Predicting pituitary stalk position by in vivo visualization of the hypothalamo-hypophyseal tract in craniopharyngioma using diffusion tensor imaging tractography.

The pituitary stalk (PS) is crucial to endocrine function and water-electrolyte equilibrium. Preservation of the PS during craniopharyngioma (CP) surgery is critical; however, in a pathological state, it is difficult to identify. The hypothalamo-hypophyseal tract (HHT) connects the hypothalamus and the posterior pituitary gland and projects through the PS. Thus, visualization of the HHT can help locate the PS. Preoperative visualization of the neural fasciculus has been widely achieved using diffusion tensor imaging (DTI) tractography. Therefore, this study evaluated the use of DTI tractography to identify and characterize the human HHT. We used DTI tractography to track the HHT in 10 patients with CP and compared the location of the tract with the intraoperative view of the PS in these patients. We successfully tracked the HHT in nine patients, indicating that delineating and quantifying the tracked HHT using this method is feasible. In addition, we found that the tract was consistent with the intraoperative view of the PS in seven out of eight patients (87.50%). Finally, we found that the mean number of tracts was 7.11 ± 12.28, the mean fractional anisotropy (FA) was 0.11 ± 0.04, and the mean tract length was 24.22 ± 9.39 mm. Taken together, our results demonstrate that the HHT can be visualized and characterized with DTI even in a clinical application, which may aid in preoperative identification of the PS. Characterization of the tracked HHT with this technique could also be used to advance our understanding of the HHT.

Fertility preservation in the male: from childhood to adulthood.

Approximately 50% of males will develop cancer during their lifetime. In the past, oncologic therapies have largely been focused primarily on cure of the underlying malignancy. With improvements in both diagnostic modalities and treatments, pediatric and adult cancer patients are routinely surviving their disease. For this large group of patients, survivorship issues have become a major concern. Central among these survivorship issues is fertility. For males diagnosed with a malignancy, impaired reproductive potential is often noted even before any cancer therapy has been initiated. Furthermore, cancer treatments, in the form of chemotherapy, radiation therapy, and surgery, can all have potentially deleterious and lasting effects on male reproductive capability. For these reasons, a change in oncologic treatment paradigms has occurred. Now, the offer of fertility preservation to males diagnosed with cancer is a key component of comprehensive oncologic care.

Role of the hypothalamo-pituitary-adrenal axis in the modulation of pollinosis induced by pollen antigens.

BACKGROUND: To clarify the mechanism of stress-induced modification of allergic diseases, we studied the effect of restraint stress on plasma levels of cytokines and the symptoms of pollinosis in mice. METHODS: The effects of restraint stress and the role of the hypothalamo-pituitary-adrenal axis (HPA-axis) in the development of pollen antigen-induced pollinosis were studied in control, hypophysectomized, adrenalectomized or ACTH-administered mice. Twenty days after sensitization, animals were subjected to mild restraint stress for 3 hours, and plasma levels of IFN-gamma, IL-10, and IgE were measured. We analyzed the incidence of sneezing and nasal rubbing in the sensitized animals. RESULTS: Plasma levels of IL-10 and IgE increased in the sensitized animals with a concomitant increase in the incidence of sneezing and nasal rubbing. The increases in plasma IgE, IL-10 and the incidence of sneezing and nasal rubbing were suppressed by restraint stress. Adrenalectomy increased IFN-gamma, inhibited the increase in plasma IL-10 and IgE, and suppressed the incidence of sneezing. In contrast, hypophysectomy increased plasma levels of IL-10, IFN-gamma, and IgE and the incidence of sneezing. Intraperitoneal administration of ACTH decreased IL-10 in plasma but increased IFN-gamma and suppressed the incidence of nasal rubbing. CONCLUSIONS: The present findings show that the HPA-axis and ACTH play important roles in the regulation of plasma cytokines and IgE thereby modulating symptoms of pollinosis. The results also suggest that a mild restraint stress suppresses the increase in Th2-dependent cytokines and IgE to reduce the symptoms of pollinosis.

Surgical management of giant craniopharyngiomas.

