Role of surgery, radiotherapy and chemotherapy in papillary tumors of the pineal region: a multicenter study.

Papillary tumor of the pineal region (PTPR), recently described as a distinct clinicopathological entity, can show aggressive biological behavior. The optimal therapeutic approach of PTPR has not been well defined. The role of surgery, radiotherapy, and chemotherapy in the treatment of PTPR was analyzed in a large multicenter series. In order to determine factors that influence prognosis, outcome data of a series of 44 patients with histopathologically proven PTPR were retrospectively analyzed. Of the 44 patients, 32 were still alive after a median follow-up of 63.1 months. Twelve patients experienced progressive disease, with seven undergoing two relapses and five more than two. Median overall survival (OS) was not achieved. Median progression-free survival (PFS) was 58.1 months. Only gross total resection and younger age were associated with a longer OS, radiotherapy and chemotherapy having no significant impact. PFS was not influenced by gross total resection. Radiotherapy and chemotherapy had no significant effect. This retrospective series confirms the high risk of recurrence in PTPR and emphasizes the importance of gross total resection. However, our data provide no evidence for a role of adjuvant radiotherapy or chemotherapy in the treatment of PTPR.

Utility of Ki67 immunostaining in the grading of pineal parenchymal tumours: a multicentre study.

AIMS: Pineal parenchymal tumours (PPTs) are rare neoplasms that are divided into pineocytoma (PC), pineoblastoma (PB) and PPT of intermediate differentiation (PPTID). Factors affecting the survival of patients with PPTs are morphological subtype and histological grading according to mitotic index and neurofilament immunostaining. Grading criteria to distinguish PPTIDs are difficult to define, particularly when using small specimens. The Ki67 labelling index (LI) might be helpful in distinguishing between grade II and III PPTIDs. Our study was performed to assess the predictive value of the Ki67 LI in a large cooperative series of PPTs and to evaluate whether inclusion of this data would improve and refine the World Health Organization classification. METHODS: A retrospective analysis of 33 PPTs was performed. The histological features of the tumours were reviewed and Ki67 LI scoring was evaluated by immunohistochemistry. Data were correlated with the patients' survival. RESULTS: The mean Ki67 LI was significantly different for tumour grades (0 in PC, 5.2 ± 0.4 in PPTID grade II, 11.2 ± 2.0 in PPTID grade III, 36.4 ± 6.2 in PB; P < 0.0001). However, there was no statistically significant difference in either overall or disease-free survival evaluated by the Kaplan-Meier method for patients with different grade tumours or Ki67 LI, possibly due to the different clinical management of patients in different centres. CONCLUSIONS: The Ki67 LI may be a useful additional tool for grading PPTs, more particularly in small tumour samples.

Blood-brain interfaces and cerebral drug bioavailability.

The low cerebral bioavailability of various drugs is a limiting factor in the treatment of neurological diseases. The restricted penetration of active compounds into the brain is the result of the same mechanisms that are central to the maintenance of brain extracellular fluid homeostasis, in particular from the strict control imposed on exchanges across the blood-brain interfaces. Direct drug entry into the brain parenchyma occurs across the cerebral microvessel endothelium that forms the blood-brain barrier. In addition, local drug concentration measurements and cerebral imaging have clearly shown that the choroid plexuses - the main site of the blood-cerebrospinal fluid (CSF) barrier - together with the CSF circulatory system also play a significant role in setting the cerebral bioavailability of drugs and contrast agents. The entry of water-soluble therapeutic compounds into the brain is impeded by the presence of tight junctions that seal the cerebral endothelium and the choroidal epithelium. The cerebral penetration of many of the more lipid-soluble molecules is also restricted by various classes of efflux transporters that are differently distributed among both blood-brain interfaces, and comprise either multidrug resistance proteins of the ATP-binding cassette superfamily or transporters belonging to several solute carrier families. Expression of these transporters is regulated in various pathophysiological situations, such as epilepsy and inflammation, with pharmacological consequences that have yet to be clearly elucidated. As for brain tumour treatments, their efficacy may be affected not only by the intrinsic resistance of tumour cells, but also by endothelial efflux transporters which exert an even greater impact than the integrity of the endothelial tight junctions. Relevant to paediatric neurological treatments, both blood-brain interfaces are known to develop a tight phenotype very early on in postnatal development, but the developmental profile of efflux transporters still needs to be assessed in greater detail. Finally, the exact role of the ependyma and pia-glia limitans in controlling drug exchanges between brain parenchyma and CSF deserves further attention to allow more precise predictions of cerebral drug disposition and therapeutic efficacy.

