Hypoxia-inducible factor 1alpha/vascular endothelial growth factor axis in astrocytomas. Associations with microvessel morphometry, proliferation and prognosis.

Hypoxia-inducible factor (HIF)-1alpha is a transcription factor that promotes ischaemia-driven angiogenesis. The aim of this study was to determine the relation of HIF-1alpha to vascular endothelial growth factor (VEGF; an important angiogenic molecule in brain tumours), p53 expression, angiogenesis, proliferative potential and clinical outcome in a large series of diffuse astrocytomas. Expression of HIF-1alpha, VEGF, Ki-67 (a proliferation-associated marker) and p53 was determined immunohistochemically in 83 adult patients with supratentorial diffuse astrocytomas. Microvessels, highlighted by means of anti-CD34 immunohistochemistry, were enumerated with computer-assisted image analysis. Although HIF-1alpha and VEGF were expressed in the majority of cases, their levels increased significantly with increasing grade and proliferative potential. HIF-1alpha positively correlated with microvessel counts and VEGF with total vascular area and the presence of rounder vessel sections. There was a positive correlation of VEGF with p53 expression in astrocytomas and anaplastic astrocytomas. In univariate analysis, both VEGF and HIF-1alpha were associated with shortened survival in the entire cohort, but lost significance when grades II/III and grade IV were analysed separately. Multivariate analysis revealed that the combination of HIF-1alpha with grade was a significant prognostic indicator. HIF-1alpha expression may be used to refine the prognostic information provided by grade in patients with diffuse astrocytomas. Its adverse prognostic effect is most likely mediated by hypoxia, the driving force for HIF-1alpha accumulation.

Pituitary apoplexy: a pathologic entity from an otolaryngologist's view.

A case of pituitary apoplexy, which was initially misdiagnosed as 'acute frontal sinusitis', is reported. The presenting symptoms and signs of the patient were headache, moderate fever, left periorbital edema, marked tenderness over the left frontal sinus and purulent secretion over the left middle turbinate and nasopharynx. These clinical symptoms were wrongly perceived as complicated frontal sinusitis. The CT scan and the elective right carotid angiography showed a pituitary adenoma. Therefore pituitary apoplexy of a preexisting pituitary adenoma was diagnosed. The patient underwent surgical removal of the adenoma and his postoperative course was uneventful. Thus otolaryngologists should consider pituitary apoplexy in the differential diagnosis of pathologies concerning the anatomic area of the anterior cranial fossa.

Prognostic implications of microvessel morphometry in diffuse astrocytic neoplasms.

Astrocytic brain tumours, particularly malignant astrocytomas, are recognized to be highly vascular neoplasms with potent angiogenic activity. Recent research has shown that quantification of microvessel density (MVD), as a measure of the degree of angiogenesis, constitutes a strong prognostic indicator in patients with astrocytomas. However, the significance of other morphometric aspects of microvessel network has not been tested so far. In this report, histological sections from 70 astrocytomas (grades II to IV), immunostained for CD34, were evaluated by image analysis for the quantification of MVD, total vascular area (TVA), and microvascular branching, as well as several morphometric parameters related to vessel size or shape. Minor axis length increased with grade (P = 0.045) but MVD and TVA presented a peak in grade III (P = 0.033 and P < 0.001, respectively). Size and shape related parameters affected survival in univariate analysis of grade IV and grades II/III, respectively. In multivariate analysis, only branching counts, along with age and grade, were the independent predictors of survival. Although MVD, TVA and branching counts were adversely related to disease-free survival in grades II and III (univariate analysis), only TVA remained statistically significant in multivariate analysis. It is concluded that TVA and branching counts are prognostically more informative than MVD for patients with diffuse astrocytic tumours.

Mitosin and DNA topoisomerase IIalpha: two novel proliferation markers in the prognostication of diffuse astrocytoma patient survival.

The expression of two novel proliferation-associated markers, mitosin and topoisomerase IIalpha (Topo IIalpha), was evaluated immunohistochemically in consecutive paraffin sections from 60 diffuse astrocytomas (grades 2 to 4) in relation to clinicopathologic parameters, proliferating cell nuclear antigen (PCNA) and Ki-67 (MIB-1) expression and survival. The percentage of mitosin and Topo IIalpha-positive cells (LI) increased with grade and Ki-67 LI, but could not discriminate between grade 3 on the one hand and grades 2 or 4 on the other hand. In 51% of cases, Ki-67 LI exceeded Topo IIalpha LI, especially within grade 4. Topo IIalpha and mitosin expression was adversely related to overall and disease-free survival in the entire cohort and in grades 2/3. However, only Topo IIalpha LI affected disease-free survival in grade 4 tumors. Multivariate analysis selected only mitosin LI along with the age of the patient, as the independent parameters predicting overall survival, whereas Topo IIalpha emerged as the single independent predictor of disease-free survival. It is concluded that the proliferative potential of astrocytomas, as measured by mitosin and Topo IIalpha immunostaining, conveys useful prognostic information, in addition to that obtained by standard clinicopathologic parameters.