INTRODUCTION: Multimodal treatment in the management of giant craniopharyngiomas (>4 cm in diameter) is necessary to obtain optimal results, and includes conservative or palliative treatment and "aggressive" removal. The significance of a new treatment algorithm including direct surgical resection with the intent to avoid radiation therapy and regrowth will be discussed here. MATERIALS AND METHODS: Between January 1996 and January 2005 16 patients were diagnosed with giant craniopharyngiomas. Two of them underwent only cyst aspiration because of their advanced age and/or lack of improvement of neuropsychological deficits. One patient underwent transsphenoidal operation and in the remaining 13 transcranial surgery was performed. Four additional patients underwent surgery for recurrence. The prospective protocol included pre- and post-operative dynamic endocrine tests, high field 1.5 T MRI and ophthalmological as well as neuropsychological examinations. RESULTS: In resectable tumours, the rate of total removal was ten out of 12 with two recurrences. In the remaining two patients with recurrences this intention was abandoned because of a firm tumour or a deteriorating neuropsychological status prior to the scheduled additional operation. There was no mortality and the morbidity rate was 6.3%. Visual function improved in 11, was unchanged in one and deteriorated in two patients. Secretion of different adenohypophyseal hormones deteriorated after tumour resection in one to three patients, and new diabetes insipidus occurred in six patients. There was no permanent deterioration of neuropsychological function. CONCLUSION: Special reference is given to direct resection of tumours at an optimal timing within this management. If hypothalamic disturbances are absent or improving due to pre-treatment (medical therapy, symptomatic surgery), giant craniopharyngiomas can be surgically removed in more than two of three patients with low morbidity and only moderate deterioration of endocrine function. The latter has to be accepted when curative surgery is intended, but even then, recurrences cannot be prevented. Contraindication for curative surgery is persisting hypothalamic damage necessitating conservative treatment modalities.

Pediatric craniopharyngiomas: classification and treatment according to the degree of hypothalamic involvement.

OBJECT: The current treatment of craniopharyngiomas is evolving into one of a multimodal approach in which the aim is disease control and improved preservation of quality of life (QOL). To date, an appropriate classification system with which to individualize treatment is absent. The objectives of this study were to identify preoperative prognostic factors in patients with craniopharyngiomas and to develop a risk-based treatment algorithm. METHODS: The authors reviewed data obtained in a retrospective cohort of 66 children (mean age 7.4 years, mean follow-up period 7 years) who underwent resection between 1984 and 2001. Postoperative recurrence rates, vision status, and endocrine function were consistent with those reported in the literature. The postoperative morbidity was related to hypothalamic dysfunction. The preoperative magnetic resonance imaging grade, clinically assessed hypothalamic function, and the sugeon's operative experience (p = 0.007, p = 0.047, p = 0.035, respectively) significantly predicted poor outcome. Preoperative hypothalamic grading was used in a prospective cohort of 22 children (mean age 8 years, mean follow-up period 1.2 years) treated between 2002 and 2004 to stratify patients according to whether they underwent gross-total resection (GTR) (20%), complete resection avoiding the hypothalamus (40%), or subtotal resection (STR) (40%). In cases in which residual disease was present, the patient underwent radiotherapy. There have been no new cases of postoperative hyperphagia, morbid obesity, or behavioral dysfunction in this prospective cohort. CONCLUSIONS: For many children with craniopharyngiomas, the cost of resection is hypothalamic dysfunction and a poor QOL. By using a preoperative classification system to grade hypothalamic involvement and stratify treatment, the authors were able to minimize devastating morbidity. This was achieved by identifying subgroups in which complete resection or STR, performed by an experienced craniopharyngioma surgeon and with postoperative radiotherapy when necessary, yielded better overall results than the traditional GTR.

Rats with physically disconnected hypothalamo-pituitary tracts no longer contain vasopressin-oxytocin gene transcripts in the posterior pituitary lobe.

In rats, vasopressin- and oxytocin-encoding mRNAs are present in the posterior but absent in the anterior lobe of the pituitary gland. RNase protection experiments indicate that in the posterior pituitary and hypothalamus identical transcriptional start points are used. Furthermore, the two transcripts from posterior pituitary and hypothalamus show identical nucleotide sequences. Animals operated by paired electrical lesions in such a way that connections between the supraoptic nucleus (SON) and paraventricular nucleus (PVN) of the hypothalamus and the posterior pituitary lobe are destroyed continue to express the vasopressin and oxytocin gene in the hypothalamus but not in the posterior pituitary. Operated animals subjected to chronic intermittent salt loading for 6 days similarly contain vasopressin and oxytocin encoding transcripts in the hypothalamus but not in the posterior pituitary.

