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Neurosurgery clinics of North America 10/2012; 23(4):ix. · 1.73 Impact Factor
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ABSTRACT: The evaluation and management of patients with residual Cushing’s disease is one of the more complex issues facing neurosurgeons
and neuroendocrinologists in clinical practice. There is considerable controversy over several relevant issues such as the
timing of the assessment of whether a patient is in remission, what biochemical parameters define remission, the most appropriate
course of action to take after residual disease has been defined, etc. As a consequence of the controversies, treating physicians
develop notions and fall into certain practice patterns based on evidence of varying levels, their anecdotal experiences,
and information gleaned from scientific meetings. This practice pattern, we believe, constitutes the “art of medicine.” We
conducted a PubMed literature search to identify manuscripts containing data relevant to Cushing’s disease, outcomes of various
therapeutic modalities, and recurrences. Reference lists were used to identify additional relevant manuscripts. We focused
our review on manuscripts that included reasonably large series of patients, those reflecting the experience of pituitary
centers and physicians recognized as experts in the field, and those papers felt to represent seminal contributions to the
literature. Furthermore, trends in the evaluation and management of relevant patients have been incorporated by the senior
author who has seen and evaluated over 750 patients with documented Cushing’s syndrome over the past 18years in clinical
practice. An analysis of current evidence indicated that, despite advances in neurosurgical techniques and recent developments
in adjuvant therapies, patients with residual Cushing’s disease present significant management challenges to treating physicians.
In this era, however, it is indeed possible to gain control of the hypercortisolism in most patients. Despite the wide variability
in research methodology designed to collect relevant data, a step-wise approach to the management of these patients can be
achieved. A logical step-wise approach to the evaluation of postoperative patients with Cushing’s disease is essential. Patients
with residual disease require the development of an individualized plan of management that takes into account numerous factors
pertaining to status of disease, the experience of treating physicians, and available therapeutic modalities.
Journal of Neuro-Oncology 04/2012; 94(3):313-319. · 3.21 Impact Factor
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ABSTRACT: Syndrome of inappropriate antidiuretic hormone secretion (SIADH) is the most common cause of hyponatremia in hospitalized patients and is frequently associated with neurologic disorders and neurosurgical procedures. Traditional therapies such as fluid restriction, sodium repletion, and diuretics can help correct hyponatremia but do not address the underlying pathophysiology of excess arginine vasopressin secretion. Conivaptan is an arginine vasopressin receptor antagonist that has been shown to be both safe and effective in the treatment of euvolemic and hypervolemic hyponatremia.
To analyze the use of conivaptan to treat SIADH in a mixed neurosurgical population.
We conducted a retrospective review of 13 patients with neurosurgical disorders with SIADH that were treated with intravenous conivaptan at our institution between 2007 and 2009.
The mean pretreatment serum sodium concentration was 125.8 ± 3.5 mEq/L. Conivaptan administration resulted in a rise in serum sodium to 132.5 ± 5.6 mEq/L at 12 hours (P < .01) and 134.1 ± 4.7 mEq/L at 24 hours posttreatment (P < .01). The mean time to an increase in serum sodium ≥ 6 mEq/L was 17.8 hours. There were no instances of rapid overcorrection. There were 3 cases of asymptomatic hyperkalemia, 3 cases of asymptomatic hypotension, and 1 case of elevated creatinine associated with conivaptan administration.
These data provide further support that conivaptan can be safely used for the treatment of SIADH-induced hyponatremia in the neurosurgical arena.
Neurosurgery 08/2011; 69(2):268-73. · 2.79 Impact Factor
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ABSTRACT: Rathke cleft cysts (RCCs), benign remnants of the Rathke pouch typically arising in the sella, sometimes have suprasellar extension. Purely suprasellar RCCs are rarely reported.
To compare the presentations, surgical outcomes, and pathology of purely suprasellar RCCs and sellar-based RCCs.
