Anne Klibanski

Treatment of Adrenocorticotropin-Dependent Cushing’s Syndrome: A Consensus Statement

OBJECTIVE Our objective was to evaluate the published literature and reach a consensus on the treatment of patients with ACTH-dependent Cushings syndrome, because there is no recent consensus on the management of this rare disorder. PARTICIPANTS Thirty-two leading endocrinologists, clinicians, and neurosurgeons with specific expertise in the management of ACTH-dependent Cushings syndrome representing nine countries were chosen to address 1) criteria for cure and remission of this disorder, 2) surgical treatment of Cushings disease, 3) therapeutic options in the event of persistent disease after transsphenoidal surgery, 4) medical therapy of Cushings disease, and 5) management of ectopic ACTH syndrome, Nelsons syndrome, and special patient populations. EVIDENCE Participants presented published scientific data, which formed the basis of the recommendations. Opinion shared by a majority of experts was used where strong evidence was lacking. CONSENSUS PROCESS Participants met for 2 d, during which there were four chaired sessions of presentations, followed by general discussion where a consensus was reached. The consensus statement was prepared by a steering committee and was then reviewed by all authors, with suggestions incorporated if agreed upon by the majority. CONCLUSIONS ACTH-dependent Cushings syndrome is a heterogeneous disorder requiring a multidisciplinary and individualized approach to patient management. Generally, the treatment of choice for ACTH-dependent Cushings syndrome is curative surgery with selective pituitary or ectopic corticotroph tumor resection. Second-line treatments include more radical surgery, radiation therapy (for Cushings disease), medical therapy, and bilateral adrenalectomy. Because of the significant morbidity of Cushings syndrome, early diagnosis and prompt therapy are warranted.

Long-term treatment of acromegaly with pegvisomant, a growth hormone receptor antagonist

BACKGROUND Pegvisomant is a new growth hormone receptor antagonist that improves symptoms and normalises insulin-like growth factor-1 (IGF-1) in a high proportion of patients with acromegaly treated for up to 12 weeks. We assessed the effects of pegvisomant in 160 patients with acromegaly treated for an average of 425 days. METHODS Treatment efficacy was assessed by measuring changes in tumour volume by magnetic resonance imaging, and serum growth hormone and IGF-1 concentrations in 152 patients who received pegvisomant by daily subcutaneous injection for up to 18 months. The safety analysis included 160 patients some of whom received weekly injections and are excluded from the efficacy analysis. FINDINGS Mean serum IGF-1 concentrations fell by at least 50%: 467 mg/L (SE 24), 526 mg/L (29), and 523 mg/L (40) in patients treated for 6, 12 and 18 months, respectively (p<0.001), whereas growth hormone increased by 12.5 mg/L (2.1), 12.5 mg/L (3.0), and 14.2 mg/L (5.7) (p<0.001). Of the patients treated for 12 months or more, 87 of 90 (97%) achieved a normal serum IGF-1 concentration. In patients withdrawn from pegvisomant (n=45), serum growth hormone concentrations were 8.0 mg/L (2.5) at baseline, rose to 15.2 mg/L (2.4) on drug, and fell back within 30 days of withdrawal to 8.3 mg/L (2.7). Antibodies to growth hormone were detected in 27 (16.9%) of patients, but no tachyphylaxis was seen. Serum insulin and glucose concentrations were significantly decreased (p<0.05). Two patients experienced progressive growth of their pituitary tumours, and two other patients had increased alanine and asparate aminotransferase concentrations requiring withdrawal from treatment. Mean pituitary tumour volume in 131 patients followed for a mean of 11.46 months (0.70) decreased by 0.033 cm(3) (0.057; p=0.353). INTERPRETATION Pegvisomant is an effective medical treatment for acromegaly.

A consensus on criteria for cure of acromegaly

OBJECTIVE The Acromegaly Consensus Group met in April 2009 to revisit the guidelines on criteria for cure as defined in 2000. PARTICIPANTS Participants included 74 neurosurgeons and endocrinologists with extensive experience of treating acromegaly. EVIDENCE/CONSENSUS PROCESS: Relevant assays, biochemical measures, clinical outcomes, and definition of disease control were discussed, based on the available published evidence, and the strength of consensus statements was rated. CONCLUSIONS Criteria to define active acromegaly and disease control were agreed, and several significant changes were made to the 2000 guidelines. Appropriate methods of measuring and achieving disease control were summarized.

