Metode i tehnici de msurare i localizare a hormonilor i receptorilor endocrini

Corin Badiu, 2015

Hipertensiunea arteriala endocrina

Sindromul CushingHiperaldosteronismul primarFeocromocitomulBlood Pressure Classification (JNC8)BP ClassificationSBP mmHgDBP mmHg

James PA et al, 2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA. 2014;311(5):507.Normal110FREQUENCY OF VARIOUS DIAGNOSES IN HYPERTENSIVE PATIENTSPRIMARY CAREREFERRAL Essential 92-95% 89% Chronic kidney disease 3-6% 4% Renovascular disease 0.2-1.0% 4% Pheochromocytoma 0.1-0.2% 0.2% Aldosteronism 0.1-0.3% 0.5% Cushings syndrome 0.1-0.2% 0.2% Coarctation 0.1-0.2% 1% Oral contraceptives 0.2-1.0% 1%HBP in children / adolescents: 50-85% is secondaryProtocol Confirmarea hipertensiunii Identifica etiologia

Afectarea periferica

Identifica riscul cardiovascularMasurareMetodaDescriereIn cabinetDoua determinari, la 5 minute interval, in sezand. Confirma valorile crescute prin citiri la bratul contralateral. Monitorizare ambulatorie Indicata pt evaluarea HTA de halat-alb. Absenta scaderii cu 1020% a TA in somn indica risc CV crescut. Auto-determinareFurnizeaza informatii asupra raspunsului la terapie. Poate ajuta sa imbunatateasca complianta la terapie. Factori de Risc pt Hipertensiune SecundaraRaspuns slab la terapie (HTA rezistenta la > 3 medic din clase )Pierderea controlului la pacienti stabili pe medicatie anti HTAHipertensiune stadiul 3 (SBP>180 sau DBP>110)Debut inainte de 20 ani sau peste 50 aniAfectare semnificativa a organelor tinta (cord, ochi, rinichi)Lipsa istoricului familial de hipertensiune Elemente de HTA secundara in anamneza, ex clinic sau paraclinic

Mineralocorticoid excessCushings syn.PheochromocytomaHipertensiunea endocrina secundara suprarenalaSuprarenaleGlucocorticoizi (Cortizol)CortexMineralocorticoizi (Aldosteron)Androgeni Adrenocortical

MedullaCatecolamineHistologie

CapsulaZona glomerulosaZona fasciculataZona reticularisMedulosuprarenalaVena centralHistologie

CGA17aHOlaza Steroidogeneza specific

Glucocorticoizi (C21)MedulosuprarenalaMineralocorticoizi (C21)Androgeni (C19)Vena central Substratul steroidogenezei1819 20CH 25 CH3 HO ABCDCH3CH3CH3CH3CH2CH2CH2CH2724262221231267891012131415161711534Steroidogeneza

Steroidogeneza

ZGZFZRZGZFZR

Reglarea Axei CSR CRH / VP ACTH Cortisol Leptina Citokine GR, CRHR, V1b, ACTH R, Ritmul CircadianTimpPlasma[ cortisol ](nmol/L)Stres00:0012:0000:0018:0006:00100600Cortisol

90% - CBG: D4-3Keto5% - albumina5% -liberT1/2 70-120 minSindromul CushingSindrom clinic si biochimic determinat de excesul secretiei autonome endogene de cortizol mineralocorticoizi si androgeni din CSRACTH dependent82% ACTH Hipofizar 66% ACTH Ectopic 12%ACTH cu sursa necunoscuta4%

ACTH independent18%Adenom adrenal10% Carcinom adrenal 7%Hiperplazie macronodulara1%

CushingIstoric tablou clinicCrestere ponderalaTegumentar: piele subtire, acnee, , hirsutism, echimoze, vergeturi, hiperpigmentare (ACTH dependent)Obezitate centrala, facies in luna plina, adipozitate interscapulo-vertebral si mobilizarea tesutului adipos de pe membreInfectii recurenteAmenoree secundara, infertilitateScaderea fortei musculare, urca greu scarileDepresie, labilitate psiho-afectivaHTA, DZ, osteoporoza: secundare

Cushing

Cushing

Screening in CushingTeste screening pentru sindrom Cushing:Cortizol urinar liberOvernight (ON) 1-mg dexamethasone suppression test.

