Contact endoscopy as a novel technique for intra-operative identification of normal pituitary gland and adenoma

Intraoperative distinction of pituitary adenoma from normal gland is critical in maximizing tumor resection without compromising pituitary function. Contact endoscopy provides a noninvasive technique that allows for real-time in vivo visualization of differences in tissue vascularity. Two illustrative cases of endoscopic endonasal approaches (EEAs) for resection of pituitary adenoma illustrate the use of contact endoscopy in identifying tumor from gland and differentiating a thin section of normal gland draped over the underlying tumor, thereby allowing for safe extracapsular tumor resection. Contact endoscopy may be used as an adjunct for intraoperative, in vivo differentiation of pituitary gland and adenoma. The video can be found here: https://stream.cadmore.media/r10.3171/2021.10.FOCVID21199

Corticotroph hyperplasia and Cushing disease: diagnostic features and surgical management

OBJECTIVEThis study was done to compare corticotroph hyperplasia and histopathologically proven adenomas in patients with Cushing disease by analyzing diagnostic features, surgical management, and clinical outcomes.METHODSPatients with suspected pituitary Cushing disease were included in a retrospective cohort study and were excluded if results of pathological analysis of the surgical specimen were nondiagnostic or normal. Cases were reviewed by two experienced neuropathologists. Total lesion removal was used as a dichotomized surgical variable; it was defined as an extracapsular resection (including a rim of normal gland) in patients with an adenoma, and for hyperplasia patients it was defined as removal of the presumed lesion plus a rim of surrounding normal gland. Bivariate and multivariate analyses were performed. Recurrence-free survival was compared between the two groups.RESULTSThe final cohort consisted of 63 patients (15 with hyperplasia and 48 with adenoma). Normal pituitary acinar architecture was highly variable. Corticotroph hyperplasia was diagnosed based on the presence of expanded acini showing retained reticulin architecture and predominant staining for adrenocorticotropic hormone. Crooke’s hyaline change was seen in 46.7% of specimens, and its frequency was equal in nonlesional tissue of both groups. The two groups differed only by MRI findings (equivocal/diffuse lesion in 46% of hyperplasia and 17% of adenoma; p = 0.03). Diagnostic uncertainty in the hyperplasia group resulted in additional confirmatory testing by 24-hour urinary free cortisol. Total lesion removal was infrequent in patients with hyperplasia compared to those with adenoma (33% vs 65%; p = 0.03). Initial biochemical remission was similar (67% in hyperplasia and 85% in adenoma; p = 0.11). There was no difference in hypothalamic-pituitary-adrenal axis recovery or disease recurrence. The median follow-up was 1.9 years (IQR 0.7–7.6 years) for the hyperplasia group and 1.2 years (IQR 0.4–2.4 years) for the adenoma group. Lack of a discrete lesion and diagnostic uncertainty were the only significant predictors of hyperplasia (sensitivity 53.3%, specificity 97.7%, positive predictive value 88.9%, negative predictive value 85.7%). An adjusted Cox proportional hazards model showed similar recurrence-free survival in the two groups.CONCLUSIONSThis study suggests an association between biochemically proven Cushing disease and histopathologically proven corticotroph hyperplasia. Imaging and operative findings can be ambiguous, and, compared to typical adenomas with a pseudocapsule, the surgical approach is more nuanced. Nevertheless, if treated appropriately, biochemical outcomes may be similar.

Radiation dose to neuroanatomical structures of pituitary adenomas and the effect of Gamma Knife radiosurgery on pituitary function