We retrospectively reviewed records, magnetic resonance images, laboratory results, and pathology of 151 RCC patients surgically managed at our institution from 1989 to 2009. The RCCs were classified as purely sellar (type I, n = 76), sellar with suprasellar extension (type II, n = 56), or purely suprasellar (type III, n = 19).
The RCCs with a suprasellar component (types II and III) more commonly presented with visual dysfunction (P < .001). Complete cyst drainage occurred in 89%, 55%, and 38% of type I, II, and III RCCs, respectively (P < .001). Vision improved in 100%, 55%, and 33% and headache improved in 74%, 64%, and 29% of type I, II, and III patients, respectively (P = .02). Temporary or permanent postoperative diabetes insipidus occurred in 5%, 16%, and 21% of type I, II, and III patients, respectively. (P < .001). In a multivariate analysis, RCC type was the only factor predicting recurrence. Kaplan-Meier 3-year recurrence/progression rates were 0%, 16%, and 29% for type I, II, and III RCCs, respectively (P < .001, type I vs II, type I vs III; P = .5 type II vs III).
The RCCs with a suprasellar component are neurosurgically challenging because of their proximity to the optic chiasm and infundibulum. Compared with sellar-based RCCs, RCCs with a suprasellar component more frequently present with visual dysfunction, are more difficult to completely eliminate, recur more frequently, and are associated with higher postoperative endocrine morbidity, and their preoperative visual dysfunction and headache less frequently improve with surgery. These factors must be considered during the treatment of RCCs with a suprasellar component.
Neurosurgery 06/2011; 69(5):1058-68; discussion 1068-7. · 2.79 Impact Factor
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ABSTRACT: The importance of achieving tumor control in pituitary adenoma surgery is not entirely established. This manuscript reviews the literature linking residual pituitary tumor and hormonal hypersecretion to increases in long term mortality. When possible, we utilized meta-analysis methods to estimate a pooled standardized mortality ratio (SMR), which relates the risk of mortality for a cohort of patients compared to a similar age and gender matched cohort in the general population, for patients with endocrinologic evidence of residual disease. When this was not possible, we review the existing literature in the results and discussion section of this review. We identified 10 articles regarding acromegaly and three articles regarding Cushing's disease which presented SMR data for adult patients undergoing transphenoidal surgery with data divided into subgroups based on post-operative growth hormone levels. Using growth hormone levels of 2.5 μg/l as a cutoff, the mortality rate ratio was 1.83 (95% CI = 1.03-3.24) for patients with persistent acromegaly. Similarly, patients with persistent Cushing's disease experienced a marked increase in mortality rate ratio compared to those experiencing initial cure (mortality rate ratio = 3.25 (95% CI = 1.54-6.84). For other tumor subtypes, (i.e. Endocrine inactive adenomas, Prolactinomas, and TSH secreting tumors) there were not enough studies identified to allow for rigorous statistical analysis. There is an increasing body of data suggesting that treatment refractory acromegaly and Cushing's disease puts patients at risk for early mortality, suggesting that aggressive efforts to normalize hormone levels in these patients are justified.
Pituitary 04/2011; 14(3):276-83. · 1.83 Impact Factor
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ABSTRACT: Intravenous administration of conivaptan, an arginine vasopressin (AVP) receptor antagonist, has been demonstrated to be a safe and effective therapy for euvolemic and hypervolemic hyponatremia. In this case report, we report an extremely rapid correction of serum sodium with a typical dosing regimen of conivaptan. The patient was a 24 year woman who presented with nausea and vomiting, and was found on imaging to have two intracranial tumors, one of which was a large pituitary macroadenoma. Her serum sodium declined to 121mmol/L and intravenous conivaptan therapy was started. After approximately 25mg of conivaptan, her sodium increased 16mmol/L over 8.5hours. Fortunately, in this case, this correction was well tolerated, and the patient experienced no adverse effects of such a dramatic correction of serum sodium. Despite the good clinical result in this case, it should serve as a warning regarding the use of conivaptan, that although a gradual steady improvement in serum sodium can be expected in the majority of patients, more extreme corrections can be inadvertently achieved with even moderate doses. Thus, the exact clinical situation should be taken into consideration, especially in cases of subacute to chronic hyponatremia, where such an extreme correction could lead to neurologic devastation.