Histological features and expression of enzymes implicated in melatonin synthesis in pineal parenchymal tumours and in cultured tumoural pineal cells.

Pineal parenchymal tumours (PPT) are rare neoplasms and there have been few in vitro studies. Their capacity for synthesizing and secreting melatonin has been only partially examined. We investigated the presence of messenger RNA (mRNA) encoding tryptophan hydroxylase (TPH), arylalkylamine N-acetyltransferase (AANAT), hydroxyindol-O-methyltransferase (HIOMT), three enzymes involved in melatonin synthesis, and c-myc, a tumoural marker, in 10 PPT, one papillary tumour of the pineal region (PTPR), cell cultures derived from four PPTs and from three other tumours of the pineal region, and in normal pineal gland. Moreover, protein expression of TPH was investigated in three PPT and PTPR. Quantitative real-time reverse transcriptase-polymerase chain reaction and immunohistochemistry were used and the melatonin production by tumoural cells in vitro was analysed by radioimmunoassay. We showed that all the tumoural tissues and cells contained c-myc mRNA. mRNAs encoding TPH, AANAT and HIOMT were detected in all PPT, suggesting that tumour cells can synthesize melatonin. Only PPT expressed TPH protein. Cultured cells lost expression of transcripts throughout passages even if ultrastructural study revealed the presence of characteristic organelles in these tumoural cells. Nevertheless, the basal secretion of melatonin observed in one PPT culture is in favour of a maintained melatonin production and secretion by tumoural pinealocytes, but melatonin production was not stimulated by a beta noradrenergic agonist. Moreover, PTPR never expressed mRNA encoding TPH, AANAT and HIOMT. Our results may contribute to a better understanding of the biology of PTT and PTPR and may help to the diagnosis of these rare tumours.

Expression of c-Myc, neurofibromatosis Type 2, somatostatin receptor 2 and erb-B2 in human meningiomas: relation to grades or histotypes.

Meningiomas, which originate from arachnoid cells, represent one of the largest subgroups of intracranial tumors. They are generally benign, but can progress to malignancy. The aim of our study was to determine the expression of 4 genes, c-Myc, neurofibromatosis Type 2 (NF2), somatostatin receptor isoform 2 (sst2) and erb-B2, that have been associated with tumorogenesis or, possibly, with aggressive behavior or recurrence of meningiomas. We measured levels of mRNAs coding for these genes by qRT-PCR in 51 cases and levels ofc-Myc protooncogene and sst2 protein by immunohistochemistry in 26 cases of meningiomas of various grades and histotypes. C-Myc mRNA and protein levels were not grade-related, but validated subdivision of the 36 benign meningiomas into two groups, Groups IA and IB, based on histological and clinical features (Ki-67-proliferative index, absence or presence of mitoses, rate of recurrence and incidence of perilesional edema). In addition to histopathological grading, c-Myc expression may be useful in predicting tumor recurrence in patients with low-grade meningiomas. NF2 mRNA levels and sst2 mRNA and receptor levels were not grade-related, but were histotype-related, with significantly higher levels in the meningothelial subtype than in the fibroblastic subtype. Erb-B2 mRNA levels were not grade- or histotype-related. Furthermore, the high expression of sst2 in meningothelial meningioma suggests the possibility of a different tumorigenesis process in this meningioma subtype and may open perspectives for the diagnosis and therapy of this subtype using somatostatin as an antiproliferative agent.

Pathology of tumors of the pineal region.

Tumors of the pineal region are rare and relatively few centers around the world have published substantial numbers of carefully studied cases. This review gives a historical account of our understanding of the normal pineal and the evolution of the classification of tumors and other mass lesions of the pineal region in human beings. Based on our experience over the past 30 years, a working classification is proposed and recent advances in the neuropathology of these lesions are discussed.

Histopathology of pineal germ cell tumors.