Confirmarea dg de sindrom CushingRitm cortizolDXM 2x2 (0.5mg la 6 ore, 2 zile)(Normal in F familial)10% recidiveaza (> cele extra-adrenale)10% maligne10% descoperite intamplatorClinicaCinci P:Pressure (HTA)90%Pain (Headache)80%Perspiration71%Palpitation64%Pallor42%Paroxysms (the sixth P!)Triada clasica:Pain (Headache), Perspiration, PalpitationsLack of all 3 virtually excluded diagnosis of pheochromocytoma in a series of > 21,0000 patients

Efecte vegetativeReceptori AdrenergiciAlfa-Adrenergici1: vasoconstrictie, relaxare intestinala, contractie uterina, dilatare pupilara2: NE presinaptic (clonidina), agregare plachetara, vasoconstrictie, secretiei de insulina

Beta-Adrenergici1: AV / contractilitatii, lipolizei, secretiei de renina2: vasodilatatie, bronchodilatatie, glicogenoliza3: lipoliza, termogeneza in tesut adipos brunCrizaDurata 10-60 minFrecventa: zilnic ----- la cateva luniSpontanPrecipitataProceduri diagnostice, contrast I.A. (I.V. nu determina criza)Medicatie (opiode, -blocante fara a-bloc. inductia anesteziei, histamina, ACTH, glucagon, metoclopramida)Efort fizic, miscari care cresc presiunea intra-abdominalaMictiune (paragangliom vezical)NastereaHipotensiuneHipotensiune (ortostatica/paroxistica)

Mecanisme:Contractia V LECPierderea reflexelor posturale data de stimulare adrenergica prelungita Secretie tumorala de adrenomedulina (neuropeptid vasodilatator)Dureri abdominale, constipatie severa (megacolon)Dureri precordialeAnxietateAngina/IM cu artere coronare normale:Catecholamin- indusa: consumul de oxigen miocardic sau vasospasm coronarianInsuf cardiaca globalaHTA cardiomiopatie hipertrofica disfunctie diastolicaCardiomiopatie dilatativa indusa de catecolamine disfunctie sistolicaAritmii cardiace & defecte de conducereClinicaGenetica SindromAnomalie geneticaAnomalie fenotipicaMEN 2A, 2B10 q11.2(RET)MCT, HPTR, FEO, neuroame mucoase, ganglioneurinomNeuro-ectodermale NF-117q11 (NF-1)3p25-26 (VHL)NeurofibromatozaAngioame retiniene, KK renal, Hemang SNSDH BSDH C,D1p361q21, 11q23PGGL, FEO malignUn sfert din feocromocitoame- determinare geneticaMEN2 screeningS. Radian, C. Badiu et al, Acta Endocrinologica (Buc), vol. III, no. 1, p. 13 - 22, 2007

From genes to clinical pictureF, 50 y, severe HBP, Takotsubo cardiomyopathy6 mutations (4 SDHC, 2 SDHA)

Mariana Dobrescu, Simona Verzea, Corin Badiu Acta Endocrinologica (Buc), vol. V, no. 4, p.543, 2009

PreopPostopTyrosineL-DopaDopamineNorepinephrineEpinephrineCatecolamineNormetanephrineMetaneprinePNMTDBHCOMTCOMTMetabolitiHomovanillic acid(HVA)MAO, COMTVanillymandelic Acid(VMA)MAOMAOTHTyrosineL-DopaDopamineNorepinephrineEpinephrineCatecolamineNormetanefrineMetanefrinePNMTDBHCOMTCOMTMetabolitiHomovanillic acid(HVA)MAO, COMTVanilmandelic Acid(VMA)MAOMAOSecretia tumorala: Feo mare: > metaboliti (metabolizare in tumora inainte de secretie) Feo mic: more catecholamines Feo Sporadic : NE > E Feo Familial: E > NE Paragangliom: NE Chemodectom, glomus jugular: NE Ganglioneurom: NE Feo malign: Dopamina, HVA Neuroblastom: Dopamina, HVATHHTA paroxistica

