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Rina Balducci, Vincenzo Toscano, Adele Mangiantini, Patrizia Bianchi, Rinaldo Guglielmi and Brunetto Boscherini

To evaluate the effect of growth hormone on testicular response to human chorionic gonadotropins (hCG) in vivo in humans, we selected patients with combined deficits of GH and gonadotropins who were in substitution treatment with both GH (from the time of diagnosis) and gonadotropins (from the time of induction of puberty). Testicular response to gonadotropin therapy was then evaluated during and six months after the cessation of GH treatment. Blood samples were collected before and 2, 4 and 6 days after hCG administration. hCG responses were calculated and expressed as the areas under the response curve. We studied four hypogonadotropic patients (aged 18–19 years) with associated GH deficiency. Their gonadotropin treatment consisted of hCG 1500IU every six days, and FSH 75 IU every three days. The GH therapy replacement consisted of 4 IU thrice weekly. Testosterone, androstenedione, 17α-hydroxyprogesterone and estradiol were measured. In all subjects the testosterone area during GH treatment was significantly higher compared to the testosterone area obtained without GH administration (2993±1091 vs 2310±751; M±sd; p<0.04). The androstenedione area followed a similar pattern (708±377 vs 402±248; M±sd; p<0.05). The 17α-hydroxyprogesterone area, on the contrary, was significantly higher during GH withdrawal (542±307 vs 235±190; M±sd; p<0.05). As far as the estradiol area is concerned, no significant differences were found (22860±10082 vs 25697±13640; M±sd). In conclusion, GH administration seems to improve testosterone production induced by human chorionic gonadotropins. The finding of the inverse response pattern of 17α-hydroxyprogesterone with respect to testosterone led us to suppose that the increased testosterone area during GH treatment may be due to an increased activity of C17,20-lyase enzyme.

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Vincenzo Toscano, Francesco Sciarra, Maria Vittoria Adamo, Elisa Petrangeli, Sonia Foli, Stefania Caiola and Carlo Conti

Abstract.

The behaviour of 5α-reduced metabolites of testosterone, dihydrotestosterone1, 3α-androstanediol and 3β-androstanediol, was studied in 36 hirsute women: Group I: 24 patients with high plasma levels of testosterone, androstenedione and/or dehydroepiandrosterone sulphate and Group II: 12 patients with normal plasma concentrations of these steroids.

Testosterone and its 5α-reduced metabolites were determined by radioimmunoassay after chromatographic separation on celite 535 microcolumns.

Plasma 3α-androstanediol was found to be elevated both in Group I (26.9 ± 10.8 sd ng/100 ml) and in Group II patients (23.2 ± 10.5 sd ng/100 ml). 3β-Androstanediol and dihydrotestosterone, on the contrary, were elevated in only a few cases: in 6 cases in Group I and in 2 and in 1 case, respectively, in Group II.

The finding of high plasma 3α-androstanediol levels in hirsute women, with normal values of the other androgens, may be an index of hirsutism of peripheral origin, since this steroid is produced almost exclusively in the extraglandular compartment.

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Giuseppe Minniti, Claudia Scaringi, Maurizio Poggi, Marie Lise Jaffrain Rea, Giuseppe Trillò, Vincenzo Esposito, Alessandro Bozzao, Maurizio Maurizi Enrici, Vincenzo Toscano and Riccardo Maurizi Enrici

Objective

We describe the use of fractionated stereotactic radiotherapy (FSRT) for the treatment of large, invasive, nonfunctioning pituitary adenomas (NFPAs). FSRT is frequently employed for the treatment of residual or recurrent pituitary adenomas.

Patients and methods

Sixty-eight patients with a large residual or recurrent NFPAs were treated between April 2004 and December 2012, including 39 males and 29 females (median age 51 years). Visual defects were present in 34 patients, consisting of visual field defects (n=31) and/or reduced visual acuity (n=12). Forty-five patients had evidence of partial or total hypopituitarism before FSRT. For most of the patients, the treatment was delivered through 5–10 noncoplanar conformal fixed fields using a 6-MV linear accelerator to a dose of 45 Gy in 25 fractions.