Monosomy of chromosome 11 in pituitary adenoma in a patient with familial multiple endocrine neoplasia type 1.

Multiple endocrine neoplasia type 1 (MEN 1) represents an endocrine syndrome characterized by complex pituitary, parathyroid and pancreatic neoplasia. Loss of heterozygosity of the specific region 11q13 has been reported in several tumours from patients with MEN 1 inherited disorder. We present a case of a young patient with familial MEN 1 syndrome with a pituitary adenoma exhibiting monosomy of chromosome 11. The patient presented with a large and rapidly growing pituitary adenoma associated with markedly elevated serum PRL levels, progressive bilateral visual loss and hydrocephalus. The resected adenoma was chromophobic, mainly PRL-producing and to a lesser degree immunoreactive for GH. Fluorescence in situ hybridization (FISH) using an alpha-satellite centromeric probe detected loss of one chromosome 11 copy in almost all pituitary adenoma cells. Clinical and biochemical studies revealed parathyroid hyperplasia and MRI studies detected a pancreatic tumour in addition to the pituitary adenoma. To our knowledge this is the first study reporting monosomy 11 in pituitary adenoma in a patient associated with familial MEN 1 syndrome.

Structure-function correlations of growth hormone or/and prolactin-producing pituitary adenomas: an in vitro study with the reverse hemolytic plaque assay.

The purpose of this study was to detect in vitro growth hormone (GH) and prolactin (PRL) secretion from adenomas clinically associated with GH or PRL hypersecretion. The reverse hemolytic plaque assay (RHPA) was applied in order to reveal possible differences among various morphologic adenoma types, and to examine the inhibitory effects of octreotide on GH release as well. The 20 surgically resected pituitary adenomas studied included 15 from acromegalic patients and 5 from patients with hyperprolactinemia. All adenomas were diagnosed by histology, immunocytochemistry and electron microscopy. Among tumors associated with acromegaly, 5 were densely granulated (DG), 5 were sparsely granulated (SG) somatotroph (SM) adenomas, 2 were mammosomatotroph (MSM) and 3 mixed somatotroph-lactotroph cell (mixed SM-LT) adenomas; tumors causing hyperprolactinemia included 4 lactotroph (LT) adenomas and 1 mixed SM-LT adenoma. GH release assessed by the RHPA corresponded to in vivo hormone secretion and to tissue immunoreactivity. Statistical analysis showed significant differences among all morphologic types of SM adenomas, exclusive of SG-SM adenomas compared to mixed SM-LT adenomas. The mean plaque size in DG-SM and MSM adenomas was significantly greater than that of SG-SM and mixed SM-LT adenomas, indicating higher GH secretion by the former two types during the same incubation time. PRL secretion was documented in 2 mixed SM-LT adenomas. Plaques for PRL, but not for GH were formed in all LT adenomas. In all SM and LT adenomas, cells producing large plaques represented a minority of the plaque-forming cell population, however, they accounted for the largest part of the total plaque area, thus the largest part of hormone secretion. Octreotide effects on GH release were studied in 6 adenomas by the RHPA. Octreotide treatment induced a rapid and significant reduction in GH secretion by SM cells in vitro, with a selective effect on high-secreting cells.

Molecular cytogenetics of chromosome 11 in pituitary adenomas: a comparison of fluorescence in situ hybridization and DNA ploidy study.

