Position statement on the diagnosis and management of congenital pituitary deficiency in adults: The French National Diagnosis and Treatment Protocol (NDTP).

Pituitary deficiency, or hypopituitarism, is a rare chronic disease. It is defined by insufficient synthesis of one or more pituitary hormones (growth hormone, TSH, ACTH, LH-FSH, prolactin), whether or not associated with arginine vasopressin deficiency (formerly known as diabetes insipidus). In adult patients, it is usually acquired (notably during childhood), but can also be congenital, due to abnormal pituitary development. The present study focuses on congenital pituitary deficiency in adults, from diagnosis to follow-up, including special situations such as pregnancy or the elderly. The clinical presentation is highly variable, ranging from isolated deficit to multiple deficits, which may be part of a syndromic form or not. Diagnosis is based on a combination of clinical, biological (assessment of all hormonal axes), radiological (brain and hypothalamic-pituitary MRI) and genetic factors. Treatment consists in hormonal replacement therapy, adapted according to the period of life and the deficits, which may be progressive. Comorbidities, risk of complications and acute decompensation, and the impact on fertility and quality of life all require adaptative multidisciplinary care and long-term monitoring.

Belugas (Delphinapterus leucas) create facial displays during social interactions by changing the shape of their melons.

Beluga whales are considered unique among odontocetes in their ability to visibly alter the appearance of their head by changing the shape of the melon, but only anecdotal observations are available to evaluate the use or potential function of these melon shapes. This study of belugas in professionally managed care aimed to establish an ethogram for the repertoire of categorizable melon shapes and then evaluate their potential function as intentional communication signals by determining if they were produced and elaborated during social interactions of varying behavioral contexts while in the line of sight of a recipient. Five different melon shapes were reliably identified in video observations of the primary study population (n = 4) and externally validated in a second aquarium population (n = 51). Among the 2570 melon shapes observed from the primary study subjects, melon shapes occurred 34 × more frequently during social interactions (1.72 per minute) than outside of social interactions (0.05 per minute). Melon shapes occurring during social interactions were performed within the line of sight of a recipient 93.6% of the time. The frequency of occurrence of the different melon shapes varied across behavioral contexts. Elaboration of melon shapes through extended duration and the occurrence of concurrent open mouth displays varied by shape type and across behavioral contexts. Melon shapes seem to function as visual displays, with some characteristics of intentional communication. This ability could yield adaptive benefits to belugas, given their complex social structure and hypothesized mating system that emphasizes pre-copulatory female mate choice.

Position statement on the diagnosis and management of acromegaly: The French National Diagnosis and Treatment Protocol (NDTP).

Acromegaly is a rare disease with prevalence of approximately 60 cases per million, slight female predominance and peak onset in adults in the fourth decade. Clinical diagnosis is often delayed by several years due to the slowly progressive onset of symptoms. There are multiple clinical criteria that define acromegaly: dysmorphic syndrome of insidious onset, symptoms related to the pituitary tumor (headaches, visual disorders), general signs (sweating, carpal tunnel syndrome, joint pain, etc.), complications of the disease (musculoskeletal, cardiovascular, pneumological, dental, metabolic comorbidities, thyroid nodules, colonic polyps, etc.) or sometimes clinical signs of associated prolactin hypersecretion (erectile dysfunction in men or cycle disorder in women) or concomitant mass-induced hypopituitarism (fatigue and other symptoms related to pituitary hormone deficiencies). Biological confirmation is based initially on elevated IGF-I and lack of GH suppression on oral glucose tolerance test or an elevated mean GH on repeated measurements. In confirmed cases, imaging by pituitary MRI identifies the causal tumor, to best determine management. In a minority of cases, acromegaly can be linked to a genetic predisposition, especially when it occurs at a young age or in a familial context. The first-line treatment is most often surgical removal of the somatotroph pituitary tumor, either immediately or after transient medical treatment. Medical treatments are most often proposed in patients not controlled by surgical removal. Conformal or stereotactic radiotherapy may be discussed on a case-by-case basis, especially in case of drug inefficacy or poor tolerance. Acromegaly should be managed by a multidisciplinary team, preferably within an expert center such as a reference or skill center for rare pituitary diseases.

"Maybe they have found something new" participants' views on returning cohort psychosocial survey results.

