Long-term remission and recurrence rates after first and second transsphenoidal surgery for Cushing's disease: care reality in the Munich Metropolitan Region.

OBJECTIVE: Transsphenoidal surgery (TSS) presents the treatment of choice for Cushing's disease (CD). Remission and recurrence rates vary dependent on tumor size, extension, adenoma visibility on magnetic resonance imaging, and neurosurgical expertise. Other than published from single-surgeon neurosurgical series so far, we have aimed to describe long-term remission and recurrence rates of CD in a series incorporating different neurosurgeons, trying to reflect care reality in the Munich Metropolitan Region, which is accommodated by three tertiary university and multiple, smaller neurosurgical centers. DESIGN: We conducted a retrospective analysis of 120 patients who underwent first and 36 patients who underwent second TSS as treatment for CD between 1990 and 2012. METHODS: Patients were divided into three groups according to remission status. Potential risk factors for recurrence, pituitary function, and strategy in persistent disease were assessed. RESULTS: THREE OUTCOME GROUPS WERE IDENTIFIED ACCORDING TO REMISSION STATUS AFTER FIRST TSS (MEAN FOLLOW-UP 79 MONTHS): remission, 71% (85/120), disease persistence, 29% (35/120), and disease recurrence, 34% (29/85) (mean time to recurrence 54 months). After second TSS (n=36, mean follow-up 62 months), we documented remission in 42% (15/36), disease persistence in 58% (21/36), and disease recurrence in 40% (6/15) (mean time to recurrence 42 months). Postoperative hypocortisolism after first, though not after second, TSS was associated with a lower risk of suffering disease recurrence (risk=0.72; 95% CI 0.60-0.88; exact significance (two-sided) P=0.035). CONCLUSIONS: Our study shows higher recurrence rates of CD after first TSS than previously reported. Second TSS leads an additional 8% of the patients to long-term CD remission.

An unusual case of ectopic ACTH syndrome.

Ectopic ACTH-syndrome is a rare cause of Cushing's disease. Despite extensive diagnostic procedures the source of ACTH secretion often remains occult. This case describes a 45-year old woman with an ectopic Cushing's syndrome. Extensive imaging procedures including CT scan of chest and abdomen, octreotide scan and MRI of the chest and pituitary did not reveal the source of ACTH secretion. In consideration of an occult source of ACTH secretion we started a therapeutic trial with cabergoline (0.5 mg/d), a dopamine receptor agonist, which has been shown to be effective in ectopic Cushing's syndrome. 2 months after cabergoline treatment had been initiated, ACTH and cortisol levels normalized in association with significant improvement of the clinical symptoms. During follow-up a [(68)Ga-DOTA-dPhe(1), Tyr(3)]-octreotate ([(68)Ga-DOTA]-TATE) PET-CT was performed revealing a somatostatin receptor positive lesion in the right sphenoidal sinus suggesting the source of ACTH secretion. The patient was cured by transnasal resection of the polypoid lesion, which was immunohistochemically characterized as an ACTH-positive neuroendocrine tumor. This case report demonstrates the management of ectopic ACTH-syndrome by molecularly -targeted therapy with dopamine receptor -agonists as well as improved detection of the ectopic ACTH source by novel imaging modalities, such as [(68)Ga-DOTA]-TATE PET specifically targeting somatostatin receptor subtype-2 with high affinity.

Curcumin acts as anti-tumorigenic and hormone-suppressive agent in murine and human pituitary tumour cells in vitro and in vivo.

Curcumin (diferuloylmethane) is the active ingredient of the spice plant Curcuma longa and has been shown to act anti-tumorigenic in different types of tumours. Therefore, we have studied its effect in pituitary tumour cell lines and adenomas. Proliferation of lactosomatotroph GH3 and somatotroph MtT/S rat pituitary cells as well as of corticotroph AtT20 mouse pituitary cells was inhibited by curcumin in monolayer cell culture and in colony formation assay in soft agar. Fluorescence-activated cell sorting (FACS) analysis demonstrated curcumin-induced cell cycle arrest at G2/M. Analysis of cell cycle proteins by immunoblotting showed reduction in cyclin D(1), cyclin-dependent kinase 4 and no change in p27(kip). FACS analysis with Annexin V-FITC/7-aminoactinomycin D staining demonstrated curcumin-induced early apoptosis after 3, 6, 12 and 24 h treatment and nearly no necrosis. Induction of DNA fragmentation, reduction of Bcl-2 and enhancement of cleaved caspase-3 further confirmed induction of apoptosis by curcumin. Growth of GH3 tumours in athymic nude mice was suppressed by curcumin in vivo. In endocrine pituitary tumour cell lines, GH, ACTH and prolactin production were inhibited by curcumin. Studies in 25 human pituitary adenoma cell cultures have confirmed the anti-tumorigenic and hormone-suppressive effects of curcumin. Altogether, the results described in this report suggest this natural compound as a good candidate for therapeutic use on pituitary tumours.

