Prolactin-Producing Pituitary Adenoma and Carcinoma with Neuronal Components<197>A Metaplastic Lesion

Recent studies indicate that cells of various epithelial tumors are capable of transformation to neurons. Observing both neurons and neuropil in two prolactin-producing adenohypophyseal tumors, one benign and one malignant, we sought to assess their cellular differentiation, the presence of nerve growth factor receptor, and expression of the dopamine receptor gene using immunocytochemistry, electron microscopy, and in situ hybridization. Light and electron microscopy clearly revealed cells morphologically transitional between adenoma/carcinoma cells and neurons. Large neurons lacked proliferative activity. Neurons in varying number showed immunoreactivity for pituitary hormones including prolactin, growth hormone and alpha subunit in the adenoma and prolactin alone in the carcinoma. The distribution of nerve growth factor receptor staining was similar. In both tumors, in situ hybridization showed mRNAs for prolactin and dopamine receptor within adenohypophyseal cells and neurons. Our results indicate that the occurrence of neurons and neuropil in growth hormone and prolactin-producing pituitary tumors appears to be the result of metaplasia. The process is not limited to benign tumors and may be due to the production of tropic substances by the adenohypophysial cells, which by paracrine/autocrine mechanisms result in transformation of adenoma cells to nerve cells.     

A case of macroprolactinoma with subclinical growth hormone production

We describe a rare case of macroprolactinoma with subclinically synchronous growth hormone (GH) production. A 59-year-old man with a giant adenoma in his pituitary had elevated serum prolactin (PRL) and insulin-like growth factor (IGF)-I levels, despite normal levels of basal GH. Serum GH levels were paradoxically increased in response to an intravenous administration of thyrotropin-releasing hormone (TRH). Prolonged exposure to glucose as a result of oral glucose tolerance testing (oGTT) failed to decrease GH levels. Two-week treatment with cabergoline, a dopamine D2 receptor agonist, decreased serum PRL and GH levels, and size of the tumor. Immunohistochemistry and in situ hybridization revealed PRL-producing cells capable of synchronous GH production. Acidophilic stem cell adenoma may be responsible for these phenomena. The nature of high proliferation and invasive tumor growth should be kept in mind when managing patients with this cell type of adenoma. IGF-I levels should be followed in PRLoma, even when basal GH levels are within the normal range, because mixed PRL- and GH-producing tumors would lie underneath. Further endocrinological examinations such as TRH test and oGTT are recommended when elevated IGF-I levels are detected.     

Thyrotropin-induced hyperthyroidism: evidence for a common progenitor stem cell

A 36-year-old woman with hyperthyroidism, elevated blood thyroid-stimulating hormone (TSH) and alpha-subunit levels, amenorrhea, hyperprolactinemia and no evidence of acromegaly, was found to have a pituitary adenoma containing TSH, alpha-subunit and growth hormone by immunohistochemistry. Preoperative testing revealed elevated TSH and alpha-subunit with no response to thyrotropin-releasing hormone (TRH) but a normal response in prolactin to TRH. Culture of the pituitary cells showed release of TSH, alpha-subunit and prolactin. In vitro, TRH failed to cause TSH discharge; however, it increased prolactin concentrations in the culture medium. Triiodothyronine, added to the pituitary cell culture, resulted in no inhibition of TSH and prolactin discharge. By electron microscopy, the adenoma cells showed features of thyrotrophs. However, some adenoma cells contained fibrous bodies characteristic of some growth hormone cell tumors and acidophil stem cell adenomas, suggesting that the adenoma originated in a common progenitor cell.     

No evidence of somatic aryl hydrocarbon receptor interacting protein mutations in sporadic endocrine neoplasia

Germline mutations in the aryl hydrocarbon receptor interacting protein (AIP) gene were recently observed in patients with pituitary adenoma predisposition (PAP). Though AIP mutation-positive individuals with prolactin-, mixed growth hormone/prolactin-, and ACTH-producing pituitary adenomas as well as non-secreting pituitary adenomas have been reported, most mutation-positive patients have had growth hormone-producing adenomas diagnosed at relatively young age. Pituitary adenomas are also component tumors of some familial endocrine neoplasia syndromes such as multiple endocrine neoplasia type 1 (MEN1) and Carney complex (CNC). Genes underlying MEN1 and CNC are rarely mutated in sporadic pituitary adenomas, but more often in other lesions contributing to these two syndromes. Thus far, the occurrence of somatic AIP mutations has not been studied in endocrine tumors other than pituitary adenomas. Here, we have analyzed 32 pituitary adenomas and 79 other tumors of the endocrine system for somatic AIP mutations by direct sequencing. No somatic mutations were identified. However, two out of nine patients with prolactin-producing adenoma were shown to harbor a Finnish founder mutation (Q14X) with a complete loss of the wild-type allele in the tumors. These results are in agreement with previous studies in that prolactin-producing adenomas are component tumors in PAP. The data also support the previous finding that somatic AIP mutations are not common in pituitary adenomas and suggest that such mutations are rare in other endocrine tumors as well.     