Osteopenia in Men with a History of Delayed Puberty

BACKGROUND AND METHODS The effect of delayed puberty on peak bone mineral density in men is unknown. To determine whether such a delay reduces normal peak bone density and leads to osteopenia during adulthood, we measured radial bone mineral density by single-photon absorptiometry and spinal bone mineral density by dual-energy x-ray absorptiometry in 23 men who had a history of constitutionally delayed puberty and 21 men who underwent normal puberty. Their mean ages were 26 and 24 years, respectively. The groups were matched for other factors known to affect bone mass. RESULTS The mean (+/- SD) radial bone mineral density was significantly lower in the men with a history of delayed puberty than in the normal men (0.73 +/- 0.07 vs. 0.80 +/- 0.05 g per square centimeter; P less than 0.0002). Spinal bone mineral density was also significantly lower in the men with delayed puberty than in the normal men (1.03 +/- 0.10 vs. 1.13 +/- 0.11 g per square centimeter; P less than 0.003). Radial bone density was at least 1 SD below the mean value for the normal men in 15 of the 23 men with a history of delayed puberty, and spinal bone density was similarly decreased in 10 of the 23. CONCLUSIONS Adult men with a history of constitutionally delayed puberty have decreased radial and spinal bone mineral density. These findings suggest that the timing of puberty is an important determinant of peak bone density in men. Because the peak bone mineral density achieved during young adulthood is a major determinant of bone density in later life, men in whom puberty was delayed may be at increased risk for osteoporotic fractures when they are older.

Prevalence and predictive factors for regional osteopenia in women with anorexia nervosa.

