Contemporary radiologic imaging of renal cortical tumors.

Contemporary radiologic imaging has resulted in an increasing number of smaller renal cortical tumors being identified. The ability of imaging to classify these tumors is limited, although certain features may help classify the renal cortical neoplasm. The important role of radiologic imaging in tumor detection, characterization, staging, and follow-up of patients who have renal cortical tumors is reviewed in this article.

[A case of GH and TSH secreting pituitary macroadenoma]. / Przypadek makrogruczolaka przysadki wydzielacego hormon wzrostu i tyreotropin.

A case of GH and TSH secreting pituitary macroadenoma is reported. A 45-year-old female presented clinical features of acromegaly (the abnormal growth of the hands and feet, with lower jaw protrusion), diabetes mellitus, hypertension, nodular goiter and hyperthyroidism of unclear origin. NMR pituitary imaging revealed intra and extrasellar tumor. The laboratory examinations showed very high plasma levels of GH and IGF-1 and normal level of TSH coexisting with high plasma levels of free thyroid hormones. Pharmacological pretreatment with somatostatin analogues caused the substantial reduction of GH and TSH plasma levels. Histological and immunohistochemical examination of the tissue obtained at transsphenoidal surgery showed GH and TSH secreting adenoma. The laboratory examinations after surgery showed normal GH and IGF-1 plasma levels and reduced insulin requirement, what indicates radical operation. The very low plasma levels of TSH and free thyroid hormones after surgery and immunohistochemical examination suggest central hyperthyroidism due to TSH secreting pituitary tumor (thyrotropinoma).

Single-dose metyrapone test: review of a four-year experience.

Subnormal plasma 11-deoxycortisol (compound S) responses to metyrapone were found in patients with adrenal insufficiency or with Cushing syndrome caused by adrenal tumors and in those receiving long-term glucocorticoid or diphenylhydantoin sodium therapy. High normal or exaggerated responses were seen in women receiving oral contraceptives, patients with Cushing syndrome caused by adrenal hyperplasia, and those with untreated hypothyroidism. Diabetes mellitus, hypoglycemia, congestive failure, and obesity also were associated with exaggerated responses. Subnormal plasma S responses were observed in 15 patients who responded normally to a repeat test or to the standard metyrapone test. The abnormal response resulted from insufficient metyrapone, administration at the wrong time, or delay in obtaining the blood sample. The single-dose metyrapone test may be the procedure of choice in screening for adrenal insufficiency.

Pituitary apoplexy following chlorpromazine stimulation.

Chlorpromazine is frequently administered to patients with hyperprolactinemia to stimulate an increase in the serum levels of prolactin. A patient with a prolactin secreting adenoma is described in whom pituitary apoplexy developed in association with a hypotensive episode following the administration of 25 mg of chlorpromazine. Prolactin levels fell from more than 2,000 ng/ml to 340 ng/ml following infarction of the pituitary tumor. Pituitary apoplexy should be considered as a rare complication of chlorpromazine stimulation in a patient with a pituitary tumor.

Abnormal sella turcica. A tumor board review of the clinical significance.

Sixty of 146 patients with intracranial neoplasms or arterial aneurysms had roentgenographic abnormalities of the sella turcica. These abnormalities were most commonly due to chromophobe adenoma, craniopharygioma, and acromegaly, but ten of them were caused by lesions arising distant to the sella. There were also three cases of empty sella syndrome. Headache, visual disturbance, and sexual dysfunction were the most frequent presenting complaints, with visual field abnormality being most common. Pituitary dysfunction was manifested most frequently by alterations in growth hormone level and gonadotrophin secretion and less frequently by hypothyroidism and adrenocortical insufficiency. When the abnormal sella was associated with evidence of symptomatic intracranial disease, endocrine dysfunction, or visual field compromise as evidence of an anatomically aggressive intracranial neoplasm, specialized neuroroentgenographic localizing procedures were usually positive, and treatment for most of the causative lesions was highly effective.

[The strange case of a patient affected by acromegaly with osteoporomalacia without hypogonadism]. / Lo strano caso di un paziente affetto da acromegalia con osteoporomalacia senza ipogonadismo.

Acromegaly is a rare disease that, in the majority of cases, is due to the presence of a benign growth hormone (GH)-producing tumor of the pituitary. Growth hormone has profound effects on linear bone growth, bone metabolism, and bone mass. In acromegaly, the skeletal effects of chronic GH excess have been mainly addressed by evaluating bone mineral density (BMD). Most data were obtained in patients with active acromegaly, and apparently high or normal BMD was observed in the absence of hypogonadism. The Autors describe a case of patient affected by acromegaly without hypogonadism with serious osteoporosis and biological signs of osteomalacia.

