ACTA ENDOCRINOLOGICA (BUC)

At least one fifth of pituitary adenomas exhibit plurihormonality when using immunohistochemistry for anterior pituitary hormones. However, the correlation with clinical features is weak, without an agreement upon pathological predictors of tumor behavior. The aim was to determine the immunoreactivity for anterior pituitary hormones and alpha subunit in 276 consecutive pituitary adenomas patients, aged 22-79 years (44.3 ? 8), 154 F/ 122 M: 83 acromegalics (ACM), 173 nonfunctioning adenomas (NFA) and 20 prolactinomas (PRM) submitted to surgery via transfrontal (81) or transsphenoidal (195) along 10 years (1995-2005). In addition, clinical data, hormonal secretion and tumour size were evaluated before pituitary surgery. Local ethical committee approved the study design. The immunoreactivity performed by the avidin-biotin-complex method was evaluated for beta FSH, LH, TSH, alpha subunit, PRL and GH, using a semiquantitative scale of stained cells: strong (>20%), positive (10-20%), weak (5-10%) and negative (<5%). CT or MRI tumor size (less than 1 cm, 1-2 cm, 2-4 cm and over 4 cm on maximal diameter) were considered together with the Hardy neuroradiological stage. The results showed that 16/83 ACM, 53/173 NFA and 4/20 PRM exhibited immunoreactivity for beta FSH and LH. TSH immunoreactivity was positive in 13/83 ACM, 11/173 NFA and 1/20 PRM. Tumor size in gonadotrophin - positive group (> 10% of stained cells) was between 1-2 cm in 6 ACM, 21 NFA and 2 PRM, while positive bigger tumors (2-4 cm) were in 7 ACM, 24 NFA and 2 PRM. Giant, over 4 cm tumors were positive in 3 ACM, 8 NFA and no PRM. A similar trend of the tumor size distribution was observed in the monohormonal or null cell adenomas. In conclusion, tumor size and gonadotrophin plurihormonality are independent factors in the management of pituitary adenomas.

The blood-CSF barrier (BCB), as a component of the blood-brain barrier, is protective for the maternal brain. This study assesses estradiol, prolactin, glycoproteic hormones (hCG, FSH, LH, TSH) and thyroxine across the BCB in pregnancy after 38 weeks. Method. 35 pregnant women were simultaneously sampled in serum and CSF during caesarian section and compared to 27 non-pregnant fertile women undergoing surgery for benign gynecological disorders. The study was approved by the local Ethics Committee. Results were analysed as nonparametric variables. Compared to non-pregnant controls, we found high serum estradiol levels at term, also reflected in the CSF, while the CSF/serum ratio was non-significantly modified (median ratio 0.1 versus 0.1, p=NS). Prolactin showed a similar proportional increase in serum and CSF levels at term, with unmodified CSF/serum ratio (median ratio 0.14 versus 0.18, p=NS). hCG showed a similar profile across the BCB. FSH was significantly lower at term, but still conserved the CSF/ serum ratio. LH was undetectable in pregnancy. In peripartum TSH showed a unique profile across the BCB as it was the only one showing an increased CSF/serum ratio compared to non-pregnant controls (median ratio 0.11 versus 0.04, p<0.0001). Thyroxine was significantly increased in both serum and CSF, and showed a CSF/serum ratio unmodified from non-pregnant women (median ratio 0.02 versus 0.02, p=NS). Conclusion. There is an increase of BCB permeablity for TSH in term pregnancy. The peripartum increase in estradiol and decrease in HCG could be involved. We suggest that the unique TSH profile maintains the necessary thyroxine levels in pregnancy at term.