Anorexia nervosa is highly prevalent among U.S. women (1, 2) and is associated with substantial bone loss (3-6). Bone loss in women with this disorder is multifactorial; is related in part to estrogen deficiency and to direct effects of undernutrition (3, 4, 7); and is rapid, often occurring within 6 months of disease onset (4) and persisting to some degree after weight recovery (8). It is important to determine the prevalence of regional bone loss at different skeletal sites because it may predict site-specific fracture rates (9). We therefore measured bone mineral density (BMD) at several skeletal sites to determine the prevalence rates and predictive factors of regional osteopenia and osteoporosis in a large community-based sample of women with anorexia nervosa. Methods We studied 130 women with anorexia nervosa recruited through community advertisements and community physician referral. Telephone screening interviews were used to exclude patients who reported normal weight and menses; use of bisphosphonates, calcitonin, or glucocorticoids; or medical conditions other than anorexia nervosa that are known to affect BMD. Women who had regular uterine withdrawal bleeding while receiving estrogen therapy and women with concomitant bulimia nervosa were permitted to participate. Eligible patients underwent a 3-hour outpatient visit at the General Clinical Research Center of the Massachusetts General Hospital in Boston. Height, weight, age at menarche, time since last menstrual period, previous and current estrogen use, fracture history, and frame size were determined. Calcium and vitamin D intake were determined by diet history in a subset of 60 patients. The diagnosis of anorexia nervosa, according to criteria specified in Diagnostic and Statistical Manual of Mental Disorders, fourth edition, was confirmed in all patients (10). All patients gave written consent, as required by the Subcommittee on Human Studies. Bone mineral density at the anteriorposterior lumbar spine (L1L4), lateral spine, left total hip, femoral neck, and greater trochanter was determined with dual-energy x-ray absorptiometry using a Hologic 4500 densitometer (Hologic, Inc., Waltham, Massachusetts) (lumbar spine SD, 0.01 g/cm2) (11). At each skeletal site, patients were categorized as having normal BMD (T-score>1.0 SD), osteopenia (1.0 SD T-score>2.5 SD), or osteoporosis (T-score 2.5 SD), according to World Health Organization criteria. Data on BMD in a subset of 30 patients were published previously (7). Wrist and frame size were determined (12, 13), and body mass index and percentage of ideal body weight were calculated (14). Age at menarche and time since last menstrual period were assessed for all patients. Whenever possible, total duration of amenorrhea since menarche was determined (n =78). Current and previous lifetime estrogen use, including type of estrogen, was quantified and categorized for each patient. We used the MantelHaenszel test to compare BMD at the anteriorposterior and lateral spine, stratifying on patients. Standard least-squares multivariate regression models were constructed for each skeletal site by using age, age at menarche, time since last menstrual period, weight, height, wrist size, and fracture history as covariates. Covariates were chosen in advance as important clinical variables affecting BMD. Adjusted regression coefficients and confidence intervals were determined for each covariate. Data are expressed as the mean SE. The funding source had no role in the collection, analysis, or interpretation of the data or in the decision to submit the paper for publication. Results Clinical data and data on BMD are shown in Table 1. Ninety-eight percent of patients were white and 2% were Asian. Mean T-scores were 1.4 0.1 SD for the anteriorposterior spine, 1.8 0.1 SD for the lateral spine, and 1.4 0.1 SD for the total hip. Twenty-six percent of patients (n =34) reported a history of fracture (foot or ankle [n =6], hand or wrist [n =7], leg [n =1], arm or elbow [n =4], stress fracture [n =5], and other fracture [n =11]). Table 1. Clinical Characteristics of Study Patients and Comparison by Estrogen Use and Menstrual History Osteopenia and osteoporosis, respectively, were seen at the anteriorposterior spine in 50% and 13% of patients, at the lateral spine in 57% and 24% of patients, and at the total hip in 47% and 16% of patients. Normal BMD was seen at the anteriorposterior spine in only 37% of patients, at the lateral spine in 19% of patients, and at the total hip in 37% of patients. Results of lateral and anteriorposterior spinal tests of BMD were discordant in 36 patients, of whom 31 had normal BMD at the anteriorposterior spine (T-score>1.0) but low BMD at the lateral spine (T-score 1.0) (P<0.001). Bone mineral density was reduced by at least 1.0 SD at one or more skeletal sites in 92% of patients and by at least 2.5 SD in 38% of patients. No differences in BMD were observed between patients with anorexia nervosa alone and patients with anorexia nervosa and concomitant bulimia nervosa (P>0.05 at all sites; data not shown). Twenty-three percent of patients were current estrogen users (mean duration, 25.3 5.4 months) and 58% were previous estrogen users (mean duration, 23.9 3.1 months). Bone mineral density did not differ at any site according to current or previous estrogen use (Table 1). Age, body mass index, and age at menarche were similar in the subgroup comparisons according to estrogen status. Oral contraceptives were used in all but 3 of the current estrogen users (10%) and all but 7 of the ever-estrogen users (10%); these 10 women received conjugated estrogen. Similar results were obtained in a subanalysis limited to the patients receiving oral contraceptives (data not shown). Total duration of estrogen use was not correlated with BMD at the anteriorposterior spine, lateral spine, femoral neck, total hip, trochanter, or total body (P>0.10 for all comparisons). Patients with primary amenorrhea (n =7) weighed less and had lower BMD at all sites than patients with secondary amenorrhea (n =123) (Table 1), although sample size was small in the primary amenorrhea group. Total calcium intake was not correlated with BMD at any site (P>0.1 for all sites). Fifty-seven percent of patients were receiving calcium supplements, 53% were receiving a multivitamin containing 400 IU of vitamin D, and 43% were receiving both. Bone mineral density did not differ in patients receiving nutritional supplements (data not shown). Weight was a significant independent predictor of BMD at all skeletal sites (Table 2). Patients with normal BMD, osteopenia, and osteoporosis at the total hip weighed 48.7 0.8 kg, 45.9 0.8 kg, and 39.0 0.7 kg, respectively. Similar trends were seen at other skeletal sites (data not shown). Age at menarche was a significant independent predictor of BMD measured by anteriorposterior spinal densitometry. Time since last menstrual period was a significant predictor of BMD at the anteriorposterior and lateral spine. Our results were similar when we used multivariate regression models with total duration of amenorrhea instead of last menstrual period in patients for whom this information was available (n =78) (data not shown). Table 2. Univariate and Multivariate Regression Analyses Discussion Our data demonstrate the high prevalence and profound degree of site-specific bone loss in women with anorexia nervosa. Our study design had advantages: Patients were recruited from the community and were not preselected for bone loss, and we evaluated bone loss at several skeletal sites. Although weight was highly significant as a predictor of bone loss at all sites, time since last menstrual period and age at menarche were significant predictive factors for BMD at the anteriorposterior spine, suggesting a greater relative influence of estrogen deficiency at this site. Other mechanisms may also contribute to reduced BMD in patients with anorexia nervosa, such as failure to achieve peak BMD, hypercortisolemia, and reduced vitamin D intake (4). However, we did not see any association between calcium or vitamin D intake and BMD. Increased risk for fracture is the major clinical implication of bone loss in women with anorexia nervosa. Fracture risk doubles with each decrease of 1 SD in BMD (9). Our data therefore suggest that patients with anorexia are at a markedly increased risk for fracture at many skeletal sites. A relatively high percentage of patients reported a previous history of fracture, but because radiologic confirmation was not obtained, relative risk for fracture was not determined. Bone mineral density was reduced by at least 1.0 SD at one or more skeletal sites in 97% of women with fractures, but fracture site was not correlated with the location of osteopenia. Although our study was not designed to prospectively investigate the efficacy of estrogen use in women with anorexia nervosa, no effect of previous or current estrogen use on BMD was demonstrated at any skeletal sites. These retrospective data stand in partial contrast to cross-sectional data from a previous study, which suggested an effect of estrogen exposure at the lumbar spine but not at other sites (15). The minimal effect of estrogen exposure on BMD in our study is consistent with that seen in a previous randomized study, which showed no effect of estrogenprogestin replacement therapy on BMD in patients with anorexia nervosa (16). The effectiveness of estrogen in increasing or preserving BMD in women with anorexia nervosa may be mitigated by continued undernutrition, which may act to uncouple bone formation and resorption. We have previously shown that women with anorexia nervosa exhibit low bone formation rates and increased resorption rates (3). Hotta and colleagues (17) have shown that low rates of bone formation in patients with anorexia nervosa increase with feeding, suggesting a mechanism whereby bone formation is reduced by undernutrition and

