Secondary pituitary hormonal dysfunction patterns: tumor size and subtype matter

PURPOSE

Patients with sellar masses (SM) frequently have secondary hormonal deficiency (SHD) at initial presentation. While larger SM are more likely to present with SHD, it is unclear whether SHD at presentation is influenced by the type of SM.

METHODS

We conducted a retrospective analysis of patients with SM prospectively enrolled in our comprehensive provincial neuropituitary registry between November 2005 and December 2018. SM were subdivided based on size: < 1 cm, 1-1.9 cm, 2-2.9 cm, and > 3 cm.

RESULTS

A total of 914 patients met the inclusion criteria, including: 346 nonfunctioning adenomas (NFA), 261 prolactinomas (PRLoma), 51 growth hormone adenomas, 36 adrenocorticotropic adenomas, 93 Rathke's cleft cysts, 70 craniopharyngiomas and 57 meningiomas. The overall rate of SHD at presentation was highest in PRLoma (62.8%) and craniopharyngiomas (64.3%) and lowest in meningiomas (14%). While larger SM were significantly more likely to have SHD, the rate of SHD within each group was significantly different despite similar size (p < 0.001). Of the two largest groups of SM (NFA and PRLoma), NFA had significantly higher odds ratio (3.34, CI 1.89-5.89) of having multiple SHDs when compare with PRLoma, even when corrected for age, gender and size of tumor (p < 0.001).

CONCLUSION

Our study shows that the rate and distribution of SHD in SM vary dependent upon the size of the tumor and specific pathology; in particular, NFA are more likely to present with multiple SHDs. Our data will help clinicians in determining adequate hormonal testing strategy for different SM.

MON-LB076 Patterns of Secondary Hormonal Deficiency Vary among Different Types of Sellar Masses Despite Similar Tumour Size at Presentation

BACKGROUND: Secondary hormonal deficiency (SHD) is common in patients with sellar masses (SM); however, it is unclear if the rate and type of SHD at presentation is related to the size or type of SM. We conducted a study comparing SHD in various SM based on pathology and size at presentation. METHODS: A retrospective analysis of all SM in a tertiary care neuropituitary program, enrolled between November 2005 and December 2018, was conducted based on type of SM and maximum tumor size, comparing rate of secondary hypogonadism (SHG), secondary hypothyroidism (SHT), secondary hypoadrenalism (SHA), growth hormone deficiency (GHD) and diabetes insipidus (DI). RESULTS: A total of 914 patients were identified including: nonfunctioning adenoma (NFA) = 346, prolactinoma (PRLoma) = 261, growth hormone (GH) adenoma = 51, ACTH adenoma = 36, meningioma = 57, craniopharyngioma (cranio) = 70 and Rathke’s cleft cyst (RCC) = 93. SM were further subdivided based on initial size into < 9mm (group A), 10-19mm (group B), 20-29mm (group C) and ≥ 30 mm (group D). The overall SHD (%), single vs. multiple SHD (%) and most prevalent SHD, respectively, for each group were as follow. Group A - NFA (10%, 56% vs. 44%, SHG and SHT), PRLoma (48%, 90% vs. 10%, SHG), GH adenoma (13%, 100% vs 0, SHG), ACTH adenoma (29%, 83% vs. 17%, SHG), cranio (50%, 100% vs. 0, GHD) and RCC (11%, 100% vs. 0, SHG); Group B - NFA (35%, 43% vs. 57%, SHG), PRLoma (73%, 77% vs. 23%, SHG), GH adenoma (23%, 71% vs. 29%, SHG), ACTH adenoma (30%, 67% vs. 33%, SHG), meningioma (5%, 0 vs. 100%, SHG and SHA), cranio (48%, 73% vs. 27%, SHT), RCC (17%, 43% vs. 57%, SHT); Group C - NFA (64%, 28% vs. 72%, SHG), PRLoma (78%, 50% vs. 50%, SHG), GH adenoma (75%, 50% vs. 50%, SHG), ACTH adenoma (100%, 33% vs. 67%, SHG), meningioma (16%, 100% vs. 0, SHT), cranio (70%, 38% vs. 62%, SHG), RCC (41%, 29% vs. 71%, SHG): Group D - NFA (83%, 40% vs. 60%, SHG), PRLoma (100%, 47% vs. 53%, SHG), GH adenoma (80%, 0 vs. 100%, SHG and SHT), meningioma (27%, 75% vs. 25%, SHG), cranio (88%, 36% vs. 64%, SHG) [all p <0.001]. CONCLUSION: This is the first study to show that SHD patterns vary considerably in various SM of similar size at presentation. While there is a higher risk of SHD in larger SM, the pattern of SHD is also dependent upon the underlying pathology. Of the two largest categories i.e., NFA and PRLoma, NFA are more likely to present with multiple SHD while PRLoma predominantly present with single SHD. Unless otherwise noted, all abstracts presented at ENDO are embargoed until the date and time of presentation. For oral presentations, the abstracts are embargoed until the session begins. Abstracts presented at a news conference are embargoed until the date and time of the news conference. The Endocrine Society reserves the right to lift the embargo on specific abstracts that are selected for promotion prior to or during ENDO.