Asymptomatic enlargement of the sella turcica.

Forty-six patients with enlarged sella turcica and pneumographic evidence of an intrasellar mass were initially untreated. The courses were variable, and 50% did not require subsequent treatment. All patients with initial visual involvement developed progressive visual impairment. Of patients with clinical evidence of pituitary insufficiency, 66% developed visual field defects and required treatment. Only one patient, whose sole symptom was headache, was subsequently treated, and no asymptomatic patient developed subsequent symptoms and required treatment. Asymptomatic patients with an enlarged sella turcica should have an air study to exclude an "empty sella" syndrome or primary hypothyroidism.

Immunostaining of growth hormone and prolactin in paraffin-embedded and stored or previously stained materials.

In attempts to evaluate immunocytochemically autopsy and biopsy material previously obtained and processed for conventional histologic staining, we had to resort to immunostaining of tissues embedded years ago or even sections already stained with hematoxylin-eosin or aldehyde thionin-PAS-orange G. Hypophysial growth hormone and prolactin proved remarkably resistant to such prior treatment with regard to their antigenic properties, and could be readily immunostained in tissue embedded in paraffin 3-4 years earlier, and after destaining of sections prepared up to 7 years earlier. The results of such "retrospective" immunocytochemical evaluation of autopsy and biopsy materail is illustrated with the staining of "pregnancy cells" for prolactin in the hypophysis of a woman postpartum, the immunostaining for prolactin in the cells of adenomas associated with marked hyperprolactinemia, the staining for growth hormone in adenomas removed from children with gigantism, and the immunostaining for prolactin, growth hormone or both in several adenomas that were discovered at autopsy and not associated with a known clinical history of endocrine aberrations.

Suprasellar tumors and incidental optic disc anomalies. Diagnostic problems in two patients with hemianopic temporal scotomas.

Anomalous optic discs may be associated with relative temporal visual field defects that need to be distinguished from bitemporal field defects of chiasmal compression. Two patients with both anomalous discs and suprasellar tumors were hospitalized with temporal hemianopic scotomatous visual field defects. A 19-year-old woman with a chromophobe adenoma had a monocular temporal hemianopic scotoma in the eye exhibiting an inferior-nasal disc crescent. A 22-year-old man with a hypothalamic-chiasmal germinoma causing bitemporal hemianopic scotomas had minor disc colobomas bilaterally. Careful study of the optic discs and posterior fundus, as well as evaluation of the characteristics of the temporal field defects, should distinguish chiasmal compression in the occasional case where suprasellar tumor and anomalous optic discs coincide.

Acute visual loss during pregnancy after bromocriptine-induced ovulation. The elusive tumor.

The evaluation of patients complaining of amenorrhea with or without galactorrhea has been greatly enhanced by the availability of serum prolactin determinations and advances in diagnostic radiology. Likewise, the treatment of these patients with ergot derivative has resulted in the return of normal menses, and many pregnancies have been reported. The present report is of a patient with hyperprolactinemic amenorrhea-galactorrhea successfully treated with bromocriptine. A pregnancy followed resumption of menses, and a suprasellar cromophobeadenoma became manifest by producing blindness of the patient. The case is presented with recommendations for diagnosis and treatment.

Correlation between leuteinizing hormone responses to luteinizing hormone-releasing hormone (LH-RH) and to D-leu-6-LH-RH-ethylamide in patients with hypothalamo-pituitary disease.

Seventeen patients (eleven females and six males) with organic hypothalamo-pituitary disease were subjected to a test consisting of a rapid intravenous injection of 50 mug of luteinizing hormone-releasing hormone (LH-RH) at 8:00 A.M., with blood sampling before and 30 and 60 minutes afterward. Two to four weeks later, a rapid intravenous injection of 50 mug of D-Leu-6-des-Gly-10-LH-RH-ethylamide (D-Leu-6-LH-RH-EA) was given under similar conditions, with blood sampling before and 30, 60, and 90 minutes afterward. Serum LH levels were determined by radioimmunoassay. D-Leu-6-LH-RH-EA caused a greater and more sustained rise in serum LH levels than did an equal dose of LH-RH. However, functional classifications of patients were similar with either preparation. This finding suggests that acute administration of D-Leu-6-LH-RH-EA does not cause a higher number of relevant responses as compared with LH-RH, but only a greater stimulation of LH releases in responsive patients.

Conservative management of a pituitary tumor during pregnancy following induction of ovulation with gonadotropins.