Messerli et al, Am J Cardiol 2007;99:13251329Repetate crize de angor, cu documentarea EKG a 8 episoade de IMA TSR stg (feocromocitom), 1,5 cm

Dwight David Eisenhower (1890-1969)MorfologieSmall (mg), circumscribed to large (kg) masses

Small polygonal cells arranged in vascular nests

Electron microscopy - membrane bound granules (catecholamines)

Malignancy is based on metastasisMetabolismHypercalcaemiaAssociated MEN2 HPTPTHrP secretion by pheochromocytomaMild glucose intoleranceLipolysisWeight-lossKetosis > VLDL synthesis (TG)

FamilialMEN 2a50% pheochromocytoma (usually bilateral), MTC, HPTMEN 2b50% pheochromocytoma (usually bilateral), MTC, mucosal neuroma, marfanoid habitusVon Hippel-Landau50% pheochromocytoma (usually bilateral), retinoblastoma, cerebellar haemangioma, nephroma, renal/pancreas cystsNF1 (Von Recklinghausen's)2% pheochromocytoma (50% if NF-1 and HTN)Caf-au-lait spots, neurofibroma, optic gliomaFamilial paragangliomaFamilial pheochromocytoma & islet cell tumorOther: Tuberous sclerosis, Sturge-Weber, ataxia-telangectgasia, Carneys Triad (Pheochromocytoma, Gastric Leiomyoma, Pulmonary chondroma)Metanefrine plasmaticeNu sunt dependente postural: pot fi recoltate normal

Secretate continuu de feocromocitom

Sensibilitate 99%, specificitate 89%

Fals pozitiv: acetaminophenInterferente de dozareMedicatie care creste fals pozitiv nivelul metanefrinelor urinare:Tricyclic antidepressantsLevodopaLabetalolEthanolSotalolAmphetaminesBuspironeBenzodiazepinesMethyldopaChlorpromazineMedicatie care scade nivelul metanefrinelor urinare :Methyltyrosine, which inhibits tyrosine hydroxylase, the rate-limiting enzyme in catecholamine synthesisMethylglucamine, which is present in radiocontrast mediaReserpineTeste in urina24h: Creatinina, catecolamine, metanefrine, normetanefrine

Rezultate Pozitive (> 2-3 ori):24h Ucatechols > 2 ori

24h Utotal metanephrines > 1.2 ug/d (6.5 umol/d)Teste salivare

A. M. Stefanescu et al, Acta Endocrinologica (Buc), vol. VII, no. 4, p. 431-442, 2011

Localizare imagisticaUltrasonografia

CT abdomenFeocromocitom adrenal - sensibilitate 93-100%Feocromocitom extra-adrenal - sensibilitate 90%MRI> sensibilitate CT pt feocromocitom extra-adrenal

MIBG Scansensibilitate 77-90%, specificitate 95-100%EcografiaA fost inlocuita de CT si MRI; este limitata de pregatirea tractului digestiv

Valoare limitata in diferentierea leziunilor chistice de cele solide in adrenala

MRI este preferata ca modalitate de investigare. 73Findings: Ultrasonography has largely been replaced by CT and MRI, and it is limited as a result of the effects of overlying bowel gas, especially in the assessment of the left adrenal gland. Therefore, the use of ultrasonography is limited to differentiating cystic lesions from solid lesions in the adrenal gland. Even in the pediatric population, MRI is the preferred imaging modality. Ecografia in Feocromocitom