Results

At a median follow-up of 75 months (range 12–120 months), the 5- and 10-year actuarial local control were 97 and 91%, respectively, and overall survival 97 and 93%, respectively. Forty-nine patients had a tumor reduction, 16 remained stable, and three progressed. The relative tumor volume reduction measured using three-dimensional (3D) magnetic resonance imaging (MRI) was 47%. The treatment was well tolerated with minimal acute toxicity. Eighteen patients developed partial or complete hypopituitarism. The actuarial incidence of new anterior pituitary deficits was 40% at 5 years and 72% at 10 years. No other radiation-induced complications occurred.

Conclusions

Our results suggest that FSRT is an effective treatment for large or giant pituitary adenomas with low toxicity.

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Flavia Tosi, Carlo Negri, Elisabetta Brun, Roberto Castello, Giovanni Faccini, Enzo Bonora, Michele Muggeo, Vincenzo Toscano and Paolo Moghetti

Objective

In hyperandrogenic women, hyperinsulinaemia amplifies 17α-hydroxycorticosteroid intermediate response to ACTH, without alterations in serum cortisol or androgen response to stimulation. The aim of the study is to assess whether acute hyperinsulinaemia determines absolute changes in either basal or ACTH-stimulated adrenal steroidogenesis in these subjects.

Design and methods

Twelve young hyperandrogenic women were submitted in two separate days to an 8 h hyperinsulinaemic (80 mU/m2×min) euglycaemic clamp, and to an 8 h saline infusion. In the second half of both the protocols, a 4 h ACTH infusion (62.5 μg/h) was carried out. Serum cortisol, progesterone, 17α-hydroxyprogesterone (17-OHP), 17α-hydroxypregnenolone (17-OHPREG), DHEA and androstenedione were measured at basal level and during the protocols. Absolute adrenal hormone secretion was quantified by measuring C19 and C21 steroid metabolites in urine collected after the first 4 h of insulin or saline infusion, and subsequently after 4 h of concurrent ACTH infusion.

Results

During insulin infusion, ACTH-stimulated 17-OHPREG and 17-OHP were significantly higher than during saline infusion. No significant differences in cortisol and androgens response to ACTH were found between the protocols. Nevertheless, urinary excretion of ACTH-stimulated C19 and C21 steroid metabolites was significantly higher during hyperinsulinaemia than at basal insulin levels (both P<0.005). Changes in steroid metabolites molar ratios suggested stimulation by insulin of 5α-reductase activity.

Conclusions

These in vivo data support the hypothesis that insulin acutely enhances ACTH effects on both the androgen and glucocorticoid pathways.

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Rina Balducci, Vincenzo Toscano, Anna M Pasquino, Adele Mangiantini, Giovanna Municchi, Patrizia Armenise, Sandra Terracina, Giancarlo Prossomariti and Brunetto Boscherini

Balducci R, Toscano V, Pasquino AM, Mangiantini A, Municchi G, Armenise P, Terracina S, Prossomariti G, Boscherini B. Bone turnover and bone mineral density in young adult partients with panhypopituitarism before and after long-term growth hormone therapy. Eur J Endocrinol 1995;132:42–6. ISSN 0804–4643

We examined the effects of biosynthetic growth hormone (GH) on biochemical indices of bone turnover and on bone mineral density in a group of GH-deficient adults. Thirteen patients (eight males and five females) aged 24 ± 5 years (range 16–35) were studied before and 12 and 24 months after GH treatment (0.1 IU, kg day−1, 6 days a week). Serum levels of insulin-like growth factor I (IGF-I), calcitonin, parathyroid hormone, alkaline phosphatase, intact osteocalcin, fasting urinary hydroxyproline/creatinine ratio and bone mineral density (BMD), measured at the lumbar spine by dualphoton absorptiometry, were evaluated. After 12 months of treatment, IGF-I, alkaline phosphatase, osteocalcin and the fasting urinary hydroxyproline/creatinine ratio increased significantly. However, after 24 months of therapy, serum levels of osteocalcin decreased to pretreatment values while IGF-I, fasting urinary hydroxyproline/creatinine ratio and alkaline phosphatase remained elevated significantly. No changes were found in parathyroid hormone and calcitonin plasma levels or in BMD either after 12 or 24 months of treatment. These data demonstrate that GH, at the dosage that we used, activates bone turnover during 24 months of therapy in adults with panhypopituitarism, even if a downward trend for osteocalcin became apparent at 24 months. However, this activation in bone turnover was not accompanied by an increase in BMD. We can hypothesize that GH, at the relatively high dosage used, may stimulate osteoclastic activity to a greater extent than osteoblastic activity. It is probable that the dose of GH replacement therapy in adults plays a key role