Chromosome 11 abnormalities were detected by fluorescence in situ hybridization (FISH) technique and compared with DNA ploidy in 24 surgically removed pituitary adenomas. The tumors were diagnosed and classified by histology, electron microscopy, and pituitary hormone immunocytochemistry. They included 2 densely granulated somatotroph (DG-SM) and 4 sparsely granulated somatotroph (SG-SM) adenomas, 3 SG lactotroph (LT), 2 mixed somatotroph-lactotroph (SM-LT), 4 functioning corticotroph (CRT), 1 silent CRT subtype 1, 1 thyrotroph, 1 mixed thyrotroph-somatotroph, 2 gonadotrophs, and 4 null cell adenomas. FISH analysis with an alpha-satellite DNA probe specific for chromosome 11 showed numerical abnormalities in 16 functioning (94%) and 5 nonfunctioning (71%) adenomas. Ten functioning tumors showed aneuploid histograms, whereas the remaining and all nonfunctioning adenomas were diploid. Aberrant chromosome 11 signals were noted mostly in aneuploid adenomas involving 17% to 100% of their cell population. The severity of chromosome 11 aberrations in adenomas containing extra copies often correlated with a higher DNA index (DI). Monosomy 11 as dominant aberration was noted in a mixed SM-LT and to a lesser degree in 3 CRT adenomas involving 21% to 97% of their cell population. Two of these CRT adenomas were associated with normal DI, whereas the remaining third showed a high DI, indicating increased copy number of chromosomes other than of chromosome 11. In conclusion, chromosome 11 abnormalities are common in all types of pituitary adenomas, occurring more frequently in functioning tumors. Specific numerical abnormalities, such as monosomy and trisomy, tend to be associated with certain adenoma types, whereas tumors with extra chromosome 11 copies often exhibit aneuploid histograms.

Triple pituitary adenoma in Cushing's disease: case report.

A case of a triple pituitary adenoma identified in a surgically removed pituitary gland from a 52-year-old woman operated on for Cushing's disease is presented. The histology revealed 3 distinctly separate microadenomas, 1 corticotroph and 2 immunoreactive for prolactin (PRL). The latter were apparently silent, since the serum PRL levels were within normal range. The problems associated with the inability to identify multiple adenomas pre-operatively and the possible failure of selective transsphenoidal adenomectomy in case of multiple adenomas are emphasised.

Spinal cord decompression and stabilization in malignant lesions of the spine.

20 patients with neurologic deficit and pain from malignant spinal tumors (7 primary) underwent 28 decompression and stabilization procedures. Their mean age was 57 (30-74) years and 11 were women. Indications for stabilization were pathological spine fractures or a previous spinal decompression procedure. An anterior procedure was used in 2 patients with disease limited to 1 or 2 levels. A posterior procedure was used in 10 patients with widespread disease and unsatisfactory condition. Anteroposterior procedures in 1 or 2 stages were performed on 8 patients in satisfactory general condition with a malignant lesion at 1 or 2 levels and an unstable spine. Patients were submitted to radio- and/or chemotherapy postoperatively. Survival of patients treated for primary malignant tumors averaged 30 months and was 11 months for metastatic disease. 16 of the patients, especially those with nonmetastatic disease, had substantial relief of pain. Neurologic recovery was achieved in all of the anterior and combined anterior-posterior procedures and in 60% of the posterior decompressions. Complications included failure of the instrumentation in 2 cases, skin breakdown in another 2 and dislodgment of the autograft in 1.

DNA measurement in pituitary adenomas assessed on imprints by image analysis.

OBJECTIVE: To determine the DNA content and S-phase fraction (SPF) of pituitary adenomas by image analysis and to correlate them with clinical and morphologic parameters. STUDY DESIGN: The study group consisted of 26 prospectively collected cases of operated pituitary adenomas (3 microadenomas and 23 macroadenomas). The tumors were classified by histology, immunocytochemistry and electron microscopy. DNA measurement was performed on imprints from fresh pituitary tissue. Samples of nontumorous adenohypophysial parenchyma served as normal controls. RESULTS: Overall, 31% of adenomas, all but one functioning one, were aneuploid. The remaining nonfunctioning aneuploid tumor was a null cell adenoma with glycoprotein differentiation. All aneuploid tumors were macroadenomas, mostly at advanced stages, III and IV. Dural invasion, although frequent in macroadenomas (78%), was not correlated with DNA ploidy and SPF. An increased number of hyperpentaploid aneuploid cells was noted primarily in aneuploid tumors. The mean SPF was < 2.50%, with a statistically significant difference between aneuploid and diploid adenomas (3.60% vs. 1.70%). CONCLUSION: The results suggest that quantitative assessment of DNA content may provide important information, particularly in functioning adenomas. In addition, fresh tissue imprints represent excellent material for optimum cytometric measurements by image analysis systems, even for microadenomas.

Diagnosis of pituitary adenomas on touch preparations assisted by immunocytochemistry.