74CT in Feo

Leziuni adrenale >1 cm, extra-adrenale >2 cm, sensibilitate 95%, specificitate 70% 75Cavografie / CT in Feo NMN=1608/1304 pg/mL, MN=23/17 pg/mL, NMN/24 ore=2898 mcg, MN/24 ore=59 mcg Cromogranina A=638 ng/mL

76IRM in feocromocitom

T1 weightedT2 weighted77MIBG

111Indium-pentreotideSome pheochromocytomas have somatostatin receptors

PET18F-fluorodeoxyglucose (FDG)6-[18F]-fluorodopamineLocalizare imagistica nuclearaImagistica nucleara131I-MIBG si 123I-MIBG sunt concentrate in sistemul simpato-medular si pastrate in granule de neurosecretie

Aproximativ 30% din patienti, au un uptake mai mic decat cel hepatic.

In feocromocitom, 131I-MIBG evidentiaza tumora ca o arie in glanda suprarenala cu captare crescuta.

123I-MIBG permite o calitate mai buna a imaginii, poate fi evaluat prin single photon emission computed tomography (SPECT), are expunere mai mica la radiatii si rezultate in timp mai scurt.79Findings: 131I-MIBG and 123I-MIBG are concentrated in the sympathomedullary system and then sequestered in neurosecretory granules. After pretreatment with Lugol iodine to saturate thyroid uptake, 0.5-1.0 mCi of 131I-MIBG or 9-10 mCi of 123I-MIBG is intravenously injected, and posterior adrenal images are obtained after 24, 48, and 72 hours. Technetium-99m DTPA is also used to improve localization of the kidneys. A normal adrenal medulla is seen in approximately 30% of patients, with an uptake less than that of the liver. In pheochromocytoma, 131I-MIBG scans show the tumor as a focal area in the adrenal gland that has prolonged increased uptake. Tumor metastases can be demonstrated in a similar fashion. Compared with 131I-MIBG imaging, 123I-MIBG offers better image quality, single photon emission computed tomography (SPECT) capability, lower radiation exposure, and shorter imaging time. However, the US Food and Drug Administration has not approved the use of 123I-MIBG for adrenal imaging; thus, this technique is less commonly available for imaging. Other nuclear imaging modalities include imaging with the somatostatin analog octreotide and imaging with positron emitters such as carbon-11 hydroxyephedrine, 2-[fluorine-18]fluoro-2-deoxy-D-glucose (FDG), and 11C epinephrine. The use of FDG, a glucose analogue used by metabolically active cells, with positron emission tomography (PET) is described. In a study of 29 patients with benign and malignant pheochromocytomas, Shulkin et al reported tumoral uptake of FDG in 22. They noted that as many as 17 of their 29 patients had malignant pheochromocytoma, which may have resulted in this high degree of positivity. Although the sensitivity of FDG PET was lower than MIBG scanning and although its specificity was considerably lower, FDG uptake was present in all cases in which MIBG did not accumulate. Thus, when findings with other modalities fail to reveal or confirm the presence of the tumor, FDG PET may be useful. Other reports have since described the uptake of FDG in calvarial metastases from pheochromocytoma (Yamamoto, 2001).Degree of Confidence: Reportedly, sensitivity is 86-90% for pheochromocytomas (especially in extra-abdominal tumors) and specificity is as high as 99% with 131I-MIBG and higher with 123I-MIBG (90% sensitivity, 100% specificity).False Positives/Negatives: MIBG uptake may be poorly visualized in tumors with extensive necrosis, even large tumors. Occasionally, activity in the bowel can create false-positive findings, especially when extra-adrenal tumors are considered. The study can be repeated 24 hours later, when activity in the gut is displaced. As a result of the 10% false-negative rate with MIBG scanning, some authors recommend abdominal CT or MRI if a high clinical suspicion of pheochromocytoma exists but a causative tumor is not identified by assessing MIBG uptake.MIBG

In feocromocitom, 131I-MIBG evidentiaza tumora ca o arie in glanda suprarenala cu captare crescuta.12.2012: I131- MIBG scan: tracer pathological uptake on both lungs, without abdominal or cervical uptake