Cerebrospinal fluid hormone concentration in the evaluation of pituitary tumors.

Cerebrospinal fluid (CSF) concentrations of corticotropin, growth hormone, thyrotropin, prolactin, luteinizing hormone, and follicle stimulating hormone were measured in 28 patients with various neurologic disorders, in 49 patients with pituitary tumors of whom 22 had suprasellar extension, and in 6 patients with craniopharyngiomas. With the exception of 1 patient with pseudotumor cerebri, CSF adenohypophyseal hormone concentrations were low in patients with neurologic disease and in patients with pituitary tumor without suprasellar extension. In marked contrast, 21 to 22 patients with suprasellar extension of a pituitary tumor and 2 of 6 patients with a craniopharyngioma had elevations of one or more CSF adenohypophyseal hormones. Posttreatment CSF adenohypophyseal hormone levels fell from previously elevated levels in 4 of 5 patients. These data suggest that an elevated CSF adenohypophyseal hormone concentration is a sensitive indicator of suprasellar extension of a pituitary tumor, and posttreatment measurements are useful in determining efficacy of therapy.     

Pathology of acromegaly

This review summarizes current knowledge on pituitary changes in patients with acromegaly. The histologic, immunohistochemical and electron microscopic study provided conclusive evidence that a marked diversity exists between the tumors which secrete growth hormone (GH) in excess, such as densely and sparsely granulated GH cell adenoma, the mixed GH prolactin cell adenoma and the mammosomatotrope adenoma. The latter two tumors produce GH and prolactin simultaneously. Densely granulated GH cell tumors may produce thyrotropin and alpha subunit as well. Somatotrope carcinomas are extremely rare. GH cell hyperplasia can also be associated with acromegaly in patients with extrapituitary GH-releasing hormone secreting tumors. The medical therapy of acromegaly is reviewed briefly, including long-acting somatostatin analogs and pegvisomant, a GH receptor blocker.     

Characterization of a pituitary stone

Calcification of the pituitary is unusual and functional studies of such cases have not been previously reported. We have been able to document persistent prolactin secretion both in vivo and in vitro in a patient with a severely calcified pituitary adenoma (“pituitary stone”), and have also documented prolactin granules within the calcified tissue mass. Normal menstrual function was restored after surgical removal of the “stone,” and galactorrhea subsided although the prolactin response to thyrotropin-releasing hormone (TRH) remained abnormal. Two years after surgery the menstrual cycle has remained regular, but galactorrhea has recurred, emphasizing the need for prolonged follow-up in patients with prolactin-producing adenomas, despite apparent surgical cure. The in vitro studies showed that human pituitary tissue is secretory in culture and thus may serve as a useful tool for physiologic studies of the pituitary cell.     

Pegvisomant treatment in gigantism caused by a growth hormone-secreting giant pituitary adenoma.

BACKGROUND: Gigantism is rare with the majority of cases caused by a growth hormone (GH)-secreting pituitary adenoma. Treatment options for GH-secreting pituitary adenomas have been widened with the availability of long-acting dopamine agonists, depot preparations of somatostatin analogues, and recently the GH receptor antagonist pegvisomant. CASE REPORT: A 23-year-old male patient presented with continuous increase in height during the past 6 years due to a GH-secreting giant pituitary adenoma. Because of major intracranial extension and failure of octreotide treatment to shrink the tumour, the tumour was partially resected by a trans-frontal surgical approach. At immunohistochemistry, the tumour showed a marked expression of GH and a sparsely focal expression of prolactin. Somatostatin receptors (sst) 1-5 were not detected. Tumour tissue weakly expressed dopamine receptor type 2. The Gs alpha subunit was intact. Conversion from somatostatin analogue to pegvisomant normalized insulin-like-growth-factor-I (IGF-I) levels and markedly improved glucose tolerance. CONCLUSION: Pegvisomant is a potent treatment option in patients with pituitary gigantism. In patients who do not respond to somatostatin analogues, knowledge of the SST receptor status may shorten the time to initiation of pegvisomant treatment.     

Positron emission tomography in acromegaly and other pituitary adenoma patients

BACKGROUND: Positron emission tomography (PET) is a well-recognized technique used in research, especially for intracranial studies, as well as for clinical practice, and has contributed to the fast development in neuroscience during the last decades. PROCEDURES: We have used PET in pituitary tumors for in vivo characterization with respect to metabolism, 11C-L-methionine and 18F-fluorodeoxyglucose, receptor properties, 11C-N-methylspiperone and 11C-raclopride, and monoamine oxidase B enzyme content, 11C-L-deprenyl; further, for diagnosing and outlining the tumors in differential diagnostic perspectives and in the follow-up of treatment. OBSERVATIONS: 11C-raclopride, a specific dopamine antagonist, demonstrated high amounts of dopamine D2 binding in prolactinomas and some growth hormone-secreting adenomas. There was a significant correlation between high amounts of D2 receptors and the positive treatment effect of dopamine agonist therapy. When 11C-L-methionine and 18F-fluorodeoxyglucose were used for metabolic mapping, the highest metabolic activity was found in the prolactinomas, which correlated well with the serum prolactin levels. The growth hormone adenomas also showed high metabolic rates. At treatment follow-up, a considerable decrease in 11C-L-methionine uptake was observed in all tumors that responded positively to the treatment and thus foretold that the medical treatment, both concerning dopamine agonist and somatostatin analogue, was effective. In this respect, PET was valuable to monitor treatment. PET was also shown valuable in differential diagnosing between pituitary adenomas, meningiomas and skull base neuromas. CONCLUSION: We have found PET to be highly valuable in the research and clinical handling of patients with a pituitary adenoma for in vivo tumor characterization.     

Pituitary adenomas in mice transgenic for growth hormone-releasing hormone.

It has been shown that mice transgenic for human GH-releasing hormone (GRH) develop hyperplasia of pituitary somatotrophs, lactotrophs, and mammosomatotrophs, cells capable of producing both GH and PRL, by 8 months of age. We now report that GRH transgenic mice 10-24 months of age develop pituitary adenomas, which we characterized by histology, immunohistochemistry, in situ hybridization, and electron microscopy. Of 13 animals examined, all developed GH-immunoreactive neoplasms that had diffuse positivity for GH mRNA by in situ hybridization. Eleven also contained PRL immunoreactivity; in situ hybridization demonstrated focal PRL mRNA in 3 of 5 immunohistochemically positive tumors. Alpha-Subunit was positive by immunohistochemistry in 8 adenomas, and TSH beta was localized in tumor cells of 5 adenomas. The adenomas had variable ultrastructural appearances, ranging from cells that resembled somatotrophs or mammosomatotrophs to cells with features of the glycoprotein hormone cell line. These findings provide conclusive evidence that protracted GRH stimulation of secretory activity can result in proliferation, hyperplasia, and adenoma of adenohypophysial cells.     

Selective deficiency of guanine nucleotide-binding protein Go in two dopamine-resistant pituitary tumors

G proteins were quantitated by immunoblot in normal rat anterior pituitary, an estrone-induced pituitary adenoma, and in two transplantable pituitary tumors resistant to dopamine, 7315a and MtTW15. Antisera specific for the alpha o and beta subunits or the alpha i subunit of G proteins were tested with all preparations. While the alpha i and beta subunits were found to be present in variable concentrations in all preparations, the alpha o subunit was very low or undetectable in the transplantable tumors. These findings suggest that tumor resistance to the dopamine inhibitory actions on prolactin release and on tumor growth may be due to the deficiency of a Go protein.     

Pituitary apoplexy caused by luteinizing hormone-releasing hormone in prolactin-producing adenoma

We report a case in which pituitary apoplexy developed shortly after an intravenous (i.v.) injection of luteinizing hormone-releasing hormone (LH-RH). A 56-year-old man with prolactin-producing pituitary tumor complained of severe headache, visual field loss and facial nerve palsy shortly after LH-RH test. Magnetic resonance image (MRI) revealed a hemorrhage in the pituitary adenoma. He showed dramatic improvement in his symptoms after decompression surgery. These findings suggest a causal relationship between the i.v. injection of LH-RH and pituitary apoplexy. Possible pituitary apoplexy should be kept in mind during pituitary testing.     

Differential coupling with pertussis toxin-sensitive G proteins of dopamine and somatostatin receptors involved in regulation of adenohypophyseal secretion

D2 dopamine receptors and somatostatin receptors in adenohypophyseal cells are coupled through G proteins to various transduction mechanisms. To study the involvement of these different transduction mechanisms and of various G proteins in the dopamine and somatostatin regulation of prolactin (PRL), growth hormone (GH) and thyroid-stimulating hormone (TSH) secretions, we have pretreated the adenohypophyseal cells in primary culture with increasing doses of pertussis toxin. The guanosine triphosphate (GTP) dependency of the negative coupling of dopamine and somatostatin receptors with adenylate cyclase in the same membrane preparation from anterior pituitary cells was different. In fact, higher GTP doses were requested to obtain dopamine inhibition, suggesting that different G proteins were involved in the coupling of these two receptors with adenylate cyclase. However, the inhibition of adenylate cyclase activity by both neurohormones was fully sensitive to pertussis toxin pretreatment with a similar IC50 for the toxin. The IC50 for the toxin was also similar for the blockade of dopamine or somatostatin inhibition of the three-hormone secretion as well as for the stimulation on basal PRL or GH secretion or the reduction of thyrotropin-releasing hormone (TRH)-stimulated prolactin secretion, suggesting that the toxin acts through similar mechanisms on these different phenomena. Pretreatment of the cells with Bordetella pertussis toxin differentially affected the effects of both neurohormones on the three cell types. A complete reversion of the inhibition of secretion was observed only in the case of somatostatin on PRL and TSH cells. In contrast, the somatostatin inhibition of GH secretion was only partially reversed by the pertussis toxin pretreatment. This was also the case of dopamine inhibition of PRL secretion. It can be concluded that: (1) On PRL secretion dopamine and somatostatin do not share all the mechanisms since the intensity of their inhibition and the reversibility of their effects by pertussis toxin were differential. (2) Different mechanisms of action are implicated in the effect of somatostatin on PRL, GH and TSH secretions. (3) Different G proteins might be involved in the coupling of dopamine and somatostatin receptors with adenylate cyclase.     

Identification of human growth hormone messenger ribonucleic acid in pituitary adenoma cells by in situ hybridization

The technique of in situ hybridization was used to examine human GH gene expression in human GH-secreting pituitary adenoma cells. Five somatotroph adenoma specimens obtained at surgery were dispersed into single cell suspensions. Hybridization experiments were performed on cells immediately after dispersal or on cells cultured for 48-72 h in a defined serum-free medium. Tritiated GH cDNA was used to probe fixed cells, and hybridization was determined by liquid autoradiography. Of the freshly dispersed adenoma cells probed with GH cDNA, more than 70% contained GH mRNA, as determined by counting silver grains per cell. Significant cellular grain counts were obtained for GH cDNA-probed cells from all five tumors, while negative controls showed negligible silver grain counts. In cultured cells derived from three of five tumors, an average of 40% contained detectable GH mRNA. Therefore, quantitative in situ hybridization is a useful technique to demonstrate the expression of GH mRNA in human pituitary adenoma cells.     

Pegvisomant therapy in pituitary gigantism: successful treatment in a 12-year-old girl

OBJECTIVE: The use of a growth hormone (GH) receptor antagonist, pegvisomant has shown great promise in adults with acromegaly, but experience in paediatric patients is lacking. We aimed to describe the results of pegvisomant therapy in a 12-year-old girl with an aggressive GH-secreting pituitary tumour. DESIGN: To evaluate the ability of pegvisomant therapy to control the effects of peripheral GH excess in a case of pituitary gigantism. METHODS: Pegvisomant was introduced at 10 mg/day, given subcutaneously, and gradually increased to 20 mg/day until serum IGF-I was normal for age. RESULTS: A large pituitary adenoma with suprasellar extension was diagnosed in a 12-year-old girl with progressive tall stature (178 cm), GH hypersecretion without suppression during oral glucose loading (nadir serum GH, 90 mU/l), high serum IGF-I and serum prolactin levels. Surgical extirpation was not possible because tumour tissue was fibrous and adherent to the optical nerves. Histological examination showed a mixed GH- and prolactin-secreting adenoma with lymphocytic infiltration of B and T cells. Treatment with a dopamine agonist, cabergoline, normalized serum prolactin, but GH secretion was resistant to both somatostatin analogue, octreotide and cabergoline. Radiation followed by pegvisomant therapy titrated up in dose to 20 mg/day led to a marked reduction in GH secretion and normalization of IGF-I, and to growth arrest and improvement of well-being. CONCLUSIONS: We suggest that treatment in pituitary gigantism with pegvisomant is safe and may normalize IGF-I levels and effectively stop growing.     

Modification by pertussis toxin of the responses of bovine anterior pituitary cells to acetylcholine and dopamine: effects on hormone secretion and 86Rb efflux

Acetylcholine is known to stimulate the secretion of growth hormone and prolactin and the efflux of 86Rb from bovine anterior pituitary cells: dopamine prevents the stimulation of 86Rb efflux and of prolactin but not growth hormone secretion. The sensitivity of these responses to pertussis toxin has been determined. Treatment of bovine anterior pituitary cells in primary culture with pertussis toxin (18 h, 100 ng/ml) did not modify the stimulation of prolactin secretion by acetylcholine, but prevented its inhibition by dopamine. In lactotrophs, dopamine but not acetylcholine receptors are therefore coupled to secretion through a pertussis toxin substrate. The stimulation of 86Rb efflux by acetylcholine was also unaffected by pertussis toxin and, again, its inhibition by dopamine was prevented. Treatment of the cells with pertussis toxin enhanced the secretion of growth hormone in response to acetylcholine. Nitrendepine (1 mumol/l) prevented the cholinergic stimulation of growth hormone but not prolactin secretion from these cells. Acetylcholine increased the cytoplasmic calcium concentration and this rise was enhanced by treatment of the cells with pertussis toxin. Nitrendepine partially inhibited the rise in calcium caused by acetylcholine, and prevented the enhancement of the rise following pertussis toxin treatment. Cholinergic stimulation of growth hormone therefore depends on calcium entry through nitrendepine-sensitive channels, whereas stimulation of prolactin secretion does not, and in somatotrophs a pertussis toxin substrate may limit calcium entry through these channels. These different sensitivities of somatotrophs and lactotrophs to pertussis toxin and nitrendepine may reflect differences in the properties of the predominant calcium currents in the two cell types.     

Cyproheptadine-mediated inhibition of growth hormone and prolactin release from pituitary adenoma cells of acromegaly and gigantism in culture

The effect of cyproheptadine on growth hormone (GH) and prolactin (Prl) secretion from cultured pituitary adenoma cells of acromegaly and pituitary gigantism was studied. When varying doses of cyproheptadine ranging from 0.01 to 1 microM were added to the incubation media, GH secretion was consistently inhibited and a dose-response relationship was observed between the cyproheptadine concentrations and the amounts of GH released into the media. In pituitary adenomas which concurrently produced and secreted Prl, cyproheptadine likewise suppressed Prl release in a dose-related manner. This effect of cyproheptadine was not blocked by coincubation with serotonin. Similarly, coincubation with a dopaminergic antagonist, haloperidol, failed to reverse the inhibitory action produced by cyproheptadine. When coincubated with dopamine, cyproheptadine further inhibited GH and Prl secretion. These results suggest that cyproheptadine possesses a direct action on human somatotroph adenoma cells to inhibit GH and Prl secretion by an unknown mechanism that is different from serotonergic and dopaminergic systems.     

Effects of dopamine and somatostatin on phorbol ester-stimulated prolactin and growth hormone secretion

Incubation of cultured ovine pituitary cells with the tumor-promoting phorbol ester, 12-O-tetradecanoylphorbol 13-acetate (TPA) (0.1-100 nM), caused a dose-related stimulation of both growth hormone (ED50 approximately 4 nM) and prolactin (ED50 approximately 14 nM) secretion. Stimulation by TPA (100 nM) produced a substantial 10-fold increase in growth hormone with a smaller, 2-fold rise in prolactin secretion over 30 min; significant effects on the release of both hormones occurred within 2 min. Treatment with TPA also produced a small, time- and concentration-dependent rise in cellular cyclic AMP content which reached, at maximum, a level 20-30% over basal values. Non-tumor-promoting phorbol esters did not stimulate the secretion of either growth hormone or prolactin. In the presence of TPA (10 nM), dopamine (1-1000 nM) suppressed prolactin secretion to a level close to that observed for maximal inhibition of unstimulated cells. At high concentrations (0.1-1.0 microM) dopamine also partially attenuated (by 43%) the TPA-induced stimulation of growth hormone secretion. Somatostatin (0.01-1.0 microM) completely inhibited the substantial (approximately 9-fold) TPA-induced stimulation of growth hormone secretion (inhibitory ED50 approximately 47 nM), and also suppressed TPA-stimulated prolactin secretion to the control level. Our results suggest that activation of protein kinase-C may be involved in the stimulatory regulation of both growth hormone and prolactin secretion in sheep pituitary cells. Failure of TPA to attenuate the inhibitory activity of dopamine and somatostatin suggests that inhibitory regulation occurs at, or beyond, the point in the secretory process regulated by protein kinase-C.