Regeneration of neurohypophyseal hormone-producing neurons in hypophysectomized immature rats.

Age-related changes in the regeneration of vasopressin (AVP) and oxytocin (OXT) axons after hypophysectomy in rats was immunohistochemically examined. Rats were hypophysectomized at 9, 16, 23, 30 and 90 days of age, and sacrificed 10 days after the operation. AVP or OXT immunoreactivity in the external layer of the median eminence (ME) was generally stronger in hypophysectomized immature rats than in hypophysectomized adult rats, and the age-related difference in immunoreactivity was more conspicuous for AVP axons than OXT ones. The cell body size of AVP or OXT neurons in hypophysectomized adult rats was not significantly different from the value of unoperated or initial control rats. However, the neurons in immature rats became significantly larger after hypophysectomy, compared with those of initial controls. These results indicate that AVP- and OXT-producing neurons in immature rats, as early as at 9 days of age, are endowed with the capacity of axonal rearrangement to the external layer of the ME after hypophysectomy, and that the stronger immunoreactivity in the external layer of the ME in immature rats than in the adult may be due to the differences in the rate of synthesis of neurohypophyseal hormones and the regenerative potency of neurons.

Management of diabetes insipidus in neurosurgical patients.

The authors present a brief review of the problem of diabetes insipidus in neurosurgical patients, with particular emphasis on the differential diagnosis of postoperative and posttraumatic polyuria and the management of diabetes insipidus in these periods. A listing of drugs currently used in its treatment is given.

Disruptions of the hypothalamo-pituitary-adrenal axis increase anticancer drug lethality in the rat.

We have previously shown that toxicity of the anticancer agent hydroxyurea (HU) in the rat is markedly increased by hypophysectomy or adrenalectomy. In this study, we investigated whether increased toxicity in ablated animals is a unique feature of HU or it is shared with other anticancer agents; the toxic effects of five such drugs have been compared in intact, hypophysectomized (HYX) and adrenalectomized (ADX) rats. Bis-chloroethyl-nitrosourea (BCNU, 5-10 mg/kg), busulfan (0.1-10 mg/kg), cyclophosphamide (25-125 mg/kg), 5-fluorouracil (15-75 mg/kg) and vindesine (0.1-0.5 mg/kg) were given to intact and endocrine-ablated rats, and lethality was recorded over 3 weeks. It was found that mortality was low or absent in intact rats, whereas (with the exception of HYX rats receiving the highest dose of busulfan) it was dramatically increased by both hypophysectomy and adrenalectomy. However, replacement treatments with long-acting tetracosactrin and corticosterone to HYX and ADX rats respectively afforded significant protection against BCNU toxicity only. We conclude that the integrity of the hypothalamo-pituitary-adrenal axis is needed to tolerate the toxicity of various anticancer drugs, although complex mechanisms appear to underlie such protective effect.

Effect of exogenous FSH on ovulation rate in homozygous carriers or noncarriers of the Booroola FecB gene after hypothalamic-pituitary disconnection or after treatment with a GnRH agonist.

We have tested the hypothesis "that the ovulation rate in homozygous carriers (BB) and noncarriers (+2) of the Booroola FecB gene would not be different if the plasma concentrations of follicle-stimulating hormone (FSH) in the two genotypes were similar." For this purpose we used two experimental animal models: 1) the hypothalamic-pituitary disconnected (HPD) ovary-intact ewe; and 2) and GnRH agonist (i.e., Deslorelin)-treated ewe. Following HPD or Deslorelin treatment, the animals had low plasma concentrations of gonadotropins and were anovulatory. In both animal models, BB and +2 ewes were treated with exogenous pregnant mares serum gonadotropin (PMSG) and varying doses of FSH to induce preovulatory follicular growth, and human chorionic gonadotropin (hCG) to induce ovulation. HPD or Deslorelin-treated animals administered with pregnant mares serum gonadotropin without FSH followed by human chorionic gonadotropin failed to ovulate. However for both animal models, the proportion of BB and +2 ewes ovulating to various doses of FSH differed such that significantly greater proportions of +2 animals ovulated relative to the BB genotype (P < 0.05). When HPD or Deslorelin-treated BB and +2 ewes were administered identical doses of FSH, the mean ovulation rate and plasma concentrations of FSH in those animals which ovulated was the same in both genotypes. These findings confirm, at least in part, the aforementioned hypothesis. The results also demonstrated that higher ovulation rates were obtained in both genotypes as the FSH dose was increased. Collectively, these findings infer that the higher mean ovulation rate in normal intact BB ewes compared to the +2 genotype is attributable to effects of the FecB gene at the level of ovarian follicular development as well as at the level of pituitary FSH release.

