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Free access

B Gatta-Cherifi, O Chabre, A Murat, P Niccoli, C Cardot-Bauters, V Rohmer, J Young, B Delemer, H Du Boullay, M F Verger, J M Kuhn, J L Sadoul, Ph Ruszniewski, A Beckers, M Monsaingeon, E Baudin, P Goudet and A Tabarin

Objective

Limited data regarding adrenal involvement in multiple endocrine neoplasia type 1 (MEN1) is available. We describe the characteristics of MEN1-associated adrenal lesions in a large cohort to provide a rationale for their management.

Methods

Analysis of records from 715 MEN1 patients from a multicentre database between 1956 and 2008. Adrenal lesions were compared with those from a multicentre cohort of 144 patients with adrenal sporadic incidentalomas.

Results

Adrenal enlargement was reported in 20.4% (146/715) of patients. Adrenal tumours (>10 mm in size) accounted for 58.1% of these cases (10.1% of the whole patient cohort). Tumours were bilateral and >40 mm in size in 12.5 and 19.4% of cases respectively. Hormonal hypersecretion was restricted to patients with tumours and occurred in 15.3% of them. Compared with incidentalomas, MEN1-related tumours exhibited more cases of primary hyperaldosteronism, fewer pheochromocytomas and more adrenocortical carcinomas (ACCs; 13.8 vs 1.3%). Ten ACCs occurred in eight patients. Interestingly, ACCs occurred after several years of follow-up of small adrenal tumours in two of the eight affected patients. Nine of the ten ACCs were classified as stage I or II according to the European Network for the Study of Adrenal Tumors. No evident genotype/phenotype correlation was found for the occurrence of adrenal lesions, endocrine hypersecretion or ACC.

Conclusions

Adrenal pathology in MEN1 differs from that observed in sporadic incidentalomas. In the absence of relevant symptoms, endocrine biology can be restricted to patients with adrenal tumours and should focus on steroid secretion including the aldosterone–renin system. MEN1 is a high-risk condition for the occurrence of ACCs. It should be considered regardless of the size of the tumour.

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V:1. MULTIPLE ENDOCRINE NEOPLASIA SYNDROMES

V:1:1. Introduction

The presence of tumors in various endocrine organs is known under the term multiple endocrine neoplasia (MEN) syndrome. The first type, MEN 1, is characterized by the combined occurence of tumours of the pituitary gland and pancreatic islets and by hyperparathyroidism. The frequent association of medullary thyroid carcinoma (MTC) with adrenal phaeochromocytoma was first described by Sipple in 1961(1) and later called MEN 2. This is an autosomal dominant inherited disorder with a high degree of penetrance but varying in expression (2,3). MEN 2 is subdivided by Sizemore (4) into two phenotypes: MEN 2A and 2B. Type 2A or Sipple's syndrome is characterized by the occurrence of multifocal C-cell hyperplasia or medullary thyroid carcinoma, bilateral intra- and extra-adrenal phaeochromocytomas and hyperplasia, adenoma or even carcinoma of one or more of the parathyroid glands (5,6). Type 2B, the mucosoneural phenotype, is characterized by the

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Sylvia L. Asa, William Singer, Kalman Kovacs, Eva Horvath, David Murray, Nicholas Colapinto and Michael O. Thorner

Abstract. We report the first documentation of GHRH production by a tumour associated with proven multiple endocrine neoplasia (MEN). A 30-year-old woman had hypoglycaemia, hyperparathyroidism, and pituitary adenoma with hyperprolactinaemia. Serum growth hormone elevation was attributed to hypoglycaemia but plasma GHRH was elevated. Subtotal pancreatectomy revealed multiple endocrine tumours and nesidioblastosis. Immunohistochemistry demonstrated insulin, glucagon, and somatostatin in several tumours. GHRH was localized in the largest one and was released from that tumour in vitro. Post-operative plasma GH returned to normal. Excess secretion of humoural factors by one tumour may stimulate growth of other tumours in MEN syndromes. The prevalence of GHRH in MEN-I tumours remains to be established.

