Integrative Clinical, Radiological, and Molecular Analysis for Predicting Remission and Recurrence of Cushing Disease.

CONTEXT: Adrenocorticotropin (ACTH)-secreting pituitary tumors (ACTHomas) are associated with severe comorbidities and increased mortality. Current treatments mainly focus on remission and prevention of persistent disease and recurrence. However, there are still no useful biomarkers to accurately predict the clinical outcome after surgery, long-term remission, or disease relapse. OBJECTIVES: This work aimed to identify clinical, biochemical, and molecular markers for predicting long-term clinical outcome and remission in ACTHomas. METHODS: A retrospective multicenter study was performed with 60 ACTHomas patients diagnosed between 2004 and 2018 with at least 2 years' follow-up. Clinical/biochemical variables were evaluated yearly. Molecular expression profile of the somatostatin/ghrelin/dopamine regulatory systems components and of key pituitary factors and proliferation markers were evaluated in tumor samples after the first surgery. RESULTS: Clinical variables including tumor size, time until diagnosis/first surgery, serum prolactin, and postsurgery cortisol levels were associated with tumor remission and relapsed disease. The molecular markers analyzed were distinctly expressed in ACTHomas, with some components (ie, SSTR1, CRHR1, and MKI67) showing instructive associations with recurrence and/or remission. Notably, an integrative model including selected clinical variables (tumor size/postsurgery serum cortisol), and molecular markers (SSTR1/CRHR1) can accurately predict the clinical evolution and remission of patients with ACTHomas, generating a receiver operating characteristic curve with an area under the curve of 1 (P < .001). CONCLUSION: This study demonstrates that the combination of a set of clinical and molecular biomarkers in ACTHomas is able to accurately predict the clinical evolution and remission of patients. Consequently, the postsurgery molecular profile represents a valuable tool for clinical evaluation and follow-up of patients with ACTHomas.

Catecholaminergic Crisis After a Bleeding Complication of COVID-19 Infection: A Case Report.

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) presents in some cases with hemostatic and thrombotic complications. Pheochromocytomas are unusual, though potentially lethal tumors. Herein we describe the first case of hemorrhage in a pheochromocytoma related to SARS-CoV-2 infection. A 62-year-old man consulted for syncope, fever, and palpitations. He was diagnosed with SARS-CoV-2 pneumonia and presented with a hemorrhage in a previously unknown adrenal mass, which resulted in a catecholaminergic crisis. Medical treatment and surgery were required for symptom control and stabilization. We hereby alert clinicians to watch for additional/unreported clinical manifestations in COVID-19 infection.

Statins Directly Regulate Pituitary Cell Function and Exert Antitumor Effects in Pituitary Tumors.

INTRODUCTION: Pituitary neuroendocrine tumors (PitNETs), the most abundant of all intracranial tumors, entail severe comorbidities. First-line therapy is transsphenoidal surgery, but subsequent pharmacological therapy is often required. Unfortunately, many patients are/become unresponsive to available drugs (somatostatin analogues [SSAs]/dopamine agonists), underscoring the need for new therapies. Statins are well-known drugs commonly prescribed to treat hyperlipidemia/cardiovascular diseases, but can convey additional beneficial effects, including antitumor actions. The direct effects of statins on normal human pituitary or PitNETs are poorly known. Thus, we aimed to explore the direct effects of statins, especially simvastatin, on key functional parameters in normal and tumoral pituitary cells, and to evaluate the combined effects of simvastatin with metformin (MF) or SSAs. METHODS: Effects of statins in cell proliferation/viability, hormone secretion, and signaling pathways were evaluated in normal pituitary cells from a primate model (Papio anubis), tumor cells from corticotropinomas, somatotropinomas, nonfunctioning pituitary tumors, and PitNET cell-lines (AtT20/GH3-cells). RESULTS: All statins decreased AtT20-cell proliferation, simvastatin showing stronger effects. Indeed, simvastatin reduced cell viability and/or hormone secretion in all PitNETs subtypes and cell-lines, and ACTH/GH/PRL/FSH/LH secretion (but not expression), in primate cell cultures, by modulating MAPK/PI3K/mTOR pathways and expression of key receptors (GH-releasing hormone-receptor/ghrelin-R/Kiss1-R) regulating pituitary function. Addition of MF or SSAs did not enhance simvastatin antitumor effects. CONCLUSION: Our data reveal direct antitumor effects of simvastatin on PitNET-cells, paving the way to explore these compounds as a possible tool to treat PitNETs.