Direct effects of luteal regression on anterior pituitary response to GNRH.

The preovulatory period of the ewe is marked by a dramatic decrease in concentrations of progesterone in serum during the late luteal phase, followed by elevated luteinizing hormone (LH) secretion, final follicular maturation and ovulation. This experiment was designed to ascertain the extent to which removal of endogenous progesterone negative feedback at the anterior pituitary gland, independent of effects at the hypothalamus, promotes increased secretion of LH in the hours immediately after induction of luteolysis. Estrus was synchronized in ovary-intact ewes with two injections of prostaglandin F2 alpha (PGF2 alpha) analog given 10 d apart (Day 0 = second day after the second PGF2 alpha injection). Ewes were subjected to hypothalamic-pituitary disconnection (HPD; n = 6) on Day 3 and were pulsed with gonadotropin-releasing hormone (GnRH). Ewes were used during the estrous cycle or received approximately 400 IU pregnant mare serum gonadotropin (PMSG) on Day 2 to stimulate ovulation; there was no difference (P < 0.10) in ovulation rate or progesterone production between these two groups. Luteal regression was induced by injection of PGF2 alpha analog on approximately Day 10 of the estrous cycle. Blood samples were collected around exogenous GnRH pulses before and at 2- or 4-hr intervals after PGF2 alpha administration and concentrations of LH and progesterone determined. At 4, 12, and 24 hr after PGF2 alpha administration, mean serum progesterone levels in all ewes had decreased by 54.7%, 66.2% and 89.4%, respectively (P < 0.05) from pre-injection levels. The decrease in progesterone was associated with an increase (P < 0.01) in LH pulse amplitude with means at 4-hr post-PGF2 alpha ranging from 190% to 288% of pre PGF2 alpha values. Mean serum LH levels were also increased (P < 0.01) within 4 hr of PGF2 alpha administration and remained elevated at all but the 24-hr time point. The timing of this increase (within 4 hr) indicates that it is independent of changes in serum estradiol concentrations, which do not increase for at least 16 hr after induction of luteolysis. Thus, removal of endogenous progesterone negative feedback at the anterior pituitary gland in the hours immediately after induction of luteolysis seems to play a role in facilitating LH release independently of hypothalamic action.

Seasonal regulation of prolactin secretion in hypophyseal stalk transected beef calves.

Seasonal regulation of prolactin secretion was investigated in crossbred beef heifer calves. Calves were randomly assigned to hypophyseal stalk transection (HST, n = 6) or sham-operation control (SOC, n = 6) groups and fitted 1 day before surgery with an indwelling external jugular catheter. Prolactin (PRL), growth hormone (GH), thyroid stimulating hormone (TSH), thyroxine (T4), and tri-iodothyronine (T3) in peripheral serum were measured by radioimmunoassay in samples obtained before and after HST or SOC. During the first 8 days after HST, PRL concentrations remained significantly greater than SOC, but then decreased in both HST and SOC calves to 4 +/- 2 (+/- SE) and 10 +/- 3 ng/ml, respectively (P < 0.001). PRL remained low in both HST and SOC groups for three months after surgery. By four months, HST calves had lower basal PRL (5 +/- 1 ng/ml) than observed in SOC (40 +/- 4 ng/ml), and seasonal changes in PRL blood concentration also were attenuated by HST. Although HST reduced PRL secretion, it did not abolish the effect of seasonal changes (P < 0.01); circulating PRL concentration increased six-fold by shifts in photoperiod and temperature from winter to summer in these stalk-transected calves. The SOC group had higher serum GH during the winter (3.8 +/- 0.8) than in July (1.3 +/- 0.03 ng/ml). The HST group had the opposite profile of GH concentration, however, with concentrations being higher during May through July. Thyroid stimulating hormone secretion was partly sustained after stalk transection possibly by negative feedback of reduced circulating thyroxine and tri-iodothyronine. These results in both hypophyseal stalk-transected and sham-operated beef calves maintained in a natural environment strongly suggest that hypothalamic regulation of PRL secretion by adenohypophyseal cells is extremely sensitive to seasonal changes throughout the year. Additionally, immediately after HST, PRL blood concentration remains significantly greater than in SOC calves but eventually decreases to low blood concentration in HST calves, and unlike that seen after HST in primates. Regardless, basal PRL serum concentration responds to seasonal changes, but a less distinct change in basal GH serum concentration in HST calves than seen in the SOC calves.