Free access

Anouk Scholten, Menno R Vriens, Geert Jan E Cromheecke, Inne H M Borel Rinkes and Gerlof D Valk

Objective

Hemodynamic (HD) instability still underlies difficulties during pheochromocytoma resection. Little is known about HD instability in patients with multiple endocrine neoplasia (MEN) type 2-related pheochromocytoma. Our aim was to assess differences in HD during pheochromocytoma resection between MEN2 and non-MEN patients. In addition, we sought to identify risk factors for intraoperative HD instability.

Design

Retrospective cohort study.

Methods

A total of 22 MEN2 and 34 non-MEN patients underwent 61 pheochromocytoma resections at the University Medical Center Utrecht between 2000 and 2010. All MEN2-related pheochromocytomas were diagnosed by annual screening. HD instability was assessed by measuring the frequency of hypotensive (mean arterial blood pressure (MABP) <60 mmHg) and/or hypertensive (systolic arterial blood pressure (SABP) >200 mmHg) episodes.

Results

Compared with non-MEN patients, MEN2 patients were younger at diagnosis, had less symptoms, lower hormone levels, and smaller tumors. Intraoperatively, MEN2 patients had a similar frequency of hypertensive episodes (1.3 vs 1.9, P=0.162, 95% confidence interval (CI): −6.7 to 35.4) and a similar maximum SABP (200 vs 220 mmHg, P=0.180, 95% CI: −9.7 to 50.5). However, MEN2 patients experienced less frequent (1.04 vs 2.6, P=0.003, 95% CI: 0.57 to 2.6) and less severe hypotensive episodes after tumor resection (lowest MABP: 52.5 vs 45.6 mmHg, P=0.015, 95% CI: −12.6 to 1.16). Tumor size was an independent risk factor for HD instability for the total group after multivariate analysis.

Conclusion

MEN2 patients with pheochromocytoma, despite their smaller tumors, do not distinguish themselves from non-MEN patients in terms of hypertensive episodes during pheochromocytoma resection. Therefore, pretreatment with α- and β-blockade remains the standard of care in MEN2-related as well as in non-MEN-related pheochromocytomas.

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B. Eriksson, H. Arnberg, K. Öberg, U. Hellman, G. Lundqvist, C. Wernstedt and E. Wilander

Abstract

Chromogranins A, B, and C, proteins that are co-stored and co-released with peptides and amines, have been identified in a variety of neuroendocrine tissues, both normal and neoplastic. We examined the secretion of chromogranin A and chromogranin A + B by hormone-producing tumours in patients with endocrine pancreatic tumours, carcinoid tumours, pheochromocytomas, and small cell lung cancer. The radioimmunoassay determining the plasma concentrations of chromogranin A + B showed a greater sensitivity than that determining chromogranin A alone. All patients with endocrine pancreatic tumours, carcinoids, and pheochromocytomas had increased levels of chromograin A + B, whereas a small number of the patients (5/18 with endocrine pancreatic tumours and ⅓ with pheochromocytomas) had normal levels of chromogranin A. Also in immunocytochemical stainings, our polyclonal antiserum detecting both chromogranin A and B showed a greater sensitivity than other available antisera against chromogranin A, B and C. We have demonstrated that a polyclonal antiserum against a mixture of chromogranin A and B might be a more sensitive marker than chromogranin A alone for diagnosing neuroendocrine tumours. This is not surprising, since both chromogranins are widely distributed in neuroendocrine cells.