Serial stereotactic biopsy of brainstem lesions in adults improves diagnostic accuracy compared with MRI only.

OBJECTIVE: The aim of the current prospective study was to analyse the validity of MRI based diagnosis of brainstem gliomas which was verified by stereotactic biopsy and follow-up evaluation as well as to assess prognostic factors and risk profile. METHODS: Between 1998 and 2007, all consecutive adult patients with radiologically suspected brainstem glioma were included. The MRI based diagnosis of the lesions was made independently by an experienced neuroradiologist. Histopathological evaluation was performed in all patients from paraffin embedded specimens obtained by multimodal image guided stereotactic serial biopsy technique. Histopathological results were compared with prior radiological assessment. Length of survival was estimated with the Kaplan-Meier method and prognostic factors were calculated using the Cox model. RESULTS: 46 adult patients were included. Histological evaluation revealed pilocytic astrocytoma (n = 2), WHO grade II glioma (n = 14), malignant glioma (n = 12), metastasis (n = 7), lymphoma (n = 5), cavernoma (n = 1), inflammatory disease (n = 2) or no tumour/gliosis (n = 3). Perioperative morbidity was 2.5% (n = 1). There was no permanent morbidity and no mortality. All patients with "no tumour" or "inflammatory disease" survived. Patients with low grade glioma and malignant glioma showed a 1 year survival rate of 75% and 25%, respectively; the 1 year survival rate for patients with lymphoma or metastasis was 30%. In the subgroup with a verified brainstem glioma, negative predictors for length of survival were higher tumour grade (p = 0.002) and Karnofsky performance score < or =70 (p = 0.004). CONCLUSION: Intra-axial brainstem lesions with a radiological pattern of glioma represent a very heterogeneous tumour group with completely different outcomes. Radiological features alone are not reliable for diagnostic classification. Stereotactic biopsy is a safe method to obtain a valid tissue diagnosis, which is indispensible for treatment decision.

The positive predictive value of O-(2-[18F]fluoroethyl)-L-tyrosine (FET) PET in the diagnosis of a glioma recurrence after multimodal treatment.

OBJECTIVE: To explore prospectively the positive predictive value of O-(2-[(18)F]fluoroethyl)-L-tyrosine (FET)-PET in selected patients with a magnetic resonance imaging (MRI)-based suspicion of a glioma recurrence or progression. Methods Patients with a supratentorial glioma (initial World Health Organization (WHO) grade II, III or IV) were considered eligible if they had both an MRI-(new/progressive contrast-enhancing lesion) and FET-PET-based diagnosis of a recurrence/progression after various forms and combinations of irradiation and chemotherapy. Criterion for tumour recurrence/progression in FET-PET was a standardized uptake value (SUVmax)/Background (BG) ratio of >2.0 in the late uptake phase. All patients underwent multimodal (MRI, FET-PET) imaging-guided stereotactic biopsy. The positive predictive value was defined as the proportion of MRI and FET-PET findings indicating glioma recurrence/progression that also tested positive for tumour recurrence/progression after stereotactic biopsy. RESULTS: Thirty-one patients with initially WHO grade II (17), WHO grade III (6), and grade IV glioma (8) were included. In 26 patients FET-PET results indicating tumour recurrence/progression were concordant with the biopsy results. In five patients histopathologic evaluation failed to reveal a "vital" tumour. FET-PET findings were also discordant with the radiographic and clinical follow-up in these five patients. The positive predictive value of FET-PET was 84%. CONCLUSION: The positive predictive value of FET-PET using the standard ratio method is high, but not high enough to replace stereotactic biopsy in this highly selected study cohort. Whether the calculation of FET uptake in the early phase and/or the evaluation of uptake kinetics will improve the positive predictive value of FET-PET deserves prospective evaluation.

Oedema formation in experimental photo-irradiation therapy of brain tumours using 5-ALA.