Recombinant bovine somatotropin does not improve superovulatory response in sheep.

Although treatment of heifers and ewes with recombinant bovine somatotropin (rbST) does not increase ovulation rate, data for heifers indicate that the number of small antral follicles is approximately doubled. Accordingly, the objectives of this study were to determine whether 1) treatment of ewes with rbST would increase the number of small antral follicles, thereby increasing the number of follicles that could potentially respond to superovulation treatment, and 2) superovulatory responses could be improved in ewes with "synchronized" populations of follicles. Twenty-four ewes were divided into four groups: control, control+rbST, hypothalamic-pituitary stalk disconnected (HPD), and HPD+rbST. Beginning on d 5 of the estrous cycle, ewes were injected once daily for 13 d with either rbST (3 mg) or saline. The superovulatory regimen consisted of a single dose of PMSG followed by twice-daily injections of FSH for four consecutive days. After ovariectomy, ovulation sites and follicles were counted. Twice-daily blood samples were assayed for somatotropin (ST) and IGF-I. The concentrations of ST in rbST-treated ewes were greater (P < .05) than those in controls. Treatment with rbST increased (P < .05) the mean serum concentration of IGF-I in control but not in HPD ewes. There was no increase in ovulation rate or number of small antral follicles in response to rbST. Synchronizing follicle populations also failed to increase ovulation rate or reduce variability of response. We conclude that supplementation with rbST and synchronization of follicles does not increase the superovulatory response in sheep.

Messenger ribonucleic acid for gonadotropin-releasing hormone receptor and numbers of gonadotropin-releasing hormone receptors in ovariectomized ewes after hypothalamic-pituitary disconnection and treatment with estradiol.

To study the regulation of ovine GnRH receptors in the absence of GnRH, hypothalamic input was removed by hypothalamic-pituitary disconnection (HPD). Steady-state concentrations of GnRH receptor mRNA and numbers of GnRH receptors were measured after HPD and subsequent treatment with estradiol. Anterior pituitary glands were collected 24 (n = four), 36 (n = two), 48 (n = four), and 72 h (n = four) after HPD. An additional group of ewes received subcutaneous implants of estradiol 24 h after HPD, and pituitary glands were collected 0 (n = four), 12 (n = four), 24 (n = three), and 48 h (n = four) after exposure to estradiol. Pituitary glands were also obtained from four ovariectomized ewes that did not undergo HPD (OVX controls). At 24 h after HPD, mean number of GnRH receptors had decreased (P < .05) by 73%; however, mean concentration of GnRH receptor mRNA was not different from OVX controls. Relative to HPD ewes, treatment with estradiol increased mean concentrations of GnRH receptor mRNA and mean numbers of GnRH receptors (P < .01 and P < .001, respectively). From these data we conclude that 1) acute removal of GnRH decreases the numbers of GnRH receptors but does not affect steady-state concentrations of GnRH receptor mRNA and 2) estradiol increases the numbers of GnRH receptors and steady-state concentrations of GnRH receptor mRNA via direct effects at the level of the pituitary gland.

[DDAVP in the treatment of acute neurosurgical diabetes insipidus]. / Il DDAVP nel trattamento del diabete insipido neurochirurgico acuto.

