AIP mutation in pituitary adenomas in the 18th century and today

Gigantism results when a growth hormone-secreting pituitary adenoma is present before epiphyseal fusion. In 1909, when Harvey Cushing examined the skeleton of an Irish patient who lived from 1761 to 1783, he noted an enlarged pituitary fossa. We extracted DNA from the patient's teeth and identified a germline mutation in the aryl hydrocarbon-interacting protein gene (AIP). Four contemporary Northern Irish families who presented with gigantism, acromegaly, or prolactinoma have the same mutation and haplotype associated with the mutated gene. Using coalescent theory, we infer that these persons share a common ancestor who lived about 57 to 66 generations earlier.

The history of the treatment of pituitary adenomas

The immense history leading to our current understanding and treatment of pituitary pathology is inextricably linked to the evolution of the understanding of the numerous functions of the hypophysis cerebri as the "master gland" of the endocrine system. When the anatomists of old encountered this small organ sequestered "like a nugget in the innermost of Chinese boxes" at the base of the brain, they had no inkling of its importance in the control of multiple target organs in the human body. It would ultimately take two millennia and a vast amount of clinical and laboratory research for its role in the body to eventually become more completely appreciated.

Update on the medical management of pituitary adenomas

The medical treatment of pituitary adenomas has changed significantly over the past decade. Pharmacologic therapy for prolactinomas in the form of dopamine agonists has been available since the 1970s, and somatostatin analogues for treatment of growth hormone (GH)-secreting adenomas were introduced in the 1980s. However, the recent introduction of long-acting forms of these agents has markedly improved efficacy. Furthermore, long-acting somatostatin analogues also have utility in treating thyrotropin adenomas and a subset of adrenocorticotroph tumors. Limited clinical studies with long-acting dopamine agonists suggest that a subset of patients with GH, adrenocorticotroph, and gonadotropin/nonsecreting adenomas may also benefit from therapy with these agents. The introduction of a GH receptor antagonist in the 1990s has added to the pharmacologic armamentarium for treatment of acromegaly. In parallel with improved medical therapy, hormonal assays for assessing tumor activity have improved in sensitivity, necessitating new standards for treatment optimization. This article highlights some of these evolving new ideas and approaches to the pharmacologic management of pituitary adenomas.

[Giantism. A historical and medical view]

Patients with giantism were displayed as curiosities to large audiences in the past. The (medical) histories of famous giants like Daniel Cajanus (born in 1702 or 1703, Finland), Charles Byrne (1761, Ireland), Edouard Beaupré (1881, Canada) and Robert Wadlow (1918, Illinois, USA) are well described in the international medical literature. Extensive data from the entertainment world and/or medical data exist on famous Dutch giants like Klaas van Kyeten (end of 13th century), Gerrit Bastiaansz. de Hals (1620), Albert Johan Kramer (1897) and Rigardus Rijnhout (1922). Famous Dutch giantesses are Trijntje Kornelisse Keever (1614) and Kaatje van Dijk (1904). In most giants, excessive growth was caused by a somatotroph pituitary adenoma, sometimes in combination with hypogonadotrophic hypogonadism. In the western world, it is unlikely that there will be many more people with fully developed giantism due to the current high level of medical care.

A case of pituitary adenoma: Thomas Willis revisited

Thomas Willis (1621-1675) was the founder of modern clinical neuroscience. His habit of taking detailed histories with acute clinical observation often accompanied by post mortem studies has left a body of work which still provokes thought and debate. While we were considering a case of pituitary tumour described by Willis, a similar case presented coincidentally at our hospital. The two cases are compared and contrasted.

Cushing's case XLV: Minnie G

A 23-year-old patient who was examined in 1910 by Harvey Cushing triggered his lifelong interest in the syndrome that bears his name. "Minnie G.," as she became historically known, presented with a "...syndrome of painful obesity, hypertrichosis, and amenorrhea with overdevelopment of secondary sexual characteristics accompanying a low grade of hydrocephalus and increased cerebral tension." This case stimulated Harvey Cushing's inquisitive mind and sparked an interest that 20 years later culminated in his seminal report, "The basophil adenomas of the pituitary gland and their clinical manifestations (pituitary basophilism)." In this classic work, Cushing reported in detail the cases of two patients encountered from his own practice and 10 similar cases collected from the literature. Minnie G. was the first case that Cushing reported. The clinical course of that case is briefly reviewed in this article.

History of pituitary surgery from the technical aspect

Transcranial and trans-sphenoidal pituitary surgery were developed independently with few exceptions by different groups of surgeons. The transcranial approaches, primarily the transfrontal-parasagittal and the frontotemporal along the sphenoid ridge, evolved without many variations within a short time span. The trans-sphenoidal exposures of the pituitary, on the contrary, underwent many modifications provoked by the fear of postoperative meningitis and the search for improved vision through the narrow alley leading to the target. Only Guiot in 1978 ended the extensive discussion by convincingly demonstrating that well-defined indications existed for each procedure. Improvement of diagnostic and surgical tools was a major factor for refining the surgical technique and improving the surgical results.

Benedict Cassen: the father of body organ imaging

The invention of the radioisotope scanner by Benedict Cassen was seminal to the development of body organ imaging. Cassen assembled the first automated scanning system in 1950. It was a motor-driven scintillation detector coupled to a printer. The scanner was used to image the thyroid gland after the administration of radioiodine. Later, with the development of organ-specific radiopharmaceuticals the scanner was widely used during the late 50s until the early 70s to image the body organs.