MEG3 noncoding RNA: a tumor suppressor.

Maternally expressed gene 3 (MEG3) is an imprinted gene belonging to the imprinted DLK1-MEG3 locus located at chromosome 14q32.3 in humans. Its mouse ortholog, Meg3, also known as gene trap locus 2 (Gtl2), is located at distal chromosome 12. The MEG3 gene encodes a long noncoding RNA (lncRNA) and is expressed in many normal tissues. MEG3 gene expression is lost in an expanding list of primary human tumors and tumor cell lines. Multiple mechanisms contribute to the loss of MEG3 expression in tumors, including gene deletion, promoter hypermethylation, and hypermethylation of the intergenic differentially methylated region. Re-expression of MEG3 inhibits tumor cell proliferation in culture and colony formation in soft agar. This growth inhibition is partly the result of apoptosis induced by MEG3. MEG3 induces accumulation of p53 (TP53) protein, stimulates transcription from a p53-dependent promoter, and selectively regulates p53 target gene expression. Maternal deletion of the Meg3 gene in mice results in skeletal muscle defects and perinatal death. Inactivation of Meg3 leads to a significant increase in expression of angiogenesis-promoting genes and microvessel formation in the brain. These lines of evidence strongly suggest that MEG3 functions as a novel lncRNA tumor suppressor.

Activation of p53 by MEG3 non-coding RNA

MEG3 is a maternally expressed imprinted gene suggested to function as a non-coding RNA. Our previous studies suggest that MEG3 has a function of tumor suppression. The tumor suppressor p53 plays a central role in tumor suppression and mediates the functions of many other tumor suppressors. Therefore, we hypothesized that MEG3 functions through activation of p53. We found that transfection of expression constructs for MEG3 and its isoforms results in a significant increase in p53 protein levels and dramatically stimulates p53-dependent transcription from a p53-responsive promoter. Using this as the functional assay, we demonstrated that the open reading frames encoded by MEG3 transcripts are not required for MEG3 function, and the folding of MEG3 RNA is critical to its function, supporting the concept that MEG3 functions as a non-coding RNA. We further found that MEG3 stimulates expression of the growth differentiation factor 15 (GDF15) by enhancing p53 binding to the GDF15 gene promoter. Interestingly, MEG3 does not stimulate p21CIP1 expression, suggesting that MEG3 can regulate the specificity of p53 transcriptional activation. p53 degradation is mainly mediated by the mouse double minute 2 homolog (MDM2). We found that MDM2 levels were down-regulated in cells transfected with MEG3, suggesting that MDM2 suppression contributes at least in part to p53 accumulation induced by MEG3. Finally, we found that MEG3 is able to inhibit cell proliferation in the absence of p53. These data suggest that MEG3 non-coding RNA may function as a tumor suppressor, whose action is mediated by both p53-dependent and p53-independent pathways.