The mechanism underlying anovulation in the polycystic ovary syndrome (PCOS) remains unclear, although an excessive number of small antral follicles at ultrasound scans and discrepancies with selected follicles sustain the hypothesis of altered follicular development. Anti-M?llerian (AMH) hormone is a member of TGF-b super family of growth factors produced by granulosa cells of pre- and small-antral follicle. The 2 to 3 fold increase in the number of growing follicles in the ovary from PCOS women is reflected by an increase in serum concentration of AMH and thus, this hormone may be a good marker of PCOS.\r\nAim. This study was intended to implement ultra-sensitive ELISA measurement of serum AMH from PCOS women and search for a potential correlation with clinical and laboratory parameters.\r\nSubjects and methods. Sera from patients with PCOS (n = 42) and control women (n = 22) were used for ELISA measurement of AMH (AMH-EIA, Beckman Coulter) with sensitivity of 0.7 pmol/L.\r\nResults. We found a serum concentration of AMH almost 3 folds higher in patients with PCOS compared to controls (73.7 ? 7.5 vs. 25.7 ? 3.9 pmol/L, P < 0.0001). Differences were even higher in lean subjects. A positive correlation was found between total testosterone and LH levels, but not with serum FSH or insulin. Moreover, AMH concentration was correlated to more hyperandrogenic PCOS and with amenorrhea, and thus to the severity of the syndrome.\r\nConclusion. Measurement of serum AMH may be used as a valuable marker for PCOS to confirm diagnosis and evaluate the extent of follicular dysfunction in relation with hyperandrogenism and menstrual disturbances.

Background. Risk stratification and an appropriate therapeutic approach could be lifesaving in acute pulmonary embolism (PE). Echocardiographic (ECHO) acute right ventricular dysfunction (RVD) is the actual &#8220;gold standard&#8221; in risk evaluation of PE. We previously demonstrated that plasma BNP levels were significantly higher in patients with PE and acute RVD on ECHO vs. patients with normal RV function on ECHO.\r\nAim. Evaluation of the limits of plasma BNP in signalling acute RVD in PE. \r\nMethods. 70 patients with PE were prospectively investigated: 42(60.0%) men, mean ? SD(standard deviation) age 52.51?8.82. BNP was measured on admission using a quantitative fluorescence immunoassay (TriageBNP). ECHO evaluation of the RV function was performed in the first hour after admission. Study protocol was approved by local Ethical Committee. Patients were divided into two groups: group 1-with acute RVD on ECHO, n=24(34.3%) patients; group 2 - without acute RVD on ECHO, n=46(65.7%).Patients from group 1 were further divided into two subgroups: subgroup 1A-admitted in <12 hours after their PE symptoms onset, n=12(50.0%) patients, and subgroup 1B-admitted in >12 hours after the onset of PE symptoms, n=12(50.0%) patients.\r\nResults. BNP proved good in discriminating between patients with and without acute RVD (AUC=0.88, P<0.0001). The cut-off level of plasma BNP=50 pg/mL showed the best sensitivity=0.86 and specificity=0.82 in identifying acute RVD. BNP levels were significantly lower in subgroup 1A (admitted soon) compared to subgroup 1B (admitted later than 12 hours): medians 45.25 pg/mL vs. 344.50 pg/mL, P<0.0001. Eight patients from subgroup 1A, all admitted soon after the onset of their PE symptoms, and all experiencing at least one syncopal episode showed BNP under the cut-off level. In subgroup 1A BNP did not correlate with RV end-diastolic diameter (R=0.23, P=NS), while in subgroup 1B BNP and RV end-diastolic diameter showed a consistent positive correlation (R=0.91, P<0.0001). In subgroup 1A BNP correlated significantly, but negatively, with RV systolic pressure (R=-0.64, P<0.01). In subgroup 1B BNP was significantly positively correlated with RV systolic pressure (R=0.76, P<0.001).\r\nConclusions. BNP higher than a cut-off level of 50 pg/mL could predict acute RVD in patients with PE with a good sensitivity and specificity. Exception of this rule was found in some patients with recent (<12 hours) PE symptoms onset and poor clinical condition.