Germ cell tumors (GCTs) classically occur in gonads. However, they are the most frequent neoplasms in the pineal region. The pineal location of GCTs may be caused by the neoplastic transformation of a primordial germ cell that has mismigrated. The World Health Organization (WHO) recognizes 5 histological types of intracranial GCTs: germinoma and non-germinomatous tumors including embryonal carcinoma, yolk sac tumor, choriocarcinoma and mature or immature teratoma. Germinomas and teratomas are frequently encountered as pure tumors whereas the other types are mostly part of mixed GCTs. In this situation, the neuropathologist has to be able to identify each component of a GCT. When diagnosis is difficult, use of recent immunohistochemical markers such as OCT(octamer-binding transcription factor)3/4, Glypican 3, SALL(sal-like protein)4 may be required. OCT3/4 is helpful in the diagnosis of germinomas, Glypican 3 in the diagnosis of yolk sac tumors and SALL4 in the diagnosis of the germ cell nature of an intracranial tumor. When the germ cell nature of a pineal tumor is doubtful, the finding of an isochromosome 12p suggests the diagnosis of GCT. The final pathological report should always be confronted with the clinical data, especially the serum or cerebrospinal fluid levels of ß-human chorionic gonadotropin (HCG) and alpha-fetoprotein.

Papillary tumor of the pineal region: Histopathological characterization and review of the literature.

BACKGROUND AND PURPOSE: The papillary tumor of the pineal region (PTPR) was described as a distinct new entity for the first time in 2003 by our team and has been included in the last 2007 WHO classification of tumors of the Central Nervous System. We describe the histopathological characterization of PTPR and present a review of the literature. METHODS: The description of the histological and immunological features of PTPR is based on the 2007 WHO classification. RESULTS: PTPR affects both children and adults, and mostly young adults in the third decade. PTPR is a neuroepithelial tumor occurring in the vicinity of the pineal gland, and characterized by its papillary architecture. The papillae are lined by multi-layered cuboidal to columnar epithelioid tumoral cells arranged in perivascular pseudorosettes. Immunohistochemistry shows strong reactivity for cytokeratins, particularly for cytokeratin 18. On electron microscopy, PTPR reveals ultrastructural features indicative of ependymal differentiation, including abundant microvilli at the apical cell pole. The differential diagnosis includes a variety of other papillary tumors, most notably papillary ependymoma, choroid plexus papilloma, papillary meningioma, and metastatic papillary carcinoma in adults. On the basis of ultrastructural and immunohistochemical features, it has been suggested that a PTPR arises from specialized cytokeratin-positive and nestin-positive ependymal cells that are derived from the subcommissural organ. Although the precise histological grading criteria of PTPR remain to be defined, its biological behavior may correspond to WHO grade II or III.

Anatomical, molecular and pathological consideration of the circumventricular organs.

BACKGROUND AND PURPOSE: Circumventricular organs (CVOs) are a diverse group of specialised structures characterized by peculiar vascular and position around the third and fourth ventricles of the brain. In humans, these organs are present during the fetal period and some become vestigial after birth. Some, such as the pineal gland (PG), subcommissural organ (SCO) and organum vasculosum of the lamina terminalis (OVLT), which are located around the third ventricle, might be the site of origin of periventricular tumours. In contrast to humans, CVOs are present in the adult rat and can be dissected by laser capture microdissection (LCM). METHODS: In this study, we used LCM and microarrays to analyse the transcriptomes of three CVOs, the SCO, the subfornical organ (SFO) and the PG and the third ventricle ependyma of the adult rat, in order to better characterise these organs at the molecular level. Furthermore, an immunohistochemical study of Claudin-3 (CLDN3), a membrane protein involved in forming cellular tight junctions, was performed at the level of the SCO. RESULTS: This study highlighted some potentially new or already described specific markers of these structures as Erbb2 and Col11a1 in ependyma, Epcam and CLDN3 in the SCO, Ren1 and Slc22a3 in the SFO and Tph, Anat and Asmt in the PG. Moreover, we found that CLDN3 expression was restricted to the apical pole of ependymocytes in the SCO.

Pineal parenchymal tumours and pineal cysts.