[Pituitary pathology and MEN 1]

Multiple Endocrine Neoplasia type 1 (MEN 1) is an autosomal dominant syndrome characterized by neoplasia of the parathyroid glands, the endocrine pancreas and the anterior pituitary gland. Recently the identification on chromosome 11 (locus q13) of the gene responsible for MEN 1 has allowed direct genetic diagnosis of MEN 1-affected family members. To date almost 300 families have been described and genetically characterized. The genetic etiology of most pituitary tumours remains unknown. Pituitary adenomas can develop sporadically or as a part of multiple endocrine neoplasia type 1. In this review, the recently published data on the pathology of the MEN 1 syndrome will be summarized. The clinical, morphological and genetic aspects of sporadic and MEN 1-associated pituitary adenomas will be outlined.

Development of pituitary adenoma treatment--a critical essay

The history of pituitary adenoma treatment shows, as in medicine in general, a succession of movements and counter movements. A large number of surgical techniques was proposed, but only very few survived the selection process. This selection was influenced not only by the general development of surgical techniques that also by the introduction of effective medical treatments and the arrival of new diagnostic methodology. We witness today a new selection mechanism besides the quality of the results--the economic pressure. Its importance may even increase in future because of progressing limitations of medical budgets. We subdivide the history of pituitary adenoma treatment into three main periods: the early period from Sir Victor Horsley to Norman Dott; the period of the reintroduction of the transphenoidal approach initiated by Gérard Guiot to the introduction of bromocriptine, the first effective antisecretory drug; and the period of refinement of the individual treatment methods still going on today. We present this history not so much in a retrospective way, by enumerating the single technical variations of surgical procedures but rather by presenting the momentary situations, as witnessed by our predecessors by presenting short extracts of contemporary texts to characterize the thinking in the past.

Gastric epithelial dysplasia and adenoma: historical review and histological criteria for grading

Gastric epithelial dysplasia (GED) hypothetically is a straight-forward concept: dysplastic epithelium replacing the normal gastric epithelium of the stomach. However, since its inception several decades ago, the term GED has become progressively complex and confusing because of differences in definitions and nomenclature that have been based on cytological, microscopic, endoscopic, or gross features. This has resulted in the terms "dysplasia," "adenoma," "flat adenoma," and "depressed adenoma." Some authors have also included reactive changes under the term "dysplasia."

The influence of Harvey Cushing on neuroradiologic therapy

Harvey Cushing was largely responsible for the establishment of neurosurgery as a separate discipline. He demonstrated how careful attention to technique could make surgery acceptably safe, established classifications and clinical-pathologic correlations of a wide variety of tumors, and trained dozens of future neurosurgical department heads. Less well known, however, is Cushing's contribution to the early clinical use of radiation therapy for a variety of intracranial disorders. With the aid of his meticulous clinical follow-up, large case volume, and willingness to try new treatment methods, he demonstrated the utility of therapeutic radiation in patients with pituitary tumor, medulloblastoma, and arteriovenous malformation. His less impressive results with the irradiation of patients with glioma are also worthy of note and include trials of brachytherapy. Neurosurgeons and radiation oncologists exploring new methods of delivering therapeutic radiation to the central nervous system should be aware of the lessons learned from Cushing's experience.

Oncocytic neoplasms of the thyroid gland

Among well differentiated thyroid tumors, oncocytic neoplasms feature a distinctive set of clinical, morphologic and biologic characteristics, some of which have been a matter of controversy. The world literature on this subject has been reviewed to show that: 1) Morphology accurately predicts the behavior of Hürthle cell tumors assuming that the specimen has been adequately sampled; 2) Capsular and/or vascular invasion is the sine qua non condition for a diagnosis of malignancy; 3) "Indeterminate" or "possibly malignant" categories are useless because in the absence of invasion these neoplasms almost invariably behave in a benign fashion; 4) Among cases histologically classified as malignant, a clinically aggressive behavior is to be expected in a high percentage of cases; 5) Size alone cannot be used as a criterion of malignancy; 6) Less than total thyroidectomy provides an adequate treatment for histologically benign tumors; aggressive surgical procedures (i.e. total thyroidectomy) do not diminish the incidence of metastasis; 7) Analysis of DNA content may be helpful in defining subsets of patients with Hürthle cell carcinomas having a particularly poor prognosis; 8) Mitochondrial and/or nuclear DNA abnormalities probably play an important role in the cellular alterations which characterize the phenotype of oncocytes.

[Primary hyperparathyroidism. History]

The term primary hyperparathyroidism currently refers to the clinical and biological manifestations resulting from the hypersecretion of parathyroid hormone by one or several parathyroid adenomas. This entity is a recent one since it goes back to 1925. The clinical picture resulting from this anomaly, were first described as Recklinghausen's fibrous osteitis, which was not justified since Recklinghausen had not established the relationship between the clinical manifestations and the adenoma discovered by Mandl, then under the name of parathyroid osteosis. This term was justified at a time when the disease presented only bony manifestations with biological evidence. Primary hyperthyroidism is the current appellation, demonstrating that the disease is now a biological disease, often discovered systematically, with therapeutic progress, progress in biological identification and possibility of medical forms without mandatory surgical outcome. Bibliographic references accompany the various stages of this historical reminder.