Journal of Clinical Neuroscience 10/2010; 17(10):1331-4. · 1.25 Impact Factor
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ABSTRACT: Several investigators have recommended serial measurements of serum cortisol in the days following pituitary surgery to identify patients at risk of recurrence.
We systematically reviewed the literature on this topic and analyzed the usefulness of this test in our own patient population.
We identified studies publishing data regarding recurrence rates after transsphenoidal surgery for Cushing's disease, focusing on studies with data regarding patients with early postoperative cortisol levels. We determined a cumulative relative risk of having a subnormal vs normal cortisol level postoperatively using a fixed-effects meta-analysis model. Additionally, we analyzed our own patients with Cushing's disease undergoing transsphenoidal surgery and performed Kaplan-Meier analysis of recurrence-free survival for patients with undetectable, subnormal but detectable, and normal immediate 8 AM serum cortisol levels.
Fourteen studies met inclusion criteria. The length of follow-up varied between 32 and 115 months. The cumulative rate of recurrence in the group of patients with subnormal cortisol levels was 9% (95% confidence interval: 6%-12%). The cumulative rate of recurrence in the group with normal cortisol levels was 24% (95% confidence interval: 17%-31%). We analyzed 73 of our own patients and found similar recurrence rates in patients with subnormal vs normal early postoperative cortisol levels (4% vs 22%, chi2 test, P < .05).
Although a subnormal early postoperative cortisol level is predictive of improved outcome after transsphenoidal surgery for Cushing's disease, it is not analogous with cure, nor is a normal level completely predictive of future failure.
Neurosurgery 09/2010; 67(3):688-95; discussion 695. · 2.79 Impact Factor
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ABSTRACT: It is widely accepted that the standard first-line treatment for most endocrine inactive pituitary macroadenomas (EIA) is surgery, usually via a transsphenoidal approach. What is less clear is what approach to take when these tumors recur, especially when this recurrence involves areas which are difficult to surgically remove tumor from, such as the suprasellar region or cavernous sinuses. We present long term follow-up for a series of 81 patients who underwent repeat surgery for recurrent non-secreting pituitary adenomas. We analyzed data collected from all adult patients undergoing their second microsurgical transsphenoidal resection of a histologically proven endocrine-inactive pituitary adenoma at the University of California at San Francisco between January 1970 and March 2001. Data for these patients were collected by review of medical records, mail, and/or telephone interviews. Visual function, anterior pituitary function, and tumor control rates were analyzed for the series. Records were available for a total of 81 recurrent EIA patients. The median time between their initial and repeat operations was 4.1 years. The mean tumor size was 2.2 +/- 0.2 cm. A total of 35/81 patients had greater than 5 years of follow-up. A total of 24/81 patients had greater than 10 years of follow-up. Over one half of these patients presented with visual disturbance, and we found that 39% of these patients experienced improved vision with a second surgery. More importantly, no one with normal vision suffered any appreciable decline in vision. Approximately, 35% of patients with pre-operative anterior pituitary dysfunction recovered function after surgery in our series; and no patient's function worsened. A total of 4/52 (8%) patients with greater than 2 years of post-op follow-up experienced a clinically meaningful tumor recurrence requiring additional treatment. Our data suggest that when performed by experienced transsphenoidal surgeons, durable tumor control can be obtained in these frequently locally aggressive tumors with acceptable rates of post-operative morbidity.