17.01.2013: I131- MIBG therapy 150 m Ci07.2012- present: asymptomatic, normotensive patient

Metastatic PheoMEN2 screening

S. Radian, C. Badiu et al, Acta Endocrinologica (Buc), vol. III, no. 1, p. 13 - 22, 2007Macroscopic view of a malignant pheochromocytoma,demonstrating capsular invasion, hemorrhage, necrosis,and multinodularity

The characteristic small nests pattern was seen in all pheochromocytomas, whether benign or malignant. A granular, basophilic cytoplasm was usuallyidentified surrounding slightly irregular nuclei (right)The characteristic chromogranin (left) immunoreactivityin the pheochromocytes is contrasted to the S-100protein immunoreactivity of the supporting sustentacularsupporting cells (right) in this benign pheochromocytoma

Management: medical si anestezic Antagonisti Alfa fenoxibenzamina* +/- metirosina*Incepe cu 10mg /zi cu crestere progresiva sub control HTACorecteaza depletia volumicaBeta blocada doar dupa alfa blocada completa, cu propranolol, atenolol, labetalolEvita eliberarea de histaminaMonitorizare invaziva arteriala IOpAnestezie si sedare pre-op. Se evita halotanul (poate precipita aritmii)Control volum intravascular si TANitroprusiat Na i.v in perfuzie lenta, sub monitorizarea invaziva a TANorartrinal i.v in perfuzie lenta, sub monitorizarea invaziva a TA

*Nota: tipic, sunt necesare 10-14 zile de tratament pre-op

Clase de TerapieVasodilatatoareNitroprusiat, NitroglicerinaBeta-blocante eg. LabetalolAlfa-blocante eg. FentolaminaBlocante de Ca eg. Nicardipine

Preop: + blockadeStart at least 10-14d preopAllow sufficient time for ECFv re-expansionPhenoxybenzamineSpecial pharmacy access only (no DIN)Drug of choiceCovalently binds -receptors (1 > 2)Start 10 mg po bid increase q2d by 10-20 mg/dIncrease until BP cntrl and no more paroxysmsMaintenance 40-80 mg/d (some need > 200 mg/d)Salt load: NaCl 600 mg od-tid as toleratedManagement: rezectie chirurgicalaMidline or transverse abdominal incisionBilateral adrenal exploration along with exploration of para-aortic and paracaval retroperitoneum (diaphragm to pelvis) Laparoscopic approach acceptable via a flank, retroperitoneal, or transabdominal approach Shorter hospital LOSLower morbidity rateHigher incidence of missed paragangliomas/multiple tumors Robotic surgery91posterior approach- most suitable for:-small adrenal tumors not suspected of being malignant. less postoperative pain faster return of bowel function quicker postoperative recovery compared with the anterior approach. not recommended for excision of large pheochromocytomas, adrenal tumors greater than or equal to 6 cm, or adrenal carcinoma.Feocromocitom malignRecidivele apar in 5 -10 ani dupa rezectia leziunii primarePot fi detectate 20 ani mai tarziu. Supravietuirea la cinci ani: 36 - 60%.TratamentResectia metastazelor Controlul TARadioterapia (paliativ) pentru metastaze osoase. Terapie ablativa cu I-MIBG - raspuns partialChemoterapie combinata (ciclofosfamida, vincristina si dacarbazina) poate fi eficace. ConcluziiHTA endocrina HTA secundara CSR / MSRTeste diagnostice functionale in dinamicaTratament chirurgical

Cholesterol

P450CSCC

PregnenoloneP450C17

17-hydroxy-pregnenoloneP450C17Dehydroepiandrosterone (DHEA)

3HSD

3HSD

ProgesteroneP450C1717-hydroxy-progesterone

P450C21

P450C21

Deoxycorticosterone

(DOC)

11-Deoxycortisol

P450C11B1

P450C11B1

Corticosterone

Cortisol

P450C11B2

Aldosterone