Free access

Nicolasine D Niemeijer, Johannes A Rijken, Karin Eijkelenkamp, Anouk N A van der Horst-Schrivers, Michiel N Kerstens, Carli M J Tops, Anouk van Berkel, Henri J L M Timmers, Henricus P M Kunst, C René Leemans, Peter H Bisschop, Koen M A Dreijerink, Marieke F van Dooren, Jean-Pierre Bayley, Alberto M Pereira, Jeroen C Jansen, Frederik J Hes, Erik F Hensen and Eleonora P M Corssmit

Objective

Succinate dehydrogenase B subunit (SDHB) gene germline mutations predispose to pheochromocytomas, sympathetic paragangliomas, head and neck paragangliomas and non-paraganglionic tumors (e.g. renal cell carcinoma, gastrointestinal stromal tumor and pituitary neoplasia). The aim of this study was to determine phenotypical characteristics of a large Dutch cohort of SDHB germline mutation carriers and assess differences in clinical phenotypes related to specific SDHB mutations.

Design

Retrospective descriptive study.

Methods

Retrospective descriptive study in seven academic centers.

Results

We included 194 SDHB mutation carriers consisting 65 (33.5%) index patients and 129 (66.5%) relatives. Mean age was 44.8 ± 16.0 years. Median duration of follow-up was 2.6 years (range: 0–36). Sixty persons (30.9%) carried the exon 3 deletion and 46 (23.7%) the c.423 + 1G > A mutation. Fifty-four mutation carriers (27.8%) had one or multiple head and neck paragangliomas, 4 (2.1%) had a pheochromocytoma and 26 (13.4%) had one or more sympathetic paragangliomas. Fifteen patients (7.7%) developed metastatic paraganglioma and 17 (8.8%) developed non-paraganglionic tumors. At study close, there were 111 (57.2%) unaffected mutation carriers. Statistical analyses showed no significant differences in the number and location of head and neck paragangliomas, sympathetic paragangliomas or pheochromocytomas, nor in the occurrence of metastatic disease or other tumors between carriers of the two founder SDHB mutations (exon 3 deletion vs c.423+ 1G > A).

Conclusions

In this nationwide study of disease-affected and unaffected SDHB mutation carriers, we observed a lower rate of metastatic disease and a relatively high number of head and neck paragangliomas compared with previously reported referral-based cohorts.

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Domenico Salvatore, Angela Celetti, Nicole Fabien, Christian Paulin, Maria Luisa Martelli, Caterina Battaglia, Daniela Califano, Carmen Monaco, Giuseppe Viglietto, Massimo Santoro and Alfredo Fusco

Salvatore D, Celetti A, Fabien N, Paulin C, Martelli ML, Battaglia C, Califano D, Monaco C, Viglietto G, Santoro M, Fusco A. Low frequency of p53 mutations in human thyroid tumors; p53 and Ras mutation in two out of fifty-six thyroid tumours. Eur J Endocrinol 1996;134:177–83. ISSN 0804–4643

Objective: p53 is a well-known nuclear phosphoprotein encoded by a suppressor gene known to be mutated in various kinds of human tumours. A relationship between p53 gene mutation and tumour progression seems to be a common feature of several neoplasias. Desing: In order to investigate the role of p53 mutations in human thyroid tumours, DNA samples derived from fifty-six neoplastic tissues, ranging from benign adenomas to undifferentiated carcinomas, were examined for the presence of p53 gene mutations. Methods: The analysis has been conducted using polymerase chain reaction (PCR) amplification of the exons 5–9 of the p53 gene followed by single strand conformation polymorphism (SSCP) and sequence analyses. Results: One anaplastic carcinoma and one papillary carcinoma showed p53 gene mutations in exons 5 and 8, respectively. A cell line established from the papillary carcinoma showed the same mutation present in the original tumour. Both p53 mutations were heterozygous. The p53 positive samples were analysed for other genetic alterations frequently detected in human thyroid carcinomas (mutations of the RET, TRK, and ras oncogenes): both p53-mutated samples proved to be mutated at level of codon 13 of the c-Ki-ras gene. Conclusions: Our data confirm that p53 gene alterations are rare in well-differentiated thyroid tumours, that they are an important requirement for the establishment in culture of human thyroid carcinoma cell lines, and that they can be associated with other genetic alterations, namely ras mutations, in the malignant progression of thyroid tumours.