Pituitary 03/2010; 13(3):223-9. · 1.83 Impact Factor
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ABSTRACT: Pregnancy and Cushing's syndrome rarely coexist. When they do, it is generally the result of the presence of an adrenal adenoma. Because of significantly increased morbidity and mortality in both the mother and fetus when hypercortisolism is present, it is imperative that it be treated when recognized. This treatment can take the form of definitive surgical treatment or temporary medical treatment until after delivery, both of which carry risks and benefits. Complicating the evaluation, however, it is well known that pregnancy itself can induce many of the symptoms and laboratory abnormalities associated with hypercortisolism. We present the case of a 35-year-old woman who was noted to have an adrenal mass before pregnancy, but then during evaluation became pregnant. Her case is particularly intriguing because she had only vague clinical symptoms and mild laboratory abnormalities but also had a complicating pituitary mass noted on MRI. We outline the evaluation process and eventual laparoscopic adrenalectomy during the second trimester in this unique and difficult case, and discuss risks and benefits of different treatment options for hypercortisolism during pregnancy.
The American surgeon 04/2009; 75(3):232-4. · 1.28 Impact Factor
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ABSTRACT: Normalization of serum prolactin concentrations in patients with prolactinomas is an accepted endpoint of therapy. Clinical signs and symptoms of hyperprolactinemia are usually resolved when prolactin levels are lowered to within the normal range. While most patients are treated with dopamine agonist drugs, some patients require surgical resection of their tumors. We sought to determine whether preoperative treatment with dopamine agonists alters the outcome of surgical intervention.
We present an analysis of 253 patients with prolactinomas treated surgically during the period of time when dopamine agonist therapy was first introduced and prior to its widespread use as first-line therapy. We compared both short- and long-term outcomes of patients treated with dopamine agonists prior to surgery with those undergoing surgery as their initial treatment modality. Our data showed that that patients treated with dopamine agonists prior to surgery experienced greater reductions in prolactin levels, had lower prolactin levels, were more likely to have normal prolactin levels at long term follow-up, and were less likely to require additional therapy to control their prolactin levels.
Our study provides strong evidence suggesting that, regardless of initial prolactin level, preoperative dopamine agonist therapy is not detrimental. In fact, pretreatment with dopamine agonist drugs, possibly by inducing tumor regression, seemed to improve the surgeon's ability to resect a greater percentage of the tumor and led to better control of the prolactin level.
Pituitary 01/2009; 12(3):158-64. · 1.83 Impact Factor
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ABSTRACT: To determine the prevalence of valvular heart disease in a cohort of patients taking cabergoline for the management of hyperprolactinemia.
A retrospective review of medical records identified patients with hyperprolactinemia who underwent evaluation at Vanderbilt University Medical Center between January and June 2007. The medical records of those patients who were prescribed cabergoline and who underwent elective echocardiography were reviewed for details pertaining to cardiac valvular abnormalities and cabergoline use.
Forty-five patients (mean age, 41 +/- 10 years [SD]) taking 0.91 +/- 0.96 mg of cabergoline per week for a mean duration of 39 +/- 29 months underwent echocardiography. Abnormalities of the cardiac valves were present in 3 patients (7%): 1 patient exhibited mild mitral regurgitation, 1 patient had focal aortic valve thickening, and 1 patient demonstrated mitral valve thickening. We found no significant difference in either the cumulative dose of cabergoline (P = .800) or the duration of cabergoline therapy (P = .745) between those patients with and those without these echocardiographic abnormalities.
We found echocardiographic valve abnormalities in 3 of 45 patients (7%) who had been prescribed cabergoline for the management of hyperprolactinemia. This prevalence of valvular heart disease after approximately 3 years of cabergoline treatment is no different from that previously reported in normal populations as determined by echocardiography.
Endocrine Practice 10/2008; 14(6):672-7. · 2.49 Impact Factor
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ABSTRACT: Endothelial progenitor cells (EPCs) mobilize from the bone marrow secondary to a stimulus and home to sites of injury, where they differentiate into endothelial cells and contribute to the repair of damaged vasculature. We hypothesized that growth hormone (GH) administration would increase the number of circulating EPCs in adults and thereby represent a mechanism to enhance vascular health.