Biguanides Exert Antitumoral Actions in Pituitary Tumor Cells Through AMPK-Dependent and -Independent Mechanisms.

CONTEXT: Pituitary neuroendocrine tumors (PitNETs) are a commonly underestimated pathology in terms of incidence and associated morbimortality. Currently, an appreciable subset of patients are resistant or poorly responsive to the main current medical treatments [i.e., synthetic somatostatin analogs (SSAs) and dopamine agonists]. Thus, development and optimization of novel and available medical therapies is necessary. Biguanides (metformin, buformin, and phenformin) are antidiabetic drugs that exert antitumoral actions in several tumor types, but their pharmacological effects on PitNETs are poorly known. OBJECTIVE: We aimed to explore the direct effects of biguanides on key functions (cell viability, hormone release, apoptosis, and signaling pathways) in primary cell cultures from human PitNETs and cell lines. Additionally, we evaluated the effect of combined metformin with SSAs on cell viability and hormone secretion. DESIGN: A total of 13 corticotropinomas, 13 somatotropinomas, 13 nonfunctioning PitNETs, 3 prolactinomas, and 2 tumoral pituitary cell lines (AtT-20 and GH3) were used to evaluate the direct effects of biguanides on cell viability, hormone release, apoptosis, and signaling pathways. RESULTS: Biguanides reduced cell viability in all PitNETs and cell lines (with phenformin being the most effective biguanide) and increased apoptosis in somatotropinomas. Moreover, buformin and phenformin, but not metformin, reduced hormone secretion in a cell type-specific manner. Combination metformin/SSA therapy did not increase SSA monotherapy effectiveness. Effects of biguanides on PitNETs could involve the modulation of AMP-activated protein kinase-dependent ([Ca2+]i, PI3K/Akt) and independent (MAPK) mechanisms. CONCLUSION: Altogether, our data unveil clear antitumoral effects of biguanides on PitNET cells, opening avenues to explore their potential as drugs to treat these pathologies.

Association between radiological parameters and clinical and molecular characteristics in human somatotropinomas.

Acromegaly is a rare but severe disease, originated in 95% of cases by a growth hormone-secreting adenoma (somatotropinoma) in the pituitary. Magnetic resonance imaging (MRI) is a non-invasive technique used for the diagnosis and prognosis of pituitary tumours. The aim of this study was to determine whether the use of T2-weighted signal intensity at MRI could help to improve the characterisation of somatotropinomas, by analysing its relationship with clinical/molecular features. An observational study was implemented in a cohort of 22 patients (mean age = 42.1 ± 17.2 years; 59% women; 95% size>10 mm). Suprasellar-extended somatotropinomas presented larger diameters vs. non-extended tumours. T2-imaging revealed that 59% of tumours were hyperintense and 41% isointense adenomas, wherein hyperintense were more invasive (according to Knosp-score) than isointense adenomas. A higher proportion of hyperintense somatotropinomas presented extrasellar-growth, suprasellar-growth and invasion of the cavernous sinus compared to isointense adenomas. Interestingly, somatostatin receptor-3 and dopamine receptor-5 (DRD5) expression levels were associated with extrasellar and/or suprasellar extension. Additionally, DRD5 was also higher in hyperintense adenomas and its expression was directly correlated with Knosp-score and with tumour diameter. Hence, T2-weighted MRI on somatotropinomas represents a potential tool to refine their diagnosis and prognosis, and could support the election of preoperative treatment, when required.

Variations in diabetes remission rates after bariatric surgery in Spanish adults according to the use of different diagnostic criteria for diabetes.

BACKGROUND: There are multiple criteria to define remission of type 2 diabetes (DM2) after bariatric surgery but there is not a specific one widely accepted. Our objectives were to compare diagnostic criteria for DM2 remission after bariatric surgery: Criteria from Spanish scientific associations (SEEN/SEEDO/SED) and from the American Diabetes Association (ADA). We also aim to analyse the degree of correlation between these sets of criteria. METHODS: Retrospective observational study in 127 patients undergoing bariatric surgery in a single centre (Hospital Universitario Reina Sofía, Córdoba, Spain) between January 2001 and December 2009. We analysed DM2 remission following bariatric surgery comparing DM2 diagnostic criteria approved by Spanish scientific associations and ADA criteria. RESULTS: In total, 62.2% of patients were women; mean age was 47.1 years. Following surgery, 52% achieved complete remission according to ADA criteria, and 63.8% following the criteria approved by Spanish associations (p = 0.001);18.9 and 8.7%, respectively, showed partial remission (p = 0.007), and 29.1 and 27.6% no remission, according to the criteria approved by each association (p = 0.003). There was good correlation between both sets of criteria (Rho 0.781; p < 0.001). CONCLUSIONS: In our series, using more stringent criteria for defining DM2 remission (ADA criteria) results in a lower rate of remission, although we found a a high degree of correlation between both sets of criteria.