Alfredo Fusco, Dipartimento di Biologia e Patologia Cellulare e Molecolare, Facoltà di Medicina e Chirurgia, via S. Pansini 5, 80131, Napoli, Italy

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J. Kracht and N. Hantschmann

ABSTRACT

The tumour syntropies of Cushing's syndrome are discussed on the basis of a case of metastatic mediastinal tumour – a small round cell undifferentiated carcinoma – followed by a Cushing syndrome.

These tumoral syntropies are generally limited to the thymus, the bronchial tree and the pancreas, but may also occasionally appear elsewhere. The accompanying hyperfunction of the adrenal cortex may appear in various grades of intensity, i. e.

  1. 1) As a simple increase in the output of adrenal steroids without clinical symptoms of hyperadrenocorticism.

  2. 2) As an increase of adrenal cortex output accompanied by a hypochloraemic and hypopotassaemic alkalosis, however with no manifestation of Cushing syndrome.

  3. 3) A full blown Cushing syndrome.

Either the tumour or the hyperadrenocorticism may be the primary disease. The underlying pathogenetic factor which causes the correlation between the two diseases has not yet been ascertained.

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J. Kracht and J. Tamm

ABSTRACT

A case report is presented of a female patient with an invasive basophil adenoma of the anterior pituitary gland and with Cushing's syndrome. Following a review of the literature of Cushing's syndrome with expanding and invasive pituitary tumours with and without metastases we have divided these tumours into three groups:

  1. Pituitary tumours, which arise with no surgical treatment of the adrenals.

  2. Tumours of category 1, the growth of which is accelerated following adrenalectomy.

  3. Tumours whose growth is accelerated following adrenalectomy, but which are recognized clinically only after surgical treatment of the adrenals.

Most of these tumours are now considered to be »hyperplasiogenic« growths, which continue to remain under the influence of hypothalamic factors. Primary autonomous, ACTH-secreting tumours are on the contrary seldom seen. Histological criteria are insufficient to differentiate between autonomous and regulated pituitary ACTH-producing tumours. It is assumed that this differentiation may be only possible by means of function-tests.

Free access

MA Satta, M Korbonits, RA Jacobs, DA Bolden-Dwinfour, GA Kaltsas, V Vangeli, E Adams, R Fahlbusch and AB Grossman

OBJECTIVE: Multiple endocrine neoplasia type 1 (MEN 1) is an autosomal dominant inherited disorder characterised by the combined occurrence of parathyroid, endocrine pancreas and anterior pituitary tumours. The gene responsible for MEN 1, the menin gene, a putative tumour-suppressor gene located on human chromosome 11q13, has been cloned. To investigate the role of the menin gene in sporadic anterior pituitary tumorigenesis, its mRNA was assessed in a group of pituitary tumours. METHODS: Menin gene expression, along with glyceraldehyde phosphate dehydrogenase (GAPDH) gene expression, has been studied in a group of normal pituitaries and in 23 pituitary tumours not associated with the MEN 1 syndrome. The pituitary tumours included 4 prolactinomas, 11 growth-hormone-secreting tumours and 8 non-functional tumours. Total RNA was extracted from the normal pituitaries and tumours, and cDNA was synthesised with standard reverse transcriptase methods. Duplex polymerase chain reaction (PCR) was standardised in order to quantify the expression of the menin gene using intron-spanning primers across exons 9 and 10 in relation to the 'house-keeping' gene GAPDH. The PCR products were separated on agarose gel and densitometric analysis of the bands allowed semi-quantification. RESULTS: There was no evidence for a change in menin gene expression in any of the pituitary tumours when compared with normal pituitaries. CONCLUSIONS: These studies complement previous work on mutational analysis, and do not suggest a major role for the menin suppressor gene in sporadic pituitary tumorigenesis.