitary Gland, Anterior/metabolism
- Pituitary Gland, Anterior/pathology
- Pituitary Hormones, Anterior/analysis
- Pituitary Neoplasms/chemistry
- Pituitary Neoplasms/metabolism
- Pituitary Neoplasms/pathology
- Pituitary Neoplasms/surgery
- Receptors, Androgen/metabolism
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Affiliation(s)
- W Saeger
- Institute of Pathology, Marienkrankenhaus Hamburg, Germany
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47
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Abstract
Transsphenoidal cephalocele rarely occurs in adults. We describe two adult cases with transsphenoidal cephaloceles. The first case was a 53-year-old female who presented with spontaneous cerebrospinal fluid (CSF) rhinorrhea. Magnetic resonance (MR) imaging demonstrated a transsphenoidal meningocele. Surgical repair was attempted via the transsphenoidal route. Rhinorrhea recurred at one month and also two years later. Transsphenoidal surgical repairs were repeated. There has been no evidence of CSF leakage in the four years of follow-up after the last surgery. Transsphenoidal repair seems to be the most suitable approach in this case. The second case was a 26-year-old female with secondary amenorrhea, diabetes insipidus, bitemporal hemianopsia, and see-saw nystagmus. MR imaging demonstrated a transsphenoidal encephalocele with the optic chiasma and infundibular recesses descending into the meningocele and an agenesis of the corpus callosum. The first operation was performed via the transnasal route and the second by sublabial transmaxillary transsphenoidal approach six months later. Postoperative MR imaging revealed reduction of the encephalocele. There was neither worsening nor noticeable improvement in the neurological or endocrinological function. However, in this type, complete repair is often impossible, and non-radical surgery such as transsphenoidal repair may be indicated as most suitable. They should be selected with careful assessment referring to MR findings and clinical symptoms and signs.
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Affiliation(s)
- T Abe
- Department of Neurosurgery, Showa University School of Medicine, Tokyo, Japan
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48
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Abstract
The oncogenes cyclin D1 and D3 are overexpressed in many tumors. Topoisomerase II alpha is found in proliferating cells. The immunohistological expression of cyclin D1, cyclin D3, and Topoisomerase II alpha was studied in a collection of 60 clinically inactive surgically removed pituitary adenomas of the follicle-stimulating hormone/luteinizing hormone (FSH/LH) cell complex (20 null cell adenomas, 20 oncocytomas, and 20 FSH/LH cell adenomas) for correlation with other proliferation markers (Ki-67, PCNA) and with clinical data. Whereas cyclin D1 was positive only in one invasive null cell adenoma (1.7%) with some p53-positive nuclei, cyclin D3 was overexpressed in the nuclei of 41 tumors (68%). Topoisomerase II alpha was demonstrated in the nuclei of 42 adenomas (70%) with no significant differences discernible between the three adenoma subtypes. There was no significant correlation to the time of development of tumor symptoms, but a correlation of Topoisomerase II alpha with cyclin D3 and the proliferation marker Ki-67 (Mib1). From these data we conclude that cyclin D3 and Topoisomerase II alpha appear to be additional markers for proliferation which can be used for prognosis index in surgical pathology of the pituitary.
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Affiliation(s)
- W Saeger
- Institute of Pathology of the Marienkrankenhaus Hamburg, Alfredstrasse 9, 22087 Hamburg, Germany
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49
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Münscher A, Schmid M, Saeger W, Schreiber S, Lüdecke DK. GH-, PRL-, POMC-, beta-TSH-, beta-LH-, beta-FSH-mRNA in gonadotroph adenomas of the pituitary by in situ hybridization in comparison with immunostaining and clinical data. Endocr Pathol 2001; 12:171-80. [PMID: 11579683 DOI: 10.1385/ep:12:2:171] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
In situ hybridization (ISH) enables the visualization of specific mRNA for pituitary hormones. Our collection consists of 40 surgically removed pituitary adenomas that were classified as follicle stimulating hormone/luteinizing hormone (FSH/LH) cell adenomas by structure and by immunostaining (IH) for all pituitary hormones. All forty adenomas were regarded as clinically inactive. The aim of our study was to examine nonfunctioning adenomas by ISH for demonstration of mRNAs for all pituitary hormones. The results were compared with proliferation markers, invasiveness and clinical data. ISH detected signals for all pituitary hormones at a range of 30% for prolactin (PRL) to 85% for proopiomelanocortin (POMC). mRNA for beta-FSH was detected in 70% and beta-LH mRNA in 43% of adenomas. Thirty-three percent of adenomas revealed negative mRNA detection for beta-LH but positive hormone content. The majority of adenomas (75%) expressed more than two mRNAs simultaneously, mostly the combination of POMC mRNA together with beta-FSH mRNA and one to four others. Comparison with clinical data showed no significant differences except for one adenoma with a high Ki-67 index (> 2.1% positive nuclei). This adenoma showed very high signals for PRL and beta-TSH mRNA.
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Affiliation(s)
- A Münscher
- Institute of Pathology, Marienkrankenhaus, Alfredstr. 9, D-22087 Hamburg, Germany
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50
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Abstract
OBJECTIVE The goal of this study was to evaluate the efficacy and safety of transsphenoidal pituitary surgery for elderly patients, using improved techniques of the past decade. METHODS We retrospectively analyzed 32 surgically treated cases of clinically nonsecreting pituitary adenomas in patients more than 70 years of age (mean, 73.9+/-3.4 yr). These patients were identified in a review of 982 patients with pituitary adenomas who were treated at University Hospital Eppendorf, Hamburg, between January 1991 and November 1999. RESULTS The mean preoperative duration of symptoms was 1.9 years (2 wk to 11 yr). The chiasmatic syndrome was present for 27 patients (84.4%). All patients underwent transsphenoidal surgery. Seven patients underwent reoperations. Preoperative assessments of anterior pituitary function revealed growth hormone deficiencies for 21 of 27 patients (77.8%), thyroid insufficiencies for 10 of 30 patients (33.3%), and adrenal insufficiencies for 13 of 29 patients (44.8%). Hypogonadism and hyperprolactinemia were observed for 76.7% and 46.9% of the patients, respectively. All tumors were macroadenomas, ranging from 18 to 50 mm (average, 33.6 mm) in size, including 7 enclosed and 25 invasive adenomas. Complete microscopic tumor resection was achieved in 24 cases, and subtotal removal was performed in 8 cases. There were no severe perioperative complications. In the cases involving hyperprolactinemia, serum prolactin levels were normalized for 8 of 11 patients (72.7%). Normal thyroid function was recovered for 1 of 10 patients (10.0%) with preoperative hypothyroidism. However, growth hormone or adrenal insufficiencies persisted for all patients with preoperative insufficiencies. Visual disturbances were improved for 19 of 23 patients (82.6%). All patients recovered well after surgery, with an average hospital stay of 16.3 days. Histological and immunohistochemical studies demonstrated gonadotroph adenomas in 56.7% of cases, null-cell adenomas in 26.7%, and oncocytomas in 13.3%. CONCLUSION Surgical treatment of nonsecreting pituitary adenomas causing visual disturbances is standard, even for elderly patients. In this series, transsphenoidal surgery was a safe procedure, with minimal morbidity and excellent tolerance. Age alone is not a contraindication for active treatment, particularly with transsphenoidal surgery.
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Affiliation(s)
- M Kurosaki
- Division of Neurosurgery, Institute of Neurological Sciences, Tottori University School of Medicine, Yonago, Japan
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