R Balducci, Dipartimento di Sanita Pubblica, Universita "Tor Vergata", Via di Tor Vergata 38, 00173 Roma, Italy

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Maurilio Deandrea, Francesca Garino, Mormile Alberto, Roberto Garberoglio, Ruth Rossetto, Nadia Bonelli, Stefano Spiezia, Massimo De Santis, Salvatore Monti, Maria Grazia Deiana, Toscano Vincenzo, Christian Cugini, Ghassan El Dalati and Paolo Piero Limone

Background

The purpose of this study was to confirm the generalisation of radiofrequency ablation (RFA) in the treatment of benign thyroid nodules (BTN) and to look for a correlation between final shrinkage and some ultrasound (US) findings in a large Italian population data set.

Methods

This prospective study included 337 patients with solid cold BTN from six Italian institutions. Nodule volume, US pattern, thyroid function, symptom/cosmetic scores and complications were evaluated before treatment and at 6 and 12 months. The primary outcome was to find a correlation between basal volume and US pattern of the nodules and final shrinkage. The secondary outcome was to confirm the efficacy and safety of RFA in a large data set.

Results

The median basal volume was 20.7 mL, and this significantly decreased after RFA at 6 months (7.3 mL (−63.5%), P < 0.001) and at 12 months (6 mL (−70%), P vs 6 months = 0.009). A significant correlation was found for US structure (a spongiform pattern showing a 76% reduction vs 67 and 66% of mix and solid patterns respectively, P < 0.01) as well as for vascularity (intense peripheral and intranodal patterns showing 71 vs 68 and 67% of weak peripheral and intranodal and peripheral patterns respectively, P < 0.03), but not for macrocalcifications. A slight inverse correlation was found between nodule basal volume and shrinkage (Spearman: −0.23). Mean symptoms/cosmetic scores were significantly reduced. No major complications were encountered.

Conclusions

This multicentre study validated the efficacy and safety of RFA for treating BTN and showed a clear correlation between final shrinkage and some common US findings.

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Annalisa Brozzetti, Stefania Marzotti, Cristina Tortoioli, Vittorio Bini, Roberta Giordano, Francesco Dotta, Corrado Betterle, Annamaria De Bellis, Giorgio Arnaldi, Vincenzo Toscano, Emanuela Arvat, Antonio Bellastella, Franco Mantero and Alberto Falorni

Objective

Cytotoxic T lymphocyte antigen-4 (CTLA4) gene polymorphism has been associated with human autoimmune diseases, but discordant data are available on its association with autoimmune Addison's disease (AAD). We tested the human leukocyte antigen (HLA)-independent association of CTLA4+49 (A/G) (Ala 17) and/or CTLA4 CT60 (A/G) polymorphism with AAD.

Design

DNA samples from 180 AAD patients and 394 healthy control subjects from continental Italy were analyzed, and association statistical analyses and meta-analysis of published studies were performed.

Methods

TaqMan minor groove binder chemistry assays and PCR fragment length polymorphism assays were used.

Results

Frequency of allele G of CTLA4+49 was significantly increased among AAD patients (40% alleles) than among healthy controls (27% alleles; P<0.0001). CTLA4 CT60 polymorphism was associated with AAD only in the heterozygous A/G individuals. The frequency of +49 AG+GG genotypes was significantly higher among AAD patients than among healthy control subjects, in both a co-dominant (P<0.0001) and G dominant model (P<0.0001). CTLA4+49 allele G was significantly associated with disease risk in both patients with isolated AAD and in patients with autoimmune polyendocrine syndrome. Multivariate logistic regression analysis showed that CTLA4+49 allele G was positively associated with AAD (P<0.0001, odds ratio (OR)=2.43, 95% confidence interval=1.54–3.86) also after correction for DRB1*03-DQA1*0501-DQB1*0201, DRB1*04-DQA1*0301-DQB1*0302, and sex. Meta-analysis of five studies revealed a significant association of CTLA4+49 allele G with AAD (P<0.0001) with an overall OR of 1.48 (1.28–1.71).

Conclusions

The CTLA4+49 polymorphism is strongly associated with genetic risk for AAD, independently from the well-known association with HLA class II genes.