Introduction. The blood brain barrier (BBB) restricts the transport of hydrophilic molecules such as peptidic pituitary hormones into the brain tissue. The blood-cerebrospinal fluid (CSF) is a part of the BBB.\r\nAim To compare the pituitary hormone levels on the two sides of the BBB in a group of subjects without endocrine diseases.\r\nPatients and methods. We investigated, with the approval of the local ethics committee, 78 subjects without endocrine diseases. Growth hormone (GH), prolactin (PRL), follicle-stimulating hormone (FSH), luteinizing hormone (LH) and thyroid stimulating hormone (TSH) were measured by rapid fluoroimmunoassay with Europium in the blood and cerebrospinal fluid (CSF)sampled simultaneously before rachianestesia for minor surgery.\r\nResults. CSF concentrations are significantly lower than the corresponding serum ones for all hormones studied: 0.04 ? 0.009 mU/mL vs 2.29 ? 0.57 mU/mL for GH, 1.49 ? 0.078 ng/mL vs 10.07 ? 1.42 ng/mL for PRL, 0.57 ? 0.078 U/L vs 22.71 ? 3.65 U/L for FSH, 0.39 ? 0.038 U/L vs 11.11 ? 1.55 U/L for LH and 0.01 ? 0.003 &#956;U/mL vs 1.36 ? 0.17&#956;U/mL for TSH (mean ? SEM; p<0.001). The CSF/serum ratio was below 1 in the vast majority of cases (from all subjects studied we only found 3 cases with supraunitary CSF/serum ratio). The serum and CSF levels were not significantly correlated for\r\nany of the pituitary hormones. Comparing preand postmenopausal women the CSF gonadotropin levels were slightly but nonsignificantly increased after menopause,\r\ndespite marked differences in the serum concentrations: CSF FSH 1.21 ?0.17U/L after vs 0.84? 0.4U/L before menopause, CSF LH 0.60? 0.047U/L after vs 0.43? 0.14U/L before\r\nmenopause. The CSF/ serum ratio for FSH markedly decreased after menopause (0.02?0.003 vs 0.22?0.11) although the effect did not reach statistical significance. The same\r\nwas true for CSF/serum LH ratio (0.026?0.005 vs 0.09?0.002). For none of the hormones studied the CSF levels correlated with age.\r\nConclusion. Pituitary hormones are normally found in the CSF at much lower levels than in the serum. The CSF hormonal\r\nconcentrations do not significantly correlate with the serum ones.

In some humans, the big and big-big prolactin variants represent the majority of circulating prolactin, considered to be without biological activity. Aims: to establish the clinical expression of macroprolactinemia and the interference with immunodiagnostic tests\r\nin a randomized group of 84 consecutive patients with hyperprolactinemia. IRMA and electrochemiluminescence (Elecsys) were used for PRL assay; gel filtration chromatography (GFC) and protein A precipitation test were used to reveal macroprolactinemia. Results: Macroprolactinemia was found in 16 out of 84 patients (group A), 62 patients had hyperprolactinemia of other causes (group B) and 6 had normal PRL levels and normal GFC (group C). Of 16 patients with macroprolactinemia, 6 showed normal PRL with IRMA and hyperprolactinemia with Elecsys. The difference between the two methods used (&#8710; = PRL determined by Elecsys, -PRL determined by IRMA) correlated with big big PRL level determined by GFC with Elecsys in all patients. The strongest correlation was found in patients with macroprolactinemia (group A, r=0.82, p<0.01) as compared with group B, without macroprolactinemia (r=0.39, p<0.01). Menstrual disorders were expressed, but less frequent in group A versus B (3/15 vs. 28/56, p=0.04), and the appearance of galactorrhea and infertility were not statistically different. Conclusions: In these patients, macroprolactinemia had clinical expression, but weaker than in true hyperprolactinemic patients. It determines high apparent variability of serum PRL level in current commercial assays.