Clinically nonfunctioning pituitary tumors are monoclonal in origin

Clinically nonfunctioning pituitary adenomas are benign neoplasms comprising approximately 25-30% of pituitary tumors. Little is known about the pathogenesis of pituitary neoplasia. Clonal analysis allows one to make the important distinction between a polyclonal proliferation in response to a stimulatory factor versus a monoclonal expansion of a genetically aberrant cell. We investigated the clonal origin of pituitary tumors using X-linked restriction fragment length polymorphisms at the phosphoglycerate kinase and hypoxanthine phosphoribosyl-transferase genes. Restriction enzymes were used to distinguish maternal and paternal X-chromosomes, and combined with a methylation-sensitive restriction enzyme to analyze allelic X-inactivation patterns in six pituitary adenomas. All six tumors showed a monoclonal pattern of X-inactivation. These data indicate that nonfunctioning pituitary adenomas are unicellular in origin, a result consistent with the hypothesis that this tumor type is due to somatic mutation.

Decreased Bone Density in Hyperprolactinemic Women

HYPERPROLACTINEMIA is a relatively common clinical problem, occurring in more than 25 per cent of women who present with secondary amenorrhea.1 , 2 Amenorrhea, anovulation, and galactorrhea are wel...

Effects of anorexia nervosa on clinical, hematologic, biochemical, and bone density parameters in community-dwelling adolescent girls

Objective. Anorexia nervosa (AN) is an eating disorder that leads to a number of medical sequelae in adult women and has a mortality rate of 5.6% per decade; known complications include effects on hematologic, biochemical, bone density, and body composition parameters. Few data regarding medical and developmental consequences of AN are available for adolescents, in particular for an outpatient community-dwelling population of girls who have this disorder. The prevalence of AN is increasing in adolescents, and it is the third most common chronic disease in adolescent girls. Therefore, it is important to determine the medical effects of this disorder in this young population. Methods. We examined clinical characteristics and performed hematologic, biochemical, hormonal, and bone density evaluations in 60 adolescent girls with AN (mean age: 15.8 ± 1.6 years) and 58 healthy adolescent girls (mean age: 15.2 ± 1.8 years) of comparable maturity. Nutritional and pubertal status; vital signs; a complete blood count; potassium levels; hormonal profiles; bone density at the lumbar and lateral spine; total body, hip, and femoral neck (by dual-energy x-ray absorptiometry) and body composition (by dual-energy x-ray absorptiometry) were determined. Results. All measures of nutritional status such as weight, percentage of ideal body weight, body mass index, lean body mass, fat mass, and percentage of fat mass were significantly lower in girls with AN than in control subjects. Girls with AN had significantly lower heart rates, lower systolic blood pressure, and lower body temperature compared with control subjects. Total red cell and white cell counts were lower in AN than in control subjects. Among girls with AN, 22% were anemic and 22% were leukopenic. None were hypokalemic. Mean age at menarche did not differ between the groups. However, the proportion of girls who had AN and were premenarchal was significantly higher compared with healthy control subjects who were premenarchal, despite comparable maturity as determined by bone age. Ninety-four percent of premenarchal girls with AN versus 28% of premenarchal control subjects were above the mean age at menarche for white girls, and 35% of premenarchal AN girls versus 0% of healthy adolescents were delayed >2 SD above the mean. The ratio of bone age to chronological age, a measure of delayed maturity, was significantly lower in girls with AN versus control subjects and correlated positively with duration of illness and markers of nutritional status. Serum estradiol values were lower in girls with AN than in control subjects, and luteinizing hormone values trended lower in AN. Levels of insulin-like growth factor-I were also significantly lower in girls with AN. Estradiol values correlated positively with insulin-like growth factor-I, a measure of nutritional status essential for growth (r = 0.28). All measures of bone mineral density (z scores) were lower in girls with AN than in control subjects, with lean body mass, body mass index, and age at menarche emerging as the most important predictors of bone density. Bone density z scores of <−1 at any one site were noted in 41% of girls with AN, and an additional 11% had bone density z scores of <−2. Conclusions. A high prevalence of hemodynamic, hematologic, endocrine, and bone density abnormalities are reported in this large group of community-dwelling adolescent girls with AN. Although a number of these consequences of AN are known to occur in hospitalized adolescents, the occurrence of these findings, including significant bradycardia, low blood pressure, and pubertal delay, in girls who are treated for AN on an outpatient basis is of concern and suggests the need for vigilant clinical monitoring, including that of endocrine and bone density parameters.