BACKGROUND: Although greater attention is currently being paid to participants in research, no studies have dealt so far with the issue of returning aggregate psychosocial results to cohort participants. OBJECTIVE: (i) To explore participants' views about disclosure of the aggregate results of a French national psychosocial cohort survey on the epidemiology of preventive behaviour in women from families with a hereditary breast cancer risk. (ii) To assess whether it is worth consulting participants before designing the disclosure process. DESIGN: A qualitative study using semi-structured face-to-face interviews and a thematic analysis based on Grounded Theory methods. PARTICIPANTS: Nineteen interviews were conducted with cancer-free female BRCA mutation carriers/non-carriers aged 31-79 who had participated in a cohort survey by answering self-administered questionnaires. RESULTS: Participants showed considerable interest in the issue of result disclosure. The preferences expressed about disclosure were rarely relevant to the topic investigated, however, as they often focused on medical knowledge about BRCA and not on the psychosocial findings obtained. This confusion may have been due to the participants' experience of the survey procedures, including its longitudinal nature, the occurrence of very few interactions with the investigators and the wide range of topics addressed in the questionnaires. CONCLUSION: Investigators should ascertain participants' expectations and preferences by consulting them before disclosing the results obtained. Although the disclosure process may not meet participants' expectations completely, consultation is the key to preventing them from having irrealistic expectations about the information they are going to receive.

[Having a child and PND/PGD access in women with a BRCA1/2 mutation? Different approach whether ill or healthy]. / Avoir un enfant et accéder au DPN/DPI pour des femmes porteuses d'une mutation BRCA ? Malades et indemnes appréhendent la question différemment.

Genetic tests in families with a mutation related to breast and ovarian cancers (BRCA1/2) are now offered to the persons before completion of their reproductive project. The aim of this qualitative study was to descriptively explore how the issues of reproduction are faced in women belonging to these families, and how the possible use of prenatal diagnostic (PND) and preimplantation genetic diagnosis (PGD) would be faced in a theoretical context. We conducted in-depth interviews, face to face, according to the so-called Grounded Theory approach. Twenty women with a BRCA genetic mutation participated in the study (age range: 31-57 years); 12 have had a breast and/or ovarian cancer. The knowledge of having the mutation did not modify the parental project; however prophylactic anexectomy was likely to alter it in some women. If the majority of women were in favor of PGD (n = 14), medical termination of pregnancy was a constraint towards the position in relation to PND. Besides ethical and moral arguments, the women's attitudes were constructed differently according to their own personal or familial experience of the disease. The women's perceptions of the cancer severity, risk and cure were organized according to this experience.

Contributing to research via biobanks: what it means to cancer patients.

CONTEXT AND OBJECTIVE: Biobanks have become strategic resources for biomedical and genetic research. The aim of the present empirical qualitative study was to investigate how patients with cancer perceive and experience the process of donation to biobanks, focussing on the subjective meanings associated with their decisions when they are asked in a routine context to agree to their own biological specimens being used for research projects. DESIGN: A qualitative study, using semi-structured interviews to explore in depth the reasons why patients with cancer agree to participating in biobanking. Participants Nineteen patients (aged 28-82 years) being treated for colorectal cancer or leukaemia at a French cancer centre participated in this study. RESULTS: Contributing to biobanks was experienced here as a rewarding and empowering individual experience because of the psychological issues involved, such as feelings of hope associated with research, because it makes the relationship with researchers and clinicians less asymmetrical, revalorization of otherwise 'wasted' tissue, and also as an act of solidarity and reciprocity, which makes patients part of a community. DISCUSSION AND CONCLUSION: Patients seem to regard contributing to biobanks as an act of benevolence, which they are motivated to perform because of societal welfare considerations as well as the hope of subjective benefits. Knowledge about the patients' perspective and of the psychological rewards associated with tumour donation should be taken into account by physicians and caregivers discussing this topic with their patients.

Research resource: A genome-wide study identifies potential new target genes for POU1F1.

The pituitary transcription factor POU1F1 is required for the differentiation of lactotrope, thyrotrope, and somatotrope cells. Its expression is maintained in the adult and is crucial for the expression of prolactin, GH, and TSHß-subunit. Different studies indicated that POU1F1 could also have other functions in these cells. The identification of new targets of this factor could be useful to obtain a better understanding of these functions. To address this question we combined data obtained from expression microarrays and from chromatin immunoprecipitation (ChIP)-chips. Gene expression microarray assays were used to detect genes that have their expression modified in somatolactotrope GH4C1 cells by the expression of a dominant-negative form of POU1F1, POU1F1(R271W), and led to the identification of 1346 such genes. ChIP-chip experiments were performed from mouse pituitaries and identified 1671 POU1F1-binding sites in gene-promoter regions. Intersecting the gene expression and the ChIP-chip data yielded 121 potential new direct targets. The initial set of 1346 genes identified using the microarrays, as well as the 121 potential new direct targets, were analyzed with DAVID bioinformatics resource for gene ontology term enrichment and cluster. This analysis revealed enrichment in different terms related to protein synthesis and transport, to apoptosis, and to cell division. The present study represents an integrative genome-wide approach to identify new target genes of POU1F1 and downstream networks controlled by this factor.