Uso de la glutamina en la nutricion parenteral total de pacientes sometidos a trasplante de médula ósea / Use of glutamine in total parenteral nutrition of bone marrow transplant patients

La glutamina es un amioácido esencial para la síntesis de nucleótidos y una fuente de energía para la replicación celular, existe evidencia contradictoria respecto a los beneficios de su administración como parte de la nutrición parenteral en pacientes sometidos a trasplante de médula ósea (TMO). Más del 75% de los pacientes sometidos a trasplante de precursores hematopoyéticos, presentan durante su evolución complicaciones que comprometen el tracto digestivo, principalmente mucositis, limitando la ingesta oral, de allí la necesidad del uso de nutrición parenteral total (NPT) en estos casos. Objetivo: Analizar la relación entre uso de glutamina en la NPT de TMO y la evolución de complicaciones agudas como mucositis, EICH e infecciones, así como la estancia hospitalaria y los días de nutrición parenteral total. Material y métodos: Estudio observacional retrospectivo. Se incluyeron la totalidad de TMO con NPT entre 2007 y 2013 en nuestro hospital. Se analizaron días de hospitalización, días de soporte nutricional, uso de glutamina y complicaciones agudas. Los resultados se analizaron con el programa SPSS 15.0. Resultados: Se incluyeron 73 pacientes trasplantados, se dividieron en dos grupos según el aporte de glutamina siendo ambos grupos comparables entre sí. La edad media fue de 36,96±12,89 años. El 47,9% de los pacientes estudiados recibió suplemento de glutamina en la NPT. Los pacientes que recibieron glutamina tuvieron una estancia media de 31,49±7,41 días con 14,11±5,87 días de NPT en comparación a los que no recibieron glutamina con 32,16±7,99 y 15,50±7,71 días respectivamente (p=0,71 y 0,39). La duración de la mucositis en los pacientes que recibieron glutamina fue de 12,23±5,66 días comparado con 15,50±7,71 días en los que no recibieron glutamina (p=0,042).Se observaron grados severos de EICH (II, III) en un 20,6% de los pacientes sin glutamina en comparación al 13,7% en los que la recibieron (p=0,636). Del total de los de los pacientes estudiados, el 13,7% sufrieron complicaciones infecciosas mientras recibían NPT con glutamina, comparado con 16,4% en pacientes que no recibieron (p=0,700). Conclusiones: En nuestra serie, se observó una reducción estadísticamente significativa en la duración de la mucositis en pacientes que recibieron NPT con glutamina

Glutamine is an essential amino acid for nucleotide synthesis and an important energy resource for cellular division. There is contradictory evidence about its benefits as part of parenteral nutrition. More than 75% of bone marrow transplant patients (BMTP) have, during their evolution, digestive tract complications limiting enteral nutrition, for this reason, sometimes total parenteral nutrition (TPN) is required. Objective: Our aim was to analyze the relation between the use of glutamine in TPN of BMTP, and the evolution of clinical acute complications as mucositis, graft versus host disease (GVHD) and infections days of stay and days of TPN. Materials and Methods: observational retrospective study. All BMTP with total parenteral nutrition during the period 2007-2013 were included. We analyzed days of stay, days of nutrition, glutamine use and acute complications. Results were analyzed in SPSS 15.0. Results: 73 BMTP were divided in two comparable groups depending on glutamine use. The mean age was 36,96 ± 12,89 years. 47,9% of patients received glutamine in TPN. Patients who received glutamine had a mean stay of 31,49±7,41 days with 14,11±5,87 days of TPN compared with the non-glutamine group with 32,16±7,99 and 15,50±7,71 days respectively (p=0,71 y 0,39). Mucositis lasted 12,23±5,66 days in the glutamine group, and 15,50±7,71 days in the non-glutamine group (p=0,042). Severe grades of GVHD (II,III) was observed in 20,6% of the non glutamine group compared with the 13,7% of the other group (p=0,636). In patients with glutamine suplementation, mucositis last 12,23±5,66 days compared with 15,50±7,71 days in the non-glutamine group (p=0,042).13,7% of all patients suffered infections while receiving TPN with glutamine compared with 16,4% in patients who did not receive glutamine (p=0,700). Conclusion: In our group, a statistically significant reduction in the duration of mucositis was observed in patients who received parenteral glutamine

[Use of glutamine in total parenteral nutrition of bone marrow transplant patients]. / Uso de la glutamina en la nutricion parenteral total de pacientes sometidos a trasplante de médula ósea.