BACKGROUND AND PURPOSE: Pineal parenchymal tumours (PPTs) and pineal cysts represent one third of the pineal region lesions. PPTs are subdivided into pineocytoma (PC), pineoblastoma (PB) and PPT with intermediate differentiation (PPTID). We report morphological and immunochemical features which permit to grade these tumours. METHODS: The description of histopathological features and grading is based on a large cooperative series and on the WHO 2007 classification. RESULTS: PCs occur in adults between the third and the sixth decade of life. PBs typically occur in children. PPTIDs have a peak incidence in young adults between 20 and 40 years of age. There is no sex preference. PC is characterized by a uniform cell proliferation with large fibrillary pineocytomatous rosettes. PB is a high-density tumour composed of small blue cells with hyper-chromatic, round or carrot shaped nuclei. PPTIDs have lobulated or diffuse patterns. Grading is based on morphological features, count of mitoses and neurofilament protein (NFP) expression. PCs (grade I) have no mitosis and NFP is highly expressed in pineocytomatous rosettes. PBs (grade IV) are high mitotic tumours and present low or no expression of NFPs. PPTIDs are grade II when mitoses are fewer than 6 for 10 high-power fields and NFPs are expressed, and are grade III when mitoses are greater or equal to 6 or are fewer than 6 with NFPs lowly expressed. Pineal cysts may be differentiated from PPTs by the high expression of NFPs and no expression of Ki-67.

Brain structures selectively targeted by canine distemper virus in a mouse model infection.

Paramyxoviruses such as measles virus or canine distemper virus are etiological agents for acute and chronic encephalitis (measles inclusion body encephalitis, subacute sclerosing panencephalitis and chronic distemper encephalitis or old dog encephalitis). The mechanisms by which viral injury leads to neurological diseases have not yet been fully elucidated. We have developed an experimental model in mice in order to analyze the spatial and temporal distribution of canine distemper virus in the central nervous system. Cerebral target structures for viral replication were examined for the presence of viral material (proteins and mRNA) during the two stages of the biphasic disease. During the acute stage of infection all target areas could be identified by day 6 with a similar anatomical distribution in all the animals examined, which were either intracranially or intracerebroventricularly infected. Viral mRNA and proteins were selectively localized in certain brain structures such as the thalamus, hypothalamus, substantia nigra (pars compacta), locus ceruleus and raphe nuclei (dorsalis and centralis), and limbic system (hippocampus, septum, entorhinal and cingulate cortex, amygdala). The virus was apparently unable to replicate in cerebellum, striatum, a large part of cortex, or endothelial cells. During the subacute disease, viral material was no longer detectable except in a few structures such as hypothalamus up to 4-6 weeks after inoculation. After this time, all target structures were devoid of any labeling in spite of the occurrence of pathology (obesity, paralysis) during this viral quiescent phase. These results suggest that after the initial viral exposure, expression of viral genes in defined structures might disrupt central homeostasis and finally may lead to neurological or neuroendocrine diseases, even in the absence of the hallmarks of the virus.

Pineal parenchymal tumors: a correlation of histological features with prognosis in 66 cases.

The WHO classification of CNS tumors divides pineal parenchymal tumors (PPT) into pineocytoma (PC), pineoblastoma (PB) and mixed pineocytoma-pineoblastoma or PPT with intermediate differentiation. The reported incidence of mixed/intermediate PPT varies and this may reflect the difficulty in classifying tumors of this type. In an attempt to overcome the problem of the classification of PPT with intermediate differentiation, we describe the relationship between histological features and patient survival in a large cooperative series of 66 PPT from 12 neurosurgical centres. All tumors were studied with both light microscopy and immunohistochemically using antibodies against glial markers or neural/neuroendocrine markers. Our series included 11 PC, 39 mixed/intermediate PPT and 16 PB. A number of mitoses greater than 6 and the presence of necrosis were associated with a poorer outcome, while positive immunostaining for neurofilaments was associated with a better survival. We propose a new prognostic grading of 4 grades, grade I for PC, grade II for PPT with fewer than 6 mitoses and positive immunolabelling for neurofilaments, grade III for PPT with either 6 or more than 6 mitoses or fewer than 6 mitoses but without immunostaining for neurofilaments and grade IV for PB.