OBJECTIVEGamma Knife radiosurgery (GKRS) provides a safe and effective management option for patients with all types of pituitary adenomas. The long-term adverse effects of targeted radiation to the hypothalamic-pituitary axis in relationship to radiation dose remain unclear. In this retrospective review, the authors investigated the role of differential radiation doses in predicting long-term clinical outcomes and pituitary function after GKRS for pituitary adenomas.METHODSA cohort of 236 patients with pituitary tumors (41.5% nonfunctioning, 58.5% functioning adenomas) was treated with GKRS between 1998 and 2015. Point dosimetric measurements, with no minimum volume, to 14 consistent points along the hypothalamus bilaterally, pituitary stalk, and normal pituitary were made. Statistical analyses were performed to determine the impact of doses to critical structures on clinical, radiological, and endocrine outcomes.RESULTSWith a median follow-up duration of 42.9 months, 18.6% of patients developed new loss of pituitary function. The median time to endocrinopathy was 21 months (range 2–157 months). The median dose was 2.1 Gy to the hypothalamus, 9.1 Gy to the pituitary stalk, and 15.3 Gy to the normal pituitary. Increasing age (p = 0.015, HR 0.98) and ratio of maximum dose to the pituitary stalk over the normal pituitary gland (p = 0.013, HR 0.22) were independent predictors of new or worsening hypopituitarism in the multivariate analysis. Sex, margin dose, treatment volume, nonfunctioning adenoma status, or ratio between doses to the pituitary stalk and hypothalamus were not significant predictors.CONCLUSIONSGKRS offers a low rate of delayed pituitary insufficiency for pituitary adenomas. Doses to the hypothalamus are low and generally do not portend endocrine deficits. Patients who are treated with a high dose to the pituitary stalk relative to the normal gland are at higher risk of post-GKRS endocrinopathy. Point dosimetry to specific neuroanatomical structures revealed that a ratio of stalk-to-gland radiation dose of 0.8 or more significantly increased the risk of endocrinopathy following GKRS. Improvement in the gradient index toward the stalk and normal gland may help preserve endocrine function.

SAT-300 Evading Death: Noxa in Cushing’s Disease Pituitary Adenomas

Introduction: Recurrence of Cushing’s disease (CD) caused by benign pituitary microadenomas are challenging clinical problems. Mechanisms underlying adenoma formation and recurrence remain unknown. PMAIP1 gene codes for Noxa, a Bcl-2 homology 3 (BH3) pro-apoptotic protein frequently downregulated in malignant human tumors.1-6 The role of dysregulated apoptosis remains largely unknown in benign tumors and in CD. We hypothesized that altered expression of Noxa protein is a pro-survival adaptation employed by CD adenomas. Methods: Syngeneic human pituitary adenoma and adjacent normal gland pairs (n=2), and an additional CD adenoma were analyzed with RNAseq. 10 CD, 1 growth hormone (GH) and 1 non-functioning adenoma (NFPA) underwent immunohistochemical (IHC) analysis for Noxa expression, which was graded by a neuropathologist as 0=none, 1=light, 2=medium, 3=strong. Staining grade represents relative protein expression. Results: Compared to adjacent normal pituitary tissue, we found that adenomas (n = 3) had a 3.76 fold increase in PMAIP1 mRNA. However, there was attenuated Noxa IHC staining in adenomas compared to normal pituitary in 8 of 10 CD patients (2:3, respectively), but similar staining in 2 of 10 CD patients (2:2 and 2-3:2-3). In GH and NFPA, we found similar patterns of Noxa suppression in the adenomas compared to the normal gland. Conclusion: Despite elevated PMAIP1 (Noxa) gene expression in adenomas compared to adjacent normal gland in CD, protein expression was reduced in adenomas. This downregulation of Noxa protein expression may contribute to reduced apoptosis of tumor cells. These findings suggest that CD adenomas gain pro-survival advantage by downregulating Noxa protein at post-transcriptional or post-translational level. References 1. Escobar, D. et al. Cell Death Dis.6, 1-14 (2015).2. Brinkmann, K. et al. Cell Rep.3, 881-891 (2013).3. Liu, Y. L. et al. Oncotarget5, 11237-11251 (2014).4. Dengler, M. A. et al. Cell Death Dis.5, 1-10 (2014).5. Liang, L. et al. J. Oral Pathol. Med.48, 52-59 (2019).6. Tahir, S. K. et al. Cancer Res.67, 1176-1183 (2007).