A prospective trial of low-dose GH (0.03mg/kg/week for 4 weeks followed by 0.06mg/kg/week for a maximum of four additional weeks) in 10 healthy adults (6 males and 4 females; mean age 37 years, range 26-65). Primary outcomes measured included the number of circulating EPCs as assessed by colony-forming unit (CFU) assay and flow cytometry. Secondary outcomes included plasma measurements of known mediators of EPC mobilization and indices of nitric oxide (NO). Outcomes were measured at baseline and at study completion.
GH administration increased serum IGF-1 (143ng/mL [IQR 121-164] to 222 [IQR 194-244]; P=0.005). The increase in early-outgrowth EPCs (13 CFU per high-power field [IQR 6-24] to 19 [IQR 13-40]; P=0.005) correlated with the peak IGF-1 after adjustment for the baseline number of early-outgrowth EPCs (r=0.719 [95% CI 0.06, 0.93]; P=0.027). The number of late-outgrowth EPCs as well as CD34+, VEGFR2(KDR)+, and AC133+ cells did not significantly change. Other mediators of EPC mobilization were stable while plasma nitrite trended upwards (1.3micromol/L [IQR 0-2.5] to 3.7 [IQR 2.2-8.9]; P=0.052).
GH administration selectively augments the early-outgrowth EPC population in healthy individuals. These findings both support GH replacement in the setting of GH deficiency to maintain vascular integrity and have implications for the use of GH in future regenerative cell-based therapies. Furthermore, the decrease in EPCs observed with aging may in part be explained by the declining somatotropic axis, and thereby contribute to cardiovascular senescence.
Growth Hormone & IGF Research 07/2008; 18(3):253-63. · 2.16 Impact Factor
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ABSTRACT: To describe a case of a malignant pheochromocytoma located in the organ of Zuckerkandl that required aortic and vena caval resection and reconstruction.
We present a case report that includes clinical, laboratory, and radiographic data as well as photographs, results from pathology, and a brief review of the literature.
A 46-year-old man was referred for evaluation of a 1.4-cm left adrenal mass incidentally discovered on an abdominopelvic computed tomography (CT) scan. Subsequent laboratory evaluation revealed the following values: urine norepinephrine, 252 microg/24 h; urine normetanephrine, 1122 microg/24 h; urine metanephrine, 162 microg/24 h; urine epinephrine, 7 microg/24 h; urine vanillylmandelic acid, 8 mg/24 h; and plasma metanephrine, 98 pg/ mL. Imaging characteristics of the left adrenal mass were consistent with a benign adenoma, but CT also demonstrated a hypervascular para-aortic mass. 123I-metaiodo-benzylguanidine scanning with fusion CT imaging demonstrated increased radiopharmaceutical uptake within the para-aortic mass consistent with a paraganglioma in the organ of Zuckerkandl. Findings from CT angiography of the abdomen and pelvis suggested aortic involvement and vena caval thrombus. The mass was excised en bloc, including portions of the aorta, inferior vena cava, and right ureter. The aorta and vena cava were reconstructed using Dacron grafts. The remaining right ureter and kidney were removed to avoid the possibility of a urine leak from an ureteroureterostomy. Final pathologic and operative findings confirmed a malignant pheochromocytoma of the organ of Zuckerkandl with invasion into the wall of the inferior vena cava and tumor thrombus extending into the lumen.
Malignant pheochromocytoma of the organ of Zuckerkandl involving the aorta and inferior vena cava is exceedingly rare, and although surgical resection and reconstruction can be radical and aggressive, this treatment offers the only chance for cure.
Endocrine Practice 10/2007; 13(5):493-7. · 2.49 Impact Factor
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ABSTRACT: Adults with GH deficiency (GHD) have multiple cardiovascular risk factors, including an unfavorable lipid profile and body composition as well as impairments in endothelial function and cardiac performance. We hypothesized that GHD is associated with elevated levels of plasminogen activator inhibitor-1 (PAI-1), the major inhibitor of plasminogen activation in the circulation.