BACKGROUND: Five-aminolevulinic acid (5-ALA) induces the specific accumulation of photosensitising porphyrins in malignant gliomas and has been explored for photo-irradiation therapy of these tumours. However, information is unavailable on whether and to what extent this treatment modality may induce the formation of brain oedema, and how potential oedema might be treated. METHODS: Rats were implanted with C6 gliomas. Eight days later magnetic resonance images (MRI) were obtained. On day 9 rats received 100 mg 5-ALA/kg b.w. and were craniotomized for photo-irradiation of tumours 6 hours later (100 J/cm2, 635 nm argon-dye laser). Part of the animals was treated with daily dexamethasone injections (0.3 mg/kg), beginning 6 hours before phototherapy. 72 hours later, brains were removed and dissected according to tumour dimensions on pre-therapy MRI into "tumour", "brain around tumour" (BAT), residual cortex and basal ganglia, for measurements of water contents. Measurements were also performed in untreated animals with tumours, with or without steroid treatment and in control animals. An additional group of animals lacking tumours, with or without steroid treatment, underwent 5-ALA-phototherapy to determine effects on normal brain. RESULTS: C6 gliomas induced brain oedema, which responded to steroid treatment. 5-ALA-phototherapy resulted in additional oedema, which responded partly to steroids. 5-ALA-phototherapy of normal brain increased water content moderately in irradiated cortex. This oedema was also partly counteracted by steroids. CONCLUSIONS: Photo-irradiation therapy with 5-ALA induces oedema which is partly counteracted by steroid therapy. The possibility of steroid resistant oedema formation should be considered when planning human trials with this treatment modality.

Intralesional radioimmunotherapy in the treatment of malignant glioma: clinical and experimental findings.

In the last two decades radioimmunotherapy has been used as an additional treatment option for malignant glioma in several centers. More than 400 patients have been reported, who were treated in the framework of different studies. Most of them received labelled antibodies to tenascin, an extracellular matrix-glycoprotein, which is expressed in high amounts in malignant gliomas. We report side effects and survival time of 46 patients, treated after surgical resection and conventional radiotherapy with intralesionally injected labelled (131-Iodine) antibodies to tenascin. Despite the fact, that many treatments have been performed, little is known about the distribution properties of labelled antibodies after injection in the tumour cavity. For an optimal effect labelled antibodies should be able to reach tumour cells, which have migrated into the surrounding tissue. We investigated the propagation velocity and area of distribution of labelled antibodies and their considerably smaller fragments after the injection in C6-gliomas of Wistar rats. Propagation increased with time and was significantly greater after injection of labelled fragments than after injection of labelled antibodies. According to our results labelled fragments might be better able to reach distant tumour cells in the peritumoural tissue of malignant gliomas than labelled antibodies.

The effect on the ultrastructure of dental enamel of excimer-dye, argon-ion and CO2 lasers.

This study aimed to investigate the ultrastructural changes that occur in dental enamel irradiated with pulsed excimer-dye, continuous-wave (CW) argon-ion and CW CO2 lasers. The pulsed excimer-dye laser produced deep craters, rough damaged surfaces with underlying porosity and amorphous vitrified material. The vitrification of the enamel indicated that the temperature in these areas must have been at least in the range 1280 to 1600 degrees C. The CW argon-ion laser irradiation produced a changed non-cratered surface with inter-crystalline porosity and a mixture of small and some large irregularly packed recrystallized enamel crystals. The CW CO2 laser produced shallow craters, surface crazing and lifting off the removal of the surface layer to expose the underlying roughened enamel. The ultrastructure revealed inter- and intra-crystalline porosity, a mixture of small but variable size irregularly packed recrystallized enamel crystals and also well packed large crystals which indicated further grain growth. The porosity in lased enamel was overall very similar to that seen in enamel heated in an electric furnace to a temperature of 600 degrees C. The presence of recrystallized enamel crystals indicated a temperature rise of approximately 1000 degrees C and the grain growth indicated that a temperature > or = 1000 degrees C existed for some time after the laser irradiation. In general the excimer-dye laser produced most surface destruction because of its higher power density and shorter interaction time and the argon-ion laser produced least damage. These results indicated that the lasers used in this study require much more refinement before they can find therapeutic application to dental enamel, and this may well be the case for other lasers being investigated for clinical dental practise.

Ultrastructure of spindles and tufts in human dental enamel.

A transmission electron microscope (TEM) study was made of spindles and tufts as identified in the light microscope, from samples prepared by selected-area argon-ion-beam thinning. Spindles in human dental enamel were found to be continuous with dentinal tubules across the dentin-enamel junction (DEJ) and usually appeared at the DEJ as electron-lucent, empty channels nearly circular in cross-section. The spindles were found to cross prism boundaries, branched rarely, and some were occasionally found to be occluded or partially occluded with small needle-like crystals (approximately 5 nm width and approximately 70 nm length), granular material (approximately 1.5 nm diameter) and/or amorphous material. Near the DEJ, the majority of spindles had a diameter less than 2 microns, while in the prismatic enamel away from the DEJ, spindles with a diameter greater than 2 microns were generally found. Spindle varicosity was characterized by an enlargement of their diameter. Tufts started at the DEJ and were not associated with dentinal tubules. Two types of ultrastructure were observed in the TEM: (i) disrupted regions of enamel incorporating large voids (up to approximately 0.1 microns in diameter), or, more commonly, (ii) channels within the enamel occluded or partially occluded, with small needle-like crystals and granular and/or amorphous material similar to that found in the enamel spindles. It was concluded that spindles and tufts represent areas of hypomineralization with increased void volume and partial remineralization.