The effects of a synthetic vasopressin analogue, DDAVP (1-deamino-8-d- arginine-vasopressin) were studied in 5 adults and 2 children with acute central diabetes insipidus secondary to neurosurgery. 5 mcg DDAVP was administered intranasally twice a day to the two children, whereas the adults received the drug i.m. (1 mcg twice a day, 3 patients; 1 mcg once a day, 1 patient; 4 mcg twice a day, 1 patient). All subjects displayed an early, prolonged response (12-24 hr). There were no side-effects. The effectiveness of DDAVP, its prolonged action, and virtual freedom from side-effects when given intranasally or parenterally make it the drug of choice in the treatment of acute neurosurgical diabetes insipidus.

Recovery of the hypothalamic-pituitary-adrenal axis in children and adolescents after surgical cure of Cushing's disease.

CONTEXT: Recovery of the hypothalamic-pituitary-adrenal axis (HPAA) after transsphenoidal surgery (TSS) for Cushing's disease (CD) in children has not been adequately studied. OBJECTIVE: Our objective was to assess time to recovery of the HPAA after TSS in children with CD. DESIGN AND SETTING: This was a case series at the National Institutes of Health Clinical Center. PATIENTS: Fifty-seven patients with CD (6-18 yr, mean 13.0 ± 3.1 yr) given a standard regimen of glucocorticoid tapering after TSS were studied out of a total of 73 recruited. INTERVENTIONS: ACTH (250 µg) stimulation tests were administered at approximately 6-month intervals for up to 36 months. Age, sex, pubertal status, body mass index, length of disease, midnight cortisol, and urinary free cortisol at diagnosis were analyzed for effects on recovery. MAIN OUTCOME MEASURE: The main outcome measure was complete recovery of the HPAA as defined by a cortisol level of at least 18 µg/dl in response to 250 µg ACTH. RESULTS: Full recovery was reached by 43 (75.4%) of 57 patients, with 29 of the 43 (67.4%) and 41 of the 43 (95.3%) recovering by 12 and 18 months, respectively. The overall mean time to recovery was 12.6 ± 3.3 months. Kaplan-Meier survivor function estimated a 50% chance of recovering by 12 months after TSS and 75% chance of recovering within 14 months. By receiver operating characteristic curve assessment, the cutoff of at least 10-11 µg/dl of cortisol as the peak of ACTH stimulation testing at 6 months after TSS yielded the highest sensitivity (70-80%) and specificity (64-73%) to predict full recovery of the HPAA at 12 months. Two of the four patients that recovered fully within 6 months had recurrent CD. CONCLUSIONS: Although this is not a randomized study, we present our standardized tapering regimen for glucocorticoid replacement after TSS that led to recovery of the HPAA in most patients within the first postoperative year. Multiple factors may affect this process, but an early recovery may indicate disease recurrence.

Can basal cortisol measurement be an alternative to the insulin tolerance test in the assessment of the hypothalamic-pituitary-adrenal axis before and after pituitary surgery?

BACKGROUND: The aims of this study were to evaluate the validity of preoperative basal serum cortisol levels measured in predicting preoperative adrenal insufficiency and also the validity of basal serum cortisol levels and early postoperative insulin tolerance test (ITT) in predicting postoperative adrenal insufficiency. METHODS: The study was prospectively designed and included 64 patients who underwent pituitary surgery for conditions other than Cushing's disease. An ITT was performed preoperatively, on the 6th postoperative day and at the 1st postoperative month. Basal serum cortisol levels were measured on the 2nd, 3rd, 4th, 5th, and 6th postoperative days. RESULTS: Patients with a preoperative basal cortisol level of <165 nmol/l (6 microg/dl) showed insufficient cortisol response and those with levels higher than 500 nmol/l (18 microg/dl) had sufficient cortisol response to the preoperative ITT. The positive predictive value of the ITT performed on the 6th postoperative day was 69.7%, and the negative predictive value in predicting adrenal insufficiency at the 1st postoperative month was 58%. Patients were considered to have an insufficient cortisol response to ITT at the 1st postoperative month if their basal cortisol levels were <193 nmol/l (7 microg/dl) or 220 nmol/l (8 microg/dl) or 193 nmol/l (7 microg/dl) or 165 nmol/l (6 microg/dl) or 83 nmol/l (3 microg/dl) on the 2nd-6th postoperative days respectively. CONCLUSION: Serum basal cortisol levels may be used as the first-line test in the assessment of the hypothalamic-pituitary-adrenal axis both preoperatively and postoperatively. Dynamic testing should be limited to the patients with indeterminate basal cortisol levels.