The objective of the study was to determine the fibrinolytic profile of adults with GHD in comparison with controls.
This was a prospective, observational study including 12 adults with GHD. Twelve gender-, age-, and body mass index-matched adults served as controls.
The primary outcome measures were circadian plasma PAI-1 antigen with corresponding tissue-plasminogen activator (tPA) activity values. Endothelial function was assessed by flow-mediated vasodilation and fibrinolytic potential by venous occlusion test.
Adults with GHD exhibited an unfavorable 24-h fibrinolytic profile characterized by a mean 62% elevation in PAI-1 antigen (2.77 ng/ml after adjustment for baseline PAI-1; P = 0.049) in the setting of a mean 24% reduction in tPA activity (-0.17 IU/ml after adjustment for baseline tPA; P = 0.003). Fibrinolytic response was defective in GHD, as demonstrated by a sustained elevation in PAI-1 activity greater than 4 IU/ml after venous occlusion [7.2 IU/ml (interquartile range 0.8-17.4); P = 0.018]. Endothelial function was impaired in GHD, as quantified by percent flow-mediated vasodilation over 120 sec [area under the curve 3.8 (interquartile range -2.4 to 7.9) vs. 12.8 (interquartile range 2.1-19.4); P = 0.043].
Adults with GHD demonstrate alterations in plasma fibrinolytic balance, including elevated levels of PAI-1 antigen with decreased tPA activity. These changes may contribute to the increased cardiovascular morbidity within this population.
Journal of Clinical Endocrinology & Metabolism 10/2007; 92(9):3633-9. · 6.50 Impact Factor
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ABSTRACT: Disorders of water metabolism are a common complication of pituitary surgery. The primary purpose of this study was to determine the incidence and duration of post-surgical diabetes insipidus (DI) at our institution. Secondary objectives included characterizing the incidence of post-operative hyponatremia as well as delineating factors associated with the onset of these complications. Records of 319 patients who underwent transsphenoidal pituitary surgery at the authors' institution between 1998 and 2005 were reviewed for the presence of disorders of water metabolism using pre-specified criteria. DI was diagnosed in 59 (18.5%) of our patients at a mean time of 13.6 h following surgery. DI resolved in nearly half of our patients within one week. Approximately 80% of our patients enjoyed resolution of DI at a mean time of 2.9 months following surgery. Duration of DI was not significantly influenced by tumor size or location. Additionally, 28 (8.8%) of our patients exhibited a period of hyponatremia at a mean time of 4 days following surgery. One quarter of these patients carried a diagnosis of Cushing's disease. We herein report an incidence of DI as well as hyponatremia within our post-operative population comparable to that reported by other high-volume pituitary centers. Over half of our patients still exhibited DI at the time of discharge, therefore, patient education regarding the treatment of DI, signs of its resolution, and symptoms consistent with the onset of hyponatremia should be an integral part of every hospitalization.
Pituitary 02/2006; 9(2):93-9. · 1.83 Impact Factor
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ABSTRACT: We identified 35 patients who had undergone stereotactic radiosurgery (SRS) for their biochemically proven Cushing's disease in order to assess the efficacy of SRS with regard to control of hypercortisolism, improvement of clinical features and prevention of tumor progression, and subsequent incidence of hypopituitarism. Seventeen (49%) patients achieved control of their cortisol levels following SRS; the mean time to normalization was 7.5 months (range: 1-33). Four (19%) patients experienced recurrent hypercortisolism at a mean time of 35.5 months following therapy (range: 17-64). Control of tumor progression was achieved in 91% patients. Fourteen (40%) patients demonstrated a new pituitary deficiency following SRS. Our results suggest that cortisol levels are normalized more efficiently and with a lower recurrence rate with SRS than with conventional fractionated external beam radiotherapy (EBT). We have confirmed the near 100% tumor control rate reported with SRS. The percentage of patients developing pituitary insufficiency following SRS is less than that of patients having undergone EBT; however, deficits occurred up to 10 years posttreatment. We advocate the use of SRS as the primary therapeutic modality in those patients who are poor surgical candidates, or as the adjunct treatment to microsurgery in eliminating residual tumor cells or disease that is not easily amenable to resection.