Effects of continuous-wave CO2 laser on the ultrastructure of human dental enamel.

Laser-induced changes in plano-parallel sections were examined by light microscopy (LM) and scanning electron microscopy (SEM), and correlated with ultrastructural changes as observed by transmission electron microscopy (TEM). LM and SEM revealed two different changes--extensive crazing, and crazing and cratering. Rough exposed enamel was commonly found, resulting from lifting off and removal of the top layer of crazed, or crazed and cratered, enamel. The type of induced change was mainly dependent on the energy density used (range approximately 0.8 to approximately 200 J cm-2) and on enamel prism orientation. Lased enamel was also softer than unlased enamel. TEM of both crazed enamel and rough exposed enamel revealed that most crystals generally resembled those of unlased enamel in size and shape, but that inter- and intra-crystalline voids were present in some areas. The crazed and cratered enamel had significant ultrastructural changes: new homogeneous and inhomogeneous crystals of apatite with a different shape and larger size than those of the original, and a loss of prismatic structure. The lack of uniformity of the laser effect on crazed and cratered enamel was shown by variation in crystal packing (from good to poor), variations in crystal size from area to area, and the presence of pockets of poorly packed homogeneous crystals alongside pockets of well-packed inhomogeneous crystals. The crazing, crazing and cratering, rough exposed enamel and the greater number of voids, as well as the relative softness of lased enamel do not indicate an overall ultrastructural improvement. However, the larger apatite crystal size and loss of prismatic structure in crazed and cratered areas may partly explain previous observations of reduced rates of subsurface demineralization in lased enamel.

Electron microscopic investigation relating the occlusal morphology to the underlying enamel structure of molar teeth of the wombat (Vombatus ursinus).

This investigation relates the occlusal morphology of the continuously growing molars of common wombats (Vombatus ursinus) to the underlying enamel ultrastructure that was investigated using the techniques of light microscopy, scanning electron microscopy, and transmission electron microscopy. The main feature of the occlusal enamel was a prominent ridge, which followed the contour of the dentine-enamel junction (DEJ). It was found that the occlusal morphology depended upon the orientation of the dentinal and enamel tissues, variations in prism orientation, Hunter-Schreger bands (HSB), and presence or absence of cleavage. Cleavage of enamel promoted by sheets of parallel prisms occurred along the face between the DEJ and the ridge, whereas on the face between the ridge and the cementum-enamel junction (CEJ) cleavage was inhibited by HSB. The slope of the latter face was mainly due to a decrease in wear resistance going from the ridge, where prisms were intercepted transversely, toward the CEJ, where they were intercepted obliquely. Occasionally small surface undulations were observed on the face between the ridge and the CEJ. These undulations were found to correspond to gradually decussating enamel regions. The pronounced cleavage of enamel parallel to the face between the DEJ and the ridge played an important role in conferring on the continuously growing molars a distinct property to develop and maintain a self-sharpening ridge throughout the life of the tooth.

The ultrastructure of human dental enamel heat-treated in the temperature range 200 degrees C to 600 degrees C.

Heating enamel in the temperature range 200 degrees C to 600 degrees C resulted in poor crystal packing due to void formation, permanent change in the sign of its birefringence (from negative to positive) in some areas, and an altered crystal morphology. Transmission electron microscopy of enamel heated in the temperature range 200 degrees C to 400 degrees C revealed that the distinction between the positively birefringent regions and the negatively birefringent regions (which were present up to 350 degrees C and occasionally up to 400 degrees C) at the tooth's surface was due to the greater volume of intra- and inter-crystalline voids within the positively birefringent regions. There was a significant increase in void volume at 400 degrees C, and above this all of the enamel was positively birefringent and opaque. Large remineralized crystals of beta-tricalcium phosphate (beta-TCP) phase (whitlockite) were initially formed at 400 degrees C, and their size and number increased at 500 degrees C and above. Both the greater solubility of beta-TCP crystals and the increased surface area due to the presence of voids would increase the rate of demineralization of heat-treated enamel.