Beta-lipotropin and cortisol responses to an intravenous infusion dexamethasone suppression test in Cushing's syndrome and obesity.

An i.v. infusion dexamethasone (Dex) test was used to investigate the ACTH feedback response in 9 normal subjects, 12 obese patients, and 11 patients with Cushing's syndrome. Dex phosphate was infused iv for 4 h, starting at 1100 h (1 mg/h). Plasma concentrations of beta-lipotropin (beta LPH) and cortisol were measured every 20 min between 0900 and 1600 h, then every 2 h until midnight and at 0900 h the next day. In normal subjects and obese patients, plasma beta LPH and cortisol concentrations fell rapidly to less than 40 ng/liter and 3 micrograms/dl, respectively, at the end of Dex infusion. Subsequent values remained low through 0900 h the next day. In 7 patients with Cushing's disease, basal plasma beta LPH and cortisol concentrations declined by greater than 50% during the Dex infusion. In these patients, rapid escape from suppression occurred between 1600 and 2400 h; by 0900 h the following day, beta LPH and cortisol levels were higher than 100 ng/liter and 10 micrograms/dl, respectively. In 3 patients with adrenal tumors, beta LPH concentrations were low, and cortisol concentrations did not decline during the Dex infusion. In 1 patient with ectopic ACTH secretion, beta LPH concentrations were high and were not suppressed by the Dex infusion. We conclude that the iv infusion Dex suppression test can distinguish patients with Cushing's syndrome from normal or obese subjects and can aid in the etiological diagnosis of Cushing's syndrome.

Establishment of human tumoral ependymal cell lines and coculture with tubular-like human endothelial cells.

Ependymomas, rare neoplasms of the central nervous system, occur predominantly in children. They are highly vascularized, and histological findings show many perivascular rosettes of tumoral cells radially organized around capillaries. Treatment of ependymomas relies on surgery combined with radio- or chemotherapy, but the efficiency of chemotherapy is limited, probably because of their multidrug resistance (MDR) phenotype. Progress in the therapy of these neoplasms is dramatically limited by the absence of cell line models. We established conditions for the long-term culture of human tumoral ependymocytes and their 3D coculture in Matrigel with endothelial cells. Histological, immunological, and ultrastructural studies showed that the morphological features (microvilli, cilia, and caveolae) of these cultured cells were similar to those of the tumor in vivo. The cells expressed potential oncological markers related to the immature state of tumoral cells (nestin and Notch-1), their tumorigenicity [caveolae and epidermal growth factor-receptor (EGF-R)], or the MDR phenotype [P-glycoprotein (P-gp)]. The expression of P-gp, EGF-R, and caveolin-1 by these tumoral ependymocytes could be useful in studies on new drugs. This coculture model might represent a new powerful tool to study new therapeutic delivery strategies in tumoral cells.

Twenty-four hour melatonin secretory pattern in men with idiopathic hemochromatosis.

In idiopathic hemochromatosis, iron deposits in endocrine tissue can be associated with hormonal disorders including hypogonadism. We have studied the functional status of the pineal gland in this disease in relation to gonadotrophin levels and cortisol rhythm. Plasma melatonin, luteinizing hormone (LH) and cortisol concentrations were measured by radioimmunoassay every 20 min over a 24 hr period in nine men with idiopathic hemochromatosis aged 36 to 66 years. In six patients a circadian melatonin rhythm was present. The 24 hr means were in the normal range in three patients, and varied below the control values in two patients and above the control values in one patient. These variations seemed unrelated to gonadotrophin status. In the three other patients no plasma melatonin rhythm was observed; two patients with gonadotrophin insufficiency had low melatonin levels, and one with normal gonadotrophin function had high melatonin concentrations. In all cases, the plasma cortisol rhythm was normal. We concluded that the circadian melatonin rhythmicity can be disturbed in some cases of idiopathic hemochromatosis without relationship to the cortisol rhythm and associated endocrine disorders.

Ultrastructural localization of oxytocin mRNA in the rat hypothalamus by in situ hybridization using a synthetic oligonucleotide.