Penurunan Tekanan pada Pompa Air Laut pada Mesin Induk Kapal

Tujuan penelitian ini untuk mengetahui penyebab menurunya tekanan pompa pendingin air laut pada mesin induk di kapal. Metode penelitian menggunakan analisis kuantitaif deskriptif yaitu dengan melakukan pengamatan tentang menurunnya tekanan pompa air laut pendingin mesin induk kapal. Waktu yang digunakan dalam melaksanakan penelitian dan pengumpulan data-data yang diperlukan adalah 12 bulan lebih 10 hari. Hasil pengamatan diperoleh kurangnya daya hisap dan tekanan pompa air laut disebabkan saringan isap tertutup kotoran saat kapal masuk ke perairan dangkal baik pantai maupun sungai yang terdapat kotoran terutama sampah plastik dan lumpur, kotoran tersebut akan menghalangi aliran isap dari pompa pendingin. Menurunnya kinerja impeller pada pompa disebabkan karena terjadinya penyumbatan pada Impeller oleh kotoran-kotoran, keran-keran atau binatang laut yang masuk melalui Sea Chest sehingga menyebabkan terjadinya penurunan tekanan pompa ait laut. Kebocoran pada bagian gland packing pompa berupa tetesan zat cair yang jumlahnya tidak lebih dari 0,5 cm3/s. Jika jumlah tetesan lebih dari ini, penekan Packing harus di kencangkan pelan-pelan dan merata dengan mengencangkan kedua mur secara bergantian sampai tetesan menjadi normal, apabila setelah di kencangkan tetesan masih tidak normal gland packing wajib diganti dengan yang baru.

Ultrasonographic measurement of adrenal gland-to-aorta ratio as a method of estimating adrenal size in dogs

BackgroundAdrenal size has been used as the principal criterion for differentiating a normal gland from adrenal hyperplasia. The objectives of this study were to establish an ultrasonographic measurement of adrenal gland-to-aorta (adrenal/Ao) ratio to estimate the adrenal size and to assess the effects of bodyweight, age and sex on the adrenal/Ao ratio in non-adrenal gland disease dogs.MethodsTwo hundred and thirty-four dogs (120 entire females and 114 entire males) considered non-adrenal gland disease were included in this study. Dogs were allocated into three bodyweight categories (<10 kg, 10–20 kg and >20 kg), and four age groups (<1 year, 1–5 years, 5–10 years and >10 years old). Measurements of the maximal thickness of caudal pole of both adrenal glands and the aortic luminal diameter in sagittal plane were performed on the ultrasonographic images. Three different ratios were calculated for each dog.ResultsSex and age did not influence on the adrenal/Ao ratio. There were differences (P<0.05) between the three dog sizes for adrenal/Ao ratio, being the highest value for small size and the lowest value for large size.ConclusionsIn this study, only bodyweight influences the ultrasound measurement of the adrenal/Ao ratio in non-adrenal gland disease dogs.

Observational study of comparison of BISAP score with Ranson’s score and APACHE II scores in assessing severity and prognosis in patients of acute pancreatitis

Background: Acute pancreatitis is one of the most common diseases of gastrointestinal tract, leading to tremendous emotional, physical and financial burden. Acute pancreatitis is an acute inflammation of the prior normal gland parenchyma which is usually reversible (but acute attack can occur in a pre-existing chronic pancreatitis) with raised pancreatic enzyme levels in blood and urine. It may be first attack or relapsing attacks with an apparently normal gland in between. Biliary tract disease and alcoholism are the commonest cause of pancreatitis.Methods: It was an observational study at Surat municipal institute of medical education and research (SMIMER), Department of Surgery. In present study authors used BISAP score, RANSON’S score and APACHE II score to evaluate the severity and mortality in cases of pancreatitis. In present study authors have compare all the scoring system on the basis of CT scan findings. In present study authors have included all patients above age of 18 years. Patient below 18 years of age, acute on chronic pancreatitis and hereditary pancreatitis were not included.Results: In this retrospective study, we found that incidence of colorectal carcinoma is more between 40-60 years of age with male predominance; lymph node metastasis is more than metastasis in any other sites. CT scan can diagnose lymphatic metastasis and infiltration in surrounding tissue more accurately. Percentage of sphincter saving procedure were low in rectal malignancies in our study.Conclusions: All three-scoring system assess the prognosis of the patient, but the prognosis assessed by APACHE II score is better, but for quick and easy assessment, BISAP score is good for prognosis because APACHE II score uses more parameters to assess the prognosis and BISAP score uses less parameters to assess the prognosis.