Ovulation induced with human menopausal gonadotropin-human chorionic gonadotropin in a 27-year-old woman who had been amenorrheic for 7 years resulted in pregnancy. Although pretreatment neurologic evaluation was normal, significant loss of vision was found at 30 weeks' gestation, and a skull x-ray revealed enlargement and erosion of the sella turcica. As an attempt to delay surgery, 12 mg of dexamethasone daily arrested further visual deterioration, and the pregnancy continued uneventful for 36 weeks, when triplets were born. Five days after delivery the visual fields were normal. Trans-sphenoidal resection of a prolactin-secreting chromophobe adenoma of the pituitary was carried out 6 months later. It is suggested that when disturbance in visual perception due to a pituitary tumor occurs during pregnancy, a course of high-dose corticosteroids with frequent monitoring of visual fields and acuity might be tried before surgical intervention. Although further rapid deterioration in vision may dictate immediate surgical decompression, conservative management may result in stabilization, allowing the patient to carry the pregnancy to term and obviating the need for emergency surgery.

Delayed diagnosis of pituitary tumors.

Of 38 patients with presumed or proven pituitary adenomas, 24 first presented with ocular complaints. Of these, ten patients had a physician-caused delay in the formulation of the correct diagnosis. Reasons for the physician-caused delay in diagnosis include inadequate history evaluation, failure to perform adequate testing, provide follow-up examination, and recognize typical signs of pituitary adenomas.

The application of NMR imaging to the evaluation of pituitary and juxtasellar tumors.

Nuclear magnetic resonance (NMR) imaging was used to evaluate pituitary and juxtasellar tumors in 37 patients representing a wide range of pathology. The value of the multiplanar facility of NMR is emphasized in providing accurate volumetric information and establishing the topographical relation of tumors to adjacent structures. Current limitations of the method and possible future developments to improve diagnostic precision are discussed.

Expanding intracerebral hematoma from pituitary adenoma: case report.

We report the case of a 53-year-old man presenting with a headache of sudden onset and blurred vision secondary to hemorrhage from a nonfunctioning pituitary adenoma, which had been treated 25 years previously by transcranial surgery and postoperative irradiation. The intratumoral and intracerebral hematoma expanded to three times its initial size because of a recurrent hemorrhage that occurred during a 2-day period while the patient awaited surgery. The mechanisms of hematoma expansion and the management strategy in such a case are discussed, and a review of the pertinent literature is presented.

Checkerboard visual evoked response in evaluation and management of pituitary tumors.

As a routine part of the evaluation of patients with pituitary tumor, visual evoked responses (VERs) to checkerboard pattern reversal were recorded from 83 patients with tomographically documented pituitary tumor. VER tests were correlated with examinations of visual acuity, color perception, and visual fields and with computerized tomographic scan evidence of suprasellar extension of the tumor. The purpose of the VER recording was to determine the presence of visual system compression by the tumor and thus contribute to the decision of whether surgery was necessary. Each of the patients who had suprasellar extension of the tumor sufficient to produce a visual field abnormality also had an abnormal VER. In addition, some patients with suprasellar extension had normal visual fields but abnormal visual evoked responses. Thus, the VER provided earlier evidence of suprasellar extension causing visual system compromise than did conventional visual tests.

Cerebrospinal fluid rhinorrhea as a presentation of pituitary adenoma.

We report a patient with a pituitary adenoma who presented with only cerebrospinal fluid rhinorrhea. A radiologically unrecognized defect in the floor of the sella was observed at operation.

Ptosis as the early manifestation of pituitary tumour.

Three patients who developed unilateral ptosis followed by partial third nerve palsy were found to have a pituitary tumour. The visual field defects were minimal and asymptomatic. Two patients had a chromophobe adenoma and one patient had a prolactinoma. The importance of recognising a pituitary tumour as the cause of acquired unilateral ptosis is emphasised.

Intracranial ectopic pituitary adenoma. Case report.

The authors report a unique case of ectopic intracranial pituitary adenoma, associated clinically with generalized seizures and aggressive behavior. The lesion presumably arose from cells in the pars tuberalis and did not involve the sella turcica.

The specificity of serum prolactin as a diagnostic indicator of pituitary adenoma.

Serum prolactin levels were determined in 205 patients with a variety of intracranial diseases, including 70 cases with pituitary tumors. It is concluded that although the absence of elevated prolactin levels does not help to rule out pituitary pathology, the presence of hyperprolactinemia is highly specific for diseases of the pituitary and hypothalamus, and prolactin determination should be part of the regular work-up of pituitary tumor suspects. Excluding known causes of hyperprolactinemia, such as tranquilizing drug ingestion, the presence of neurological disease outside the hypothalamic-pituitary area was not associated with increased serum prolactin concentrations.