In acromegalic patients growth hormone (GH) excess induces insulin resistance (IR) but whether this is sufficient for pre-diabetes to occur is a matter of debate.\r\nAim. To assess the relative role of IR and insulin secretion in the pre-diabetes of acromegaly.\r\nMethods. 126 patients with acromegaly (79 women, 47 men) were included. Plasma glucose, GH and insulin levels were measured basal and 30, 60 and 120 minutes during a 75 g oral glucose tolerance test (OGTT). Basal and stimulated IR was assessed by homeostasis model assessment (HOMA), insulin resistance index (HOMA-IR) and insulin sensitivity index (ISI) derived from OGTT (OGTTISI) respectively. Basal and stimulated insulin secretion was assessed using HOMA-B% index and insulinogenic index (IGI), respectively. The local Ethic Committee approved the study.\r\nResults. There were 51 subjects with pre-diabetes and 75 subjects with normal glucose tolerance (NGT). Pre-diabetes group had a significantly higher HOMA-IR index (4.8?3.3 vs 2.5?1.6, p<0.001) and nadir GH in OGTT (9.4 (4.3, 22.2) vs. 4.8 (2.2, 14.5) ng/mL, p=0.02) than NGT group. HOMA-IR did not correlate with nadir GH serum level in pre-diabetes group (r =0.22, p=0.12) but correlated significantly in NGT group (r= 0.5, p<0.001). In contrast, the pre-diabetes group had a lower HOMA-B% index than NGT group (165.4?15.7 vs 228.5?29, p<0.001). HOMA-B% did not correlate with nadir GH in both groups. Unadjusted IGI did not differ between the two groups (0.40?0.07 vs. 0.48?0.05, p=0.34) but became statistically significant after adjusting for both basal IR (HOMA-IR) (0.31?0.06 vs. 0.54?0.05, p=0.01) and stimulated IR (OGTTISI) (0.30?0.06 vs. 0.54?0.05, p=0.005). There were no significant differences between pre-diabetes and NGT groups regarding age, duration of acromegaly and sex.\r\nConclusions. Our data suggest that reduced basal and stimulated insulin secretion express the failure of &#946;-cells adaptation to increased GH-induced-insulin resistance and is the pathogenic mechanism of pre-diabetes in acromegaly.

INTRODUCTION: The aim of our study was to evaluate the cure rate of macroprolactinomas treated for a long term (> 4 years) or a short term (<4 years) with dopamine agonists (DA) alone or combined with radiotherapy (RT). Sometimes pituitary\r\nsurgery was performed.\r\nMATERIAL AND METHODS: We performed a retrospective study in 111 patients with macroprolactinomas, hospitalized in the Institute of Endocrinology, Bucharest, between 1978-2005. There were two groups, according to the length of DA therapy: group\r\nA =41 patients, treated more than 4 years and group B =70 patients, treated less than 4 years. Overall, 25 patients underwent additional radiotherapy, 13 in group A and 12 in group B. 28 patients were submitted to pituitary surgery, 9 in group A and 19 in group B.\r\nRESULTS: The cure rate (i.e. normalization of prolactin=PRL level and absence or minimal residual tumor mass, stable minimum 2 years after DA withdrawal) was 5/41 (12.1%) in group A and none in group B. 48 out of 111 patients achieved significant improvement (serum prolactin level less than 20 ng/ml and tumor shrinkage more than 50%) during DA therapy, but not after DA withdrawal: 17/41patients (41.5%) in group A and in 31/70 patients (44.3%) in group B, p=NS. Radiotherapy produced an additional improvement: in serum PRL levels only in group A, in 4/13 patients- 2/8 patients responsive to DA therapy and 2/5 patients resistant to DA therapy. In group B, the 3 patients resistant to DA submitted to radiotherapy were evaluated before the interval necessary for maximal effect of radiotherapy, but in 4/9 patients responsive to DA, we noticed further reduction in tumor volume, 2/4 progressing from mild to significant tumor shrinkage and ? progressing from no shrinkage to mild shrinkage. After radiotherapy, the medium prolactin level was 5.1 ng/ml in 10 patients from both groups on low bromocriptine (BRC) dose (7.5 mg/day), significantly less than in patients without radiotherapy, i.e. than in 19 patients from group A (serum PRL 49.5 ng/ml, p=0.02) and in 29 patients from group B (serum PRL 30.3 ng/ml, p=0.01). So, the daily BRC dose could safely decrease from 30 mg/day to 7.5 mg/day in those patients previously submitted to radiotherapy. Among 23 patients resistant to initial DA treatment, only 8 patients were submitted to radiotherapy, 2 became responsive to DA thereafter and 2 others obtained a significant decrease of prolactin levels.\r\nCONCLUSIONS: The overall cure rate is quite low in prolactinomas and it was noticed only after long-term treatment with dopamine agonists; it was improved up to 12.1% by the additional high voltage radiotherapy, useful even in DA resistant cases. The addition of radiotherapy is indicated for the cure of most prolactinomas.