UNLABELLED: Glutamine is an essential amino acid for nucleotide synthesis and an important energy resource for cellular division. There is contradictory evidence about its benefits as part of parenteral nutrition. More than 75% of bone marrow transplant patients (BMTP) have, during their evolution, digestive tract complications limiting enteral nutrition, for this reason, sometimes total parenteral nutrition (TPN) is required. OBJECTIVE: Our aim was to analyze the relation between the use of glutamine in TPN of BMTP, and the evolution of clinical acute complications as mucositis, graft versus host disease (GVHD) and infections days of stay and days of TPN. MATERIALS AND METHODS: observational retrospective study. All BMTP with total parenteral nutrition during the period 2007-2013 were included. We analyzed days of stay, days of nutrition, glutamine use and acute complications. Results were analyzed in SPSS 15.0. RESULTS: 73 BMTP were divided in two comparable groups depending on glutamine use. The mean age was 36,96 ± 12,89 years. 47,9% of patients received glutamine in TPN. Patients who received glutamine had a mean stay of 31,49±7,41 days with 14,11±5,87 days of TPN compared with the non-glutamine group with 32,16±7,99 and 15,50±7,71 days respectively (p=0,71 y 0,39). Mucositis lasted 12,23±5,66 days in the glutamine group, and 15,50±7,71 days in the non-glutamine group (p=0,042). Severe grades of GVHD (II,III) was observed in 20,6% of the non glutamine group compared with the 13,7% of the other group (p=0,636). In patients with glutamine suplementation, mucositis last 12,23±5,66 days compared with 15,50±7,71 days in the non-glutamine group (p=0,042).13,7% of all patients suffered infections while receiving TPN with glutamine compared with 16,4% in patients who did not receive glutamine (p=0,700). CONCLUSION: In our group, a statistically significant reduction in the duration of mucositis was observed in patients who received parenteral glutamine.

La glutamina es un amioácido esencial para la síntesis de nucleótidos y una fuente de energía para la replicación celular, existe evidencia contradictoria respecto a los beneficios de su administración como parte de la nutrición parenteral en pacientes sometidos a trasplante de médula ósea (TMO). Más del 75% de los pacientes sometidos a trasplante de precursores hematopoyéticos, presentan durante su evolución complicaciones que comprometen el tracto digestivo, principalmente mucositis, limitando la ingesta oral, de allí la necesidad del uso de nutrición parenteral total (NPT) en estos casos. Objetivo: Analizar la relación entre uso de glutamina en la NPT de TMO y la evolución de complicaciones agudas como mucositis, EICH e infecciones, así como la estancia hospitalaria y los días de nutrición parenteral total. Material y métodos: Estudio observacional retrospectivo. Se incluyeron la totalidad de TMO con NPT entre 2007 y 2013 en nuestro hospital. Se analizaron días de hospitalización, días de soporte nutricional, uso de glutamina y complicaciones agudas. Los resultados se analizaron con el programa SPSS 15.0. Resultados: Se incluyeron 73 pacientes trasplantados, se dividieron en dos grupos según el aporte de glutamina siendo ambos grupos comparables entre sí. La edad media fue de 36,96±12,89 años. El 47,9% de los pacientes estudiados recibió suplemento de glutamina en la NPT. Los pacientes que recibieron glutamina tuvieron una estancia media de 31,49±7,41 días con 14,11±5,87 días de NPT en comparación a los que no recibieron glutamina con 32,16±7,99 y 15,50±7,71 días respectivamente (p=0,71 y 0,39). La duración de la mucositis en los pacientes que recibieron glutamina fue de 12,23±5,66 días comparado con 15,50±7,71 días en los que no recibieron glutamina (p=0,042).Se observaron grados severos de EICH (II, III) en un 20,6% de los pacientes sin glutamina en comparación al 13,7% en los que la recibieron (p=0,636). . Del total de los pacientes estudiados, el 13,7% sufrieron complicaciones infecciosas mientras recibían NPT con glutamina, comparado con 16,4% en pacientes que no recibieron (p=0,700).Conclusiones: En nuestra serie, se observó una reducción estadísticamente significativa en la duración de la mucositis en pacientes que recibieron NPT con glutamina.