In situ hybridization (ISH) was used to study at the electron microscope level, the subcellular localization of oxytocin (OT) mRNA in the rat hypothalamic magnocellular neurons. Rat brains were fixed with paraformaldehyde and glutaraldehyde and vibratome slices were incubated with a 25-base synthetic oligonucleotide complementary to OT mRNA and labelled at the 3'-end with [3H]dCTP. Hybridized slices were embedded in Epon after post-fixation with osmium tetroxide and cut into ultrathin sections that were processed for ultrastructural radioautography. OT mRNA was observed in magnocellular neurons of supra-optic and paraventricular nuclei in the vibratome sections. On ultrathin sections, the cytological preservation appeared to be satisfactory. Except for a few silver grains over the nucleus, sometimes close to its membrane, most grains were localized over the cytoplasm of some magnocellular neurons, where they frequently overlapped the endoplasmic reticulum. To decrease exposure time, ISH was also performed with OT probes labelled with a long tritiated tail. In this case, clusters of silver grains occurred over the cell nuclei not only in magnocellular neurons but also in non-secretory neurons and even in glial cells. However, an excess of poly C added to the hybridization buffer strongly decreased this non-cytoplasmic labelling. In conclusion, the results obtained with the short-tailed oligonucleotides demonstrate that these synthetic oligonucleotides have possible applications for the ultrastructural localization of mRNAs and constitute a powerful tool for the dynamic study of cellular mRNA processing in several physiological and experimental conditions.

Effects of an acute immobilization stress upon proopiomelanocortin (POMC) mRNA levels in the mediobasal hypothalamus: a quantitative in situ hybridization study.

The aim of this study was to examine by quantitative in situ hybridization the effects of an acute stress on the expression of the POMC gene in the mediobasal hypothalamus (MBH) of the rat. In control animals, the highest levels of POMC mRNA were observed in the posterior periventricular region of the MBH. Lower levels were found in the anterior and posterior arcuate nucleus. At the end of a one hour immobilization, a small decrease (-8%) was observed in the periventricular region only. Four hours after the end of immobilization, increases in POMC mRNA levels were detected in the anterior part (7%), in the posterior part (25%) and in the periventricular region (13%) of the MBH. These results suggest that MBH POMC-derived peptides might be an important component in the central response to stress.

Developmental expression of tryptophan hydroxylase mRNAs in the rat pineal gland: an in situ hybridization study.

The expression of messenger RNAs encoding for tryptophan hydroxylase (TPOH), the first enzyme involved in serotonin and melatonin synthesis, has been investigated by in situ hybridization during the development of the rat pineal gland. TPOH mRNAs were detected as early as the twentieth day of gestation (E20) in the rat embryo before any nerve ending was observed in the pineal gland. After birth, their expression increased strongly, and attained a plateau during the second week. This coincides with the setting up of sympathetic innervation. From day 17 (D17), the TPOH mRNA expression diminished. These results indicate that noradrenergic innervation is not involved in the initiation of rat pinealocyte differentiation, but might modulate cell maturation. This study showed the existence of three types of cells arranged in patches in the young rat pineal gland (D6): regions in which cells expressed TPOH mRNAs, regions in which cells expressed vimentin, an intermediate filament protein present in the cytoskeleton of immature cells, and regions in which both TPOH mRNAs and vimentin are expressed. In older rat pineal gland (D20), almost all cells express TPOH mRNAs, and some cells still express vimentin. This suggests that all cells do not reach the same level of differentiation at the same time in the rat pineal gland.

Nycthemeral expression of tryptophan hydroxylase mRNAs in the rat pineal gland.

The expression of mRNAs coding for tryptophan hydroxylase (TPOH), the first enzyme involved in melatonin synthesis, has been studied in the rat adult pineal gland at four different circadian time points by in-situ hybridization using an oligonucleotide probe. TPOH mRNAs were detected at all chosen time-points. The lowest level was seen at 13:00 h. Quantification of the hybridization signals demonstrated a significant increase in expression (+16.5%) between 13:00 h and 19:30 h, with the values at 23:30 h and 09:00 h being similar to that of 19:30 h. These results coincide with the nycthemeral rhythm of TPOH activity. Day/night rhythms in the rat pineal gland are controlled by noradrenaline release at lights-off, which results in an increase in cAMP levels and in gene activation. This study suggests that the TPOH gene might be one such gene whose activation is stimulated in this way.