Introduction: The dexamethasone suppression tests (DST) in the diagnosis of Cushing's syndrome (CS) give frequently equivocal results. Our study evaluated the precision of DST in the diagnosis of CS. Patients and methods: 223 patients (15 - 77 years, 130 F / 93 M) were studied for putative CS by morning and midnight serum cortisol, urinary free cortisol (UFC) and 17 hydroxycorticosteroids (17OHCS) levels at baseline and after DST as follows: 1 mg overnight (oDST), 0.5mg q.d., 2 days (LDDST) and 2 mg q.d. 2 days (HDDST). Since not all cases were evaluated by all tests, statistical analysis used available results. Results: 79 patients had CS (47 pituitary, 3 ectopic, 21 adrenal adenoma and 8 adrenal carcinoma), 45 had adrenal tumor without all the criteria for CS (NCT) and 99 were controls. All patients with CS had abnormal cortisol biorhythm, but also 31.8% patients with NCT and 50% evaluated controls. The best basal screening test for CS is UFC, with a cut-off value of 100 g/24 h. For DST with a serum cortisol cutoff level (CCL) of 5 ?g/dl, oDST correctly diagnosed all CS, while lowering the CCL at 1.8 ?g/dl increased the false positive rate to 6.8%. At LDDST, the serum CCL of 5 ?g/dl correctly identified all patients with CS, but was 2.5 % false positive in controls. A significant correlation of serum cortisol values after oDST or LDDST with basal 17OHCS and UFC was found (r=0.6, p<0.001), suggesting that patients with mild CS are more prone to test as false negatives. The classical criterion of 50% suppression for UFC after LDDST correctly identified 12/14 CS patients and all 8 controls. Better sensitivity (Sn) had an UFC cutoff level of 10?g/24h, p<0.001. A 50% suppression of 17OHCS identified 45/61 CS patients and excluded the disease in 30/37 patients. In HDDST, serum cortisol suppression by > 50% diagnosed Cushing's disease (CD) with 85 % Sn and 57% specificity (Sp). The best HDDST accuracy had UFC (83%), with 27% false negative results (3/11 patients) for a cut-off value of\r\n50% from baseline. 17OHCS were suppressed by 50% in 19/35 patients with CD (54%) and in 3/33 (9%) patients with other causes of CS. NCT patients had higher basal values of UFC and 17OHCS than controls (p<0.01) and up to 50% had an abnormal biorhythm, suggesting a degree of hypercortisolism, with an inadequate oDST or LDDST . Therefore, only 6/45 NCT fulfilled the criteria for subclinical CS.\r\nConclusion: The best screening test was oDST (100% Sn and Sp), followed by UFC (100% Sn and 92% Sp). LDDST with serum CCL at 5 ?g/dl had 100% Sn and 97% Sp. HDDST identified CD by UFC with 73% Sn and 92% Sp and by serum cortisol with 85% Sn and 57% Sp. For NCT, the standard tests identified SCS in 13%. However, a thorough evaluation including multiple tests should be undertaken for the positive and differential diagnosis of Cushing's syndrome.

A 63-years old patient with severe thyrotoxicosis with cachexia and high frequency atrial fibrillation showed an inadequate secretion of TSH. A pituitary macroadenoma was revealed by computed tomography. Acute octreotide administration decreased serum TSH\r\nfrom 2.48 mU/mL to 0.06 mU/mL and T3 from 3.1 ng/mL to normal values (0.93 ng/mL) in 3 days; at the same time serum T4 remained unchanged (raised).The response to octreotide supported the diagnosis of TSH-secreting adenoma. T3 suppression test is no longer useful at present for diagnosis.Administration of long- acting somatostatin analogues (lanreotide) together with antithyroid drugs (ATD) was initially necessary. However, after removal of pituitary tumor the clinical symptoms (including atrial fibrillation) disappeared.ATD administration was no longer necessary, nor was octreotide or lanreotide. Immunohistochemistry certified that the pituitary tumor was a pure thyrotropinoma (without plurihormonal expression). Complete cure of severe thyrotoxicosis due to a TSH-secreting pituitary adenoma by pituitary surgery is possible. Thyroidectomy is not indicated.