Laminated zones in carious human dental enamel.

Laminated zones within the body of carious lesions were studied by polarized light microscopy and transmission electron microscopy. Areas from within and surrounding the laminated zones, precisely selected using light microscopy, were argon-ion-beam thinned and examined by transmission electron microscopy. Laminated zones were present in approximately 7% of the samples studied. Polarized light microscopy showed variation in mineralization from zone to zone and the enamel surrounding the zones in the body of the lesion. Laminated zones whose central region showed approximately 1% of space when examined in air and whose boundaries showed approximately 2-4% of space when imbibed in quinoline were selected for ultrastructural studies. Electron microscopy showed the laminated zone to be less demineralized than the surrounding enamel in the body of the lesion. The ultrastructure of their central regions was similar to healthy enamel but their boundaries showed demineralization which increased into the body of the lesion. Within the central region of lamination there was greater evidence of resistance to demineralization rather than the presence of remineralization.

Ultrastructure of the intact surface zone of white spot and brown spot carious lesions in human enamel.

Electron microscopy of the intact surface zone of white spot and brown spot carious lesions showed that in general their ultrastructure was similar. Their outermost crystalline surface consisted of small crystals similar to those in healthy enamel, crystals with central core dissolution, and rounded crystals. Below this, surface demineralization of enamel was observed as the enlargement of micropores, the central core dissolution of crystals, the formation of channels and the enlargement of spaces at prism boundaries. Remineralization of enamel was observed as the partial occlusion of voids, the rounding and enlargement of crystals, and some new needle-shaped crystals. Some other features indicated combined demineralization and remineralization. The occlusion of spaces at prism boundaries was a more common feature in brown spot lesions, whereas the pockets of rounded crystals were more common in white spot lesions. A relatively uniform distribution of needle-shaped crystals throughout the intact surface zone was a feature of some brown spot lesions only.

On the nature of the opaque and translucent enamel regions of some macropodinae (Macropus giganteus, Wallabia bicolor and Peradorcas concinna).

Teeth of three macropod species, M. giganteus, W. bicolor and P. concinna, have been studied using the techniques of light microscopy, scanning- and transmission-electron microscopy and hardness measurement. Light microscope observations showed that the teeth of these species had a translucent enamel region close to the dentine and an outer opaque enamel region at the tooth's surface. These regions were not related to the presence or absence of tubules which are a characteristic feature of marsupial enamel. Hardness tests showed that the opaque enamel was softer than the translucent enamel. Scanning electron microscope observations revealed that there was no correlation between any particular prism packing or orientation and the opaque and translucent enamel regions. Transmission electron microscope observations showed that the translucent enamel region consisted of well defined prisms and well packed, lath-like crystals, whereas the opaque enamel was disrupted by voids (which ranged in size from enlarged micropores to about 2 microns in diameter in extreme cases) between crystals and some randomly oriented, loosely packed crystals. This disruption within the opaque enamel region was more common at prism boundaries but pockets of disrupted enamel were also found within prisms and interprismatic regions. The opacity of the enamel was caused by scattering of light from the voids. The ultrastructure of the opaque enamel region indicated that this region was hypomineralized; hardness tests and polarized light microscope observations were consistent with these results.

Electron-microscope study of the dentine-enamel junction of kangaroo (Macropus giganteus) teeth using selected-area argon-ion-beam thinning.

Transmission electron microscopy of selected-area argon-ion-beam thinned kangaroo (Macropus giganteus) enamel revealed a complex ultrastructure in the region of the dentine-enamel junction (DEJ). Characteristic features were multiple branching of dentinal tubules, rejoining of enamel tubules, elongated defects, extended protrusions of dentine into enamel, two types (A and B) of hypomineralized enamel and a continuity between dentinal and enamel tubules. In the intertubular regions of the DEJ a complex intermingling of finer enamel and dentine crystals, similar to that found in human enamel, was observed. The varicosities observed in the light microscope were a combined optical effect caused by the hypomineralized (type A) enamel and the branching and rejoining of the enamel tubules.

Ultrastructural changes in the translucent and dark zones of early enamel caries.

Selected areas of early enamel caries ('White spot' lesion) in human teeth were argon-ion-beam thinned and examined by transmission electron microscopy. A systematic examination of areas which were histologically defined as the translucent zone and the dark zone showed that the pattern of early caries was consistent with that of demineralization of the tissue commencing with a widening of the micropores and of the inter-rod spaces and gradually progressing to a severe destruction of the original enamel crystals, with possibly some remineralization. Observations indicate that the intercrystalline micropores and inter-rod spaces are the pathways by which acidic agents reach the crystals causing carious dissolution.