ACTH-Secreting Neuroendocrine Carcinoma of the Cecum: Case Report and Review of the Literature

BACKGROUND

Approximately 30% of neuroendocrine tumors (NETs) present with secretory syndromes or develop one during the course of the disease. Cushing syndrome caused by a gastrointestinal tract NET is rare, with limited published information. We describe a patient with florid Cushing syndrome due to ectopic adrenocorticotropic hormone (ACTH) from a NET of colonic origin. A literature review was conducted to describe the spectrum of this clinical and pathologic entity as reported in the scientific literature.

PATIENT AND METHODS

Next-generation sequencing and microsatellite instability testing was carried out on the tumor from our case. A preliminary PubMed search was conducted using the following terms under the publication type "Case Reports": "Cushing" AND "colon," "neuroendocrine" AND "colon" and "neuroendocrine AND Cushing AND "colon." A manual search was performed to review all references for inclusion and relevant clinical, biochemical and pathologic data was abstracted.

RESULTS

Mutations in BRAF V600E and TP53 were detected in our case. We retrieved 18 previously reported cases of Cushing syndrome associated with a NET of colonic origin, none of which had next-generation sequencing performed. Median age at diagnosis was 54.5 years (range, 24-74 years), with equal gender distribution. ACTH was detected by immunohistochemistry in the primary tumor and/or metastatic lesion in 61.5%. Review of the reports suggested that ectopic ACTH secretion from a colonic tumor might be more common in mixed glandular and NETs, including mixed adenocarcinoma-neuroendocrine carcinoma. Among studies reporting outcomes, the unadjusted mortality rate was 77.7%, with median overall survival from presentation of 63 days (range, 17-380 days).

CONCLUSION

Cushing syndrome associated with ectopic ACTH from tumors of colonic origin is a rare phenomenon with poor outcomes and can be associated with pure NETs, adenocarcinomas, and mixed-phenotype tumors, including mixed adenocarcinoma-neuroendocrine carcinoma.

Regulation of CDX2 expression in esophageal adenocarcinoma

Reflux of acidic gastric contents and bile acids into the lower esophagus has been identified to have a central role in esophageal malignancy and is reported to upregulate caudal-related homologue 2 (CDX2), a regulatory gene involved in embryonic development and axial patterning of the alimentary tract. The aim of this study was to characterize the expression of CDX2 in a well-defined series of human esophageal tissues, comprising reflux-induced esophagitis, premalignant Barrett esophagus (BE), and primary esophageal adenocarcinoma (EADC). To explore potential molecular regulatory mechanisms, we also studied the expression of beta-catenin, SOX9, and CDX2 promoter methylation in esophageal tissues, in addition to the effect of bile acids and nitric oxide (NO) on CDX2 expression in the normal human esophageal cell line Het1A. Relative to matched normal esophageal epithelia, CDX2 was overexpressed in esophagitis (37% for RNA; cytoplasmic immunoreactivity in 48% of tissues), a high proportion (91%) of BE tissues, and in EADC (57% for RNA; cell nuclear immunopositivity in 80%). An association with beta-catenin expression was seen, but not with SOX9 or CDX2 promoter methylation. In Het1A cells, CDX2 was upregulated following exposure to bile acids and NO, alone and in combination. These results further implicate CDX2 and beta-catenin in the molecular pathogenesis of human EADC. The observed synergistic effect of NO on the efficacy of bile acid-induction of CDX2 suggests a novel role for NO in modulating the development of the Barrett phenotype and esophageal adenocarcinogenesis.