[Targeted chemotherapy for breast cancer: patients perception of the use of tumor gene profiling approaches to better adapt treatments]. / Chimiothérapie ciblée du cancer du sein basée sur une analyse génomique de la tumeur - Adhésion des patientes, craintes et malentendus.

The purpose of this review of the literature is to document how breast cancer patients perceive the use of tumor gene profiling approaches to better adapt treatments, and to identify the features of these approaches that may impact their clinical application. In general, the use of tumor genomic analysis was perceived by patients as an approach facilitating personalized medicine and received considerable support. Nevertheless, a number of confusions and worries about these practices were also identified. Improving the quality of provider/patient communications should enable patients to play a more active part in the decision-making about their treatment. This will ensure that those who agree to their tumor gene analysis have realistic expectations and sound deductions of the final result disclosure process.

[Perception by cancer patients of biomedical research in the era of large-scale biobanking]. / La recherche biomédicale à l'ère des tumorothèques - Point de vue des patients atteints de cancer.

In French hospitals, patients are increasingly asked to participate in research, particularly in oncology where the development of research is stimulated at a national level (plan Cancer). This article express our thoughts based on the literature about the perception by cancer patients of research activities developed in the care centre where they are treated. We focus mainly on the consent for biobanking in a context in which cancer patients are routinely requested to donate tumour samples for research. This article presents the results of a survey among patients treated in a comprehensive cancer centre. The available literature shows that patients have an overall positive image of medical research and of the existence of research activities intertwined with medical care. Patients are globally expressing a wish for more proposals to participate in research in collaboration with scientific teams.

Inactivation of PITX2 transcription factor induced apoptosis of gonadotroph tumoral cells.

Nonfunctioning pituitary adenomas (NFPA; gonadotroph derived), even not inducing hormonal hypersecretion, cause significant morbidity by compression neighboring structures. No effective and specific medical methods are available so far for treating these tumors. The pituitary homeobox 2 (PITX2) gene is a member of the bicoid-like homeobox transcription factor family, which is involved in the Wnt/Dvl/ß-catenin pathway. PITX2 is overexpressed in NFPA. PITX2 mutations are known to be responsible for Axenfield Rieger syndrome, a genetic disorder in which pituitary abnormalities have been detected. The R91P mutant identified in Axenfeld Rieger syndrome is a dominant-negative factor, which is able to block the expression of several pituitary genes activated by PITX2. To better understand the role of Pitx2 on gonadotroph tumorigenesis and to explore new approach for inhibiting tumoral growth, the R91P mutant was transferred via a lentiviral vector in tumoral gonadotroph cells of two kinds: the αT3-1 cell line and human adenoma cells. R91P mutant and small interfering RNA directed against Pitx2 both decreased the viability of αT3-1 cells via an apoptotic mechanism involving the activation of executioner caspase. Similar effects of the R91P mutant were observed on human gonadotroph cells in primary culture. Therefore, Pitx2 overexpression may play an antiapoptotic role during NFPA tumorigenesis.

Consent for biobanking: assessing the understanding and views of cancer patients.

Cancer patients were questioned about the consent process in a context in which they were routinely requested to donate tumor samples to research. After in-depth interviews of 19 patients, a 12-page questionnaire was designed and mailed to 745 patients who had been recently treated for colorectal cancer, breast cancer, or a hematological malignancy at a French Regional Cancer Center at which an opt-in biobanking system has existed since 2002. The response rate was 77.0% (N = 574). Among responding patients, 349 (60.8%) of the 574 were in favor of a formal and signed consent. Concordance was low (kappa = 0.23) between the number of patients who declared in the survey that they had given consent (213 of 574 [37.1%]) vs the number for whom registered consent had been recorded (267 of 574 [46.5%]). Only 2 (0.3%) of the 574 patients stated that they had signed a refusal, and only 88 (41.3%) of the 213 patients who remembered giving consent understood that their consent for biobanking also covered authorization to use their clinical data. We conclude that the opt-in consent procedure is positively perceived by most patients but should be improved for a better understanding and possibly an even better adherence to the consent process.

Women's perceptions and experience of adjuvant tamoxifen therapy account for their adherence: breast cancer patients' point of view.

OBJECTIVE: The aim of this study on primary breast cancer patients undergoing adjuvant tamoxifen treatment was to determine how their perceptions of the treatment and their experience of side-effects contributed to their adherence to the treatment. METHODS: A consecutive series of primary breast cancer patients eligible for tamoxifen therapy were studied qualitatively by conducting semi-structured in-depth interviews at two French cancer centres. RESULTS: The women aged 35-65 (N=34) were struggling with several issues involving their understanding and experience of the treatment, which have not been documented so far. These issues included confusion about the 'hormonal' nature and activity of tamoxifen and the etiology of the changes in their menopausal status, as well as the symbolic associations formed by patients about the paradox of taking a treatment that has aging effects but saves lives. CONCLUSIONS: This study shows the great physical burden often associated with tamoxifen treatment and brings to light women's own complex representations of the treatment and their interpretation of the side-effects. Better communication between health-care providers and patients should ultimately help to prevent refusal or discontinuation of tamoxifen treatment.