Stereotactic and Functional Neurosurgery 02/2004; 82(5-6):254-62. · 1.85 Impact Factor
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ABSTRACT: Carboxypeptidases may play important role(s) in prohormone processing in normal and neoplastic adenohypophyseal cells of the pituitary. We have recently demonstrated carboxypeptidase E (CPE) and carboxypeptidase Z (CPZ) in the majority of adenohypophyseal cells with carboxypeptidase D (CPD) immunoreactivity largely confined to adrenocorticotrophs. This study evaluated the expression patterns of CPE, CPD, and CPZ immunoreactivity in 48 pituitary adenomas. Our immunohistochemistry demonstrated extensive intracytoplasmic immunoreactivity for CPE, CPD, and CPZ in adrenocorticotrophic hormone (ACTH)-producing adrenocorticotroph cells, prolactin-producing lactotroph cells, and growth hormone (GH)-producing somatotroph cell adenomas, all of which require carboxypeptide processing of prohormones to produce active endocrine hormones. In contrast to the restricted expression in the normal adenohypophysis, CPD appeared to be widespread in the majority of adenomas, suggesting that CPD levels are increased in adenomas. In luteinizing hormone/follicle-stimulating hormone (LH/FSH)-producing gonadotroph adenomas, which do not require carboxypeptidases to produce gonadotropins, only CPZ immunostaining was demonstrated. In null-cell adenomas, CPE immunoreactivity was detected in the majority of tumors, but CPD and CPZ were identified only in a minority of cases. CPE in these cells may process other peptides critical for pituitary cell function, such as chromogranin A or B. These findings suggest that CPs participate in the functioning of pituitary adenomas.
Journal of Histochemistry and Cytochemistry 12/2002; 50(11):1509-16. · 2.72 Impact Factor
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Southern Medical Journal 06/2002; 95(5):486-92. · 0.83 Impact Factor
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ABSTRACT: We report the case of an adolescent boy who presented with hypertension and hypokalemia. A systematic work-up revealed hyperreninemic hyperaldosteronism. Further study revealed Page kidney caused by trauma-associated renal hematoma. The evaluation and management of hyperaldosteronism and Page kidney are discussed.
The American Journal of the Medical Sciences 05/2002; 323(4):227-30. · 1.39 Impact Factor
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ABSTRACT: The management of craniopharyngiomas has historically been controversial in terms of the extent of initial surgical resection and the use of additional treatments. Various options include radical excision versus a more conservative surgical approach followed by external beam radiation; most recently, intracystic 32P radiation has been used in selected patients.
We reviewed our experience with 25 patients with craniopharyngiomas treated between 1984 and 1999 to assess the effectiveness of external beam radiation and intracystic 32P radiation therapy in preventing progression and recurrence of local disease.
All patients underwent surgery as a component of initial therapy for their histologically-proven craniopharyngiomas. Fifteen patients additionally received external beam radiation. Forty-five percent of patients who underwent incomplete resections followed by external beam radiation required additional therapy. In contrast, 80% of patients who had incomplete resections without post-operative external beam radiation required further treatment. Seven patients had intracystic 32P colloid injections. Neither of the two patients receiving 32P intracystic radiation as part of their initial therapy needed further treatment. Only one of the five patients receiving 32P intracavitary radiation for disease progression following initial therapy required further intervention. Of the remaining four patients, three enjoyed responses to treatment and one had stable disease.
Our observations support the use of external beam radiation for prevention of tumor progression in adults unable to receive a complete surgical resection. Our results additionally suggest that intracystic 32P radiation results in control of cystic components of craniopharyngiomas in the majority of cases.
Journal of Neuro-Oncology 02/2002; 56(1):69-78. · 3.21 Impact Factor