Touch preparations from surgically removed pituitary adenomas were studied by both routine staining and immunocytochemistry for all anterior pituitary hormones. The results were correlated with the histologic, histochemical, immunohistochemical and ultrastructural findings. Several features were recognized, some of them applicable in diagnosing various adenoma types: high cellularity, cell monomorphism, nuclear irregularities and heterogeneity of immunoreactivity, all major diagnostic criteria of pituitary adenoma. The presence of numerous fibrous bodies associated with nuclear pleomorphism, multinucleation and peripheral displacement of nuclei, in association with growth hormone (GH) immunopositivity, represent diagnostic criteria for sparsely granulated GH cell adenoma. The "Golgi" pattern of prolactin (PRL) immunopositivity in conjunction with the small size of cell and nucleus and the presence of microcalcifications represents diagnostic features of PRL-secreting adenoma. Cytoplasmic accumulation of hyaline material in association with peripheral distribution of periodic acid-Schiff stain and adrenocorticotropic hormone immunoreactivity is characteristic of sparsely granulated corticotroph cell adenoma. Knowledge and application of the described features may contribute significantly to the diagnostic approach to pituitary adenomas.

Double adenomas of the pituitary: a clinicopathological study of 11 tumors.

Of more than 3000 cases of surgically removed pituitary adenomas, 11 were defined as "double adenomas," i.e., 2 morphologically or immunocytologically distinct tumors. In 8 cases, the lesions exhibited differing histological features and immunophenotypes; in 2 specimens, distinct ultrastructural features were noted as well. In another instance, despite histological and immunocytological uniformity, the two neoplastic components demonstrated distinct ultrastructure. In yet another case, the two adenomas were consecutively removed; despite similar histological features, they differed in immunocytological and ultrastructural characteristics. Last, in one case, the adenoma was histologically uniform, but a portion of the mass exhibited immunoreactivity by ultrastructural features distinct from those of the remainder of the lesion. Hormonal excess attributed to both tumors could be correlated with endocrine manifestations in two cases. Double adenomas of the pituitary occur infrequently. In routine histological sections of surgical material, they are often difficult if not impossible to identify. Presented herein are clinical and endocrinological data on 10 cases of double pituitary adenomas correlated with morphological and immunocytochemical results. The literature regarding multiple adenomas is reviewed as are the diagnostic and therapeutic difficulties associated with these rare lesions.

Magnetic resonance angiography compared to intra-arterial digital subtraction angiography in patients with subarachnoid haemorrhage.

In order to evaluate the sensitivity and specificity of magnetic resonance angiography (MRA) in spontaneous subarachnoid haemorrhage, 14 patients with recent haemorrhage verified by CT or lumbar puncture were investigated with both selective intra-arterial digital subtraction angiography (IA-DSA) and MRA by two independent teams, each having the same preangiographic information. The results were compared with each other and whenever possible (all positive cases except one) with those of surgical intervention. Seven patients were identified by MRA and IA-DSA as having a single aneurysm on the circle of Willis, 1 an aneurysm of the posterior inferior cerebellar artery 1 an aneurysm of the internal carotid artery (siphon) and 2 patients with two aneurysms on the circle of Willis. MRA and IA-DSA both failed to demonstrate aneurysms in 2 cases. Three patients had negative results on both methods and no surgical intervention was attempted. The aneurysms ranged from 0.3 to 1.5 cm in size. In most cases there was agreement between MRA and DSA, leading us to believe that, if the proper protocols are followed, MRA is a powerful alternative to other established methods in the detection of intracranial aneurysms. At this stage it will not replace IA-DSA prior to surgery, but the ability to obtain various projections using 3D MRA may improve surgical planning.

Alpha-subunit immunoreactivity in plurihormonal pituitary adenomas of patients with acromegaly.

Twelve plurihormonal pituitary adenomas, removed surgically from 11 of 20 patients with acromegaly, were investigated. The mean age of the 11 patients was 45 yr. Seven patients with eight tumors were men. The tumors were immunostained for all known adenohypophysial hormones by the avidin-biotin-peroxidase complex (ABC) technique. All 12 adenomas were immunoreactive for growth hormone (GH) and alpha-subunit; prolactin (PRL) was detected in five tumors. Stains for the beta-subunits of glycoprotein hormones [thyroid-stimulating hormone (TSH), follicle-stimulating hormone (FSH), and luteinizing hormone (LH)] revealed immunopositivity for specific beta-subunits in ten adenomas. The close association between GH and alpha-subunit in pituitary tumors of acromegalic patients remains to be explained.