Involvement of the pituitary-specific transcription factor pit-1 in somatolactotrope cell growth and death: an approach using dominant-negative pit-1 mutants.

The anterior pituitary-specific transcription factor Pit-1 was initially identified and cloned as a transactivator of the prolactin (PRL) and GH genes and later as a regulator of the TSHb gene. It was found to be a major developmental regulator, because natural Pit-1 gene mutations cause a dwarf phenotype in mice and cause combined pituitary hormone deficiency associated with pituitary hypoplasia in humans. To further investigate the growth-promoting effects of Pit-1, we used a strategy based on the use of dominant-negative Pit-1 mutants as an alternative means of inactivating endogenous Pit-1 functions. R271W, a Pit-1 mutant identified in one allele in patients with severe combined pituitary hormone deficiency, and Pit-1Delta1-123, a deletion mutant in which only the DNA binding domain of Pit-1 is conserved, were generated, and their ability to abolish the effects of the endogenous native Pit-1 in the differentiated proliferating somatolactotrope GH4C1 cell line was investigated. Enforced expression of the dominant-negative mutants in GH4C1 cells using recombinant lentiviral vectors decreased the levels of expression of known Pit-1 target genes such as PRL and GH, abolished the hormone release, and reduced cell viability by decreasing the growth rate and inducing apoptosis via a caspase-independent pathway. These results show for the first time that the growth-promoting effects of Pit-1 are at least partly due to the fact that this transcription factor prevents apoptotic cell death.

Pitx factors are involved in basal and hormone-regulated activity of the human prolactin promoter.

The pituitary-specific POU homeodomain factor Pit-1 likely interacts with other factors for cell-specific expression of prolactin. Here we identify the paired-like homeobox transcription factors Pitx1 and Pitx2 as factors functionally activating the proximal human prolactin promoter (hPRL-164luc). Using in vitro binding assays and a series of site-specific mutations of the proximal hPRL promoter, we mapped the B1 and B2 bicoid sites involved in Pitx-mediated transactivation of the hPRL-164luc construct. In somatolactotroph GH4C1 cells, basal proximal hPRL promoter activity was inhibited by a Pitx2 dominant-negative form in a dose-dependent manner, whereas binding disruptive mutations in the Pitx sites significantly reduced basal activity of the promoter. We also show that synergistic activation of hPRL-164luc by Pitx2 and Pit-1 requires the integrity of the B2 Pitx binding site, and at least one of the P1 and P2 Pit-1 response elements. In addition, mutation in the B2 Pitx site results in attenuation of the promoter's responsiveness to forskolin, thyrotropin-releasing hormone, and epidermal growth factor. Conversely, Pitx1 or Pitx2 overexpression in GH4C1 cells leads to an enhancement of the drugs stimulatory effects. Altogether, these results suggest that full responsiveness to several signaling pathways regulating the hPRL promoter requires the B2 Pitx binding site and that Pitx factors may be part of the proteic complex involved in these regulations. Finally, in situ hybridization analysis showing coexpression of the PRL and Pitx2 genes in rat and human lactotroph cells corroborates the physiological relevance of these results.

Regulation of prolactin, GH, and Pit-1 gene expression in anterior pituitary by Pitx2: An approach using Pitx2 mutants.

The transcription factor Pitx2 is required for the morphogenesis of anterior structures such as the eye, teeth, and anterior pituitary. We investigated the functional properties of Pitx2 missense mutants previously reported in Axenfeld-Rieger syndrome, using reporter genes under the control of pituitary target gene [human (h)PRL, hGH, hPit-1] promoters transfected in nonpituitary and pituitary cell lines. The five mutants appeared to be transcriptionally defective despite conserved DNA-binding in CV1 cells. In addition, one mutation, R91P, almost completely blocked the wt-Pitx2-induced activation of the target promoters, prevented the Pitx2/Pit-1 synergistic activation of the hPRL promoter, and was able to counteract the Pitx1-driven transactivation effects. The dominant negative properties of this mutant were further established in cells endogenously expressing Pitx2 because transfection of R91P in GH4C1 somatolactotroph cells resulted in a dose-dependent inhibition of basal activities of the pituitary promoters. These results, which show that Pitx2 mutants are defective in activating pituitary target genes, confirm the critical role of this homeodomain factor in the differentiated functions of the pituitary somatolactotroph cells. Furthermore, these results might form the basis for future experiments because dominant negative forms of Pitx2 such as R91P might provide instructive tools to further delineate the detailed mechanisms mediating Pitx2 